Appeal type: Experimental/Investigational
Decision: Upheld

Physician 1: The patient is a 55-year-old male with knee pain that has been unresponsive to medical management. A request has been made for a Bionicare system. The Health Plan has denied the request indicating the efficacy of the requested equipment has not been established. The Bionicare system is not indicated for treatment of the patients underlying condition. The submitted information does not include evidence of meniscal pathology. It is not known if the patent has had an orthopedic surgery consultation. Based upon the information provided, the patient is likely to benefit more from a short course of physical therapy to include quadricep strengthening. In addition, cortisone injections may be beneficial. The Bionicare system plays no role in treatment of the patients condition. No study has demonstrated any long-term benefit of the Bionicare system. Therefore, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 2: The patient has been experiencing persistent knee pain for more than a year. X-rays of the left knee revealed chondromalacia of the patella. He has been tried on quadricep muscle activity and physical therapy without sustained benefit. The patients provider has recommended the patient receive a Bionicare system. The Health Plan has denied coverage for the requested equipment on the basis it is considered investigational for treatment of the patients medical condition.Review of the current medical literature revealed only one study regarding the requested equipment. This study did not control for patients receiving concomitant treatment. Hence, it is not clear this equipment is efficacious. Furthermore, the Bionicare system has not been compared to standard treatment to determine if there is any efficacy relative to conventional therapies. As such, the superiority of the requested equipment over standard therapy has not been established. Based upon the information set forth above, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld. Physician 3: The patient is a 55-year-old male with persistent knee pain. The patient has been taking high-dose controlled substances, which his provider indicates are contraindicated due to his job and comorbid conditions. His provider has recommended use of the Bionicare system. The Health Plan has denied this request indicating the requested equipment has not been shown to be efficacious for treatment of the patients condition. There is no Class I published data establishing the Bionicare system as an effective treatment of knee osteoarthritis. This efficacy of this treatment remains unproven. Furthermore, the patients x-rays indicate only mild degenerative change of the patella femoral joint. It does not appear the patient has severe osteoarthritis. As such, conservative therapies should be effective and are likely to be more beneficial than the requested equipment. Accordingly, I have determined that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.