Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the patients left knee patella injury. The submitted documentation does not support the medical necessity of the requested services. Autologous chondrocyte implantation is a technique that was developed in 1994 to treat cartilaginous defects in various joints, including the knee. It has been performed for both the tibiofemoral cartilage and the patellofemoral cartilage. The procedure involves a two-step surgery. Following implantation, there is a period of restricted weight bearing for up to eight weeks. During this time, physical therapy emphasizing range-of-motion of the knee and strengthening activities are prescribed. A provider may also recommend the use of continuous passive motion machine to improve the grafts success. A return to light sports activities is typically allowed at approximately six months with return to full sports activities between 9 and 12 months following the procedure based on the recovery. The overall success rate of autologous chondrocyte implantation (ACI) is approximately 85 percent in allowing patients to return to pain-free activities. At issue in this case is whether magnetic resonance imaging (MRI) of the left knee is indicated to monitor the patient following surgery. There have been studies suggesting that MRI can be performed at regular intervals. In a 2003 study shows MRI studies were performed at 3 and 12-month intervals following surgery. It was reported that the overall Modified Rankin Scale score at 12 months suggested production of normal or nearly normal cartilage in 82 percent of patients, corresponding to a subjective improvement in 81 percent of patients and 88 percent of International Knee Documentation Committee A utility and B utility scores. Evidence showed that second-look surgery and biopsies in 15 patients (22 lesions) showed a moderate correlation of MRI with visual scoring; 70 percent of biopsies showed hyaline and hyaline-like cartilage. Thus, MRI at 12 months is a reasonable non-invasive means of assessment of ACI. In 2005, a study reported less than encouraging findings. MRI findings cannot predict ACI graft histologic features, and graft histologic appearance determined at biopsy was not related to graft signal intensity, graft thickness, overgrowth, surface smoothness, integration with adjacent cartilage or underlying bone, signal intensity change in underlying bone marrow, or underlying bone contour. Overgrowth and bone marrow changes underneath the graft were common. While obtaining an MRI to show regrowth may be encouraging, more important is the clinical status of the patient. This particular patient is currently asymptomatic. An MRI would not necessarily change the course of treatment or management, and would potentially be misleading. Therefore, magnetic resonance imaging (MRI) of the left knee is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.