Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for medial patellofemoral ligament (MPFL) reconstruction.Findings:  The physician reviewer found that MPFL reconstruction and medial patellofemoral soft-tissue surgery procedures were both effective in restoring the medial restraining forces preventing redislocation, but MPFL reconstruction provided better functional outcomes both at short-term and long-term follow-up. Thus, besides the treatment of predisposing factors, MPFL reconstruction seems to be, based on the results of this meta-analysis, a suitable strategy to restore the medial restraining function in the treatment of recurrent lateral patellar dislocation.  Hopper and colleagues explain, The MPFL is the main restraining force against lateral patellar displacement. It is disrupted after patellar subluxation or dislocation. Reconstruction of the MPFL is frequently performed when nonoperative management fails and the patient experiences recurrent patellar dislocation. In a study including 68 patients with recurrent dislocation of the patella treated with MFPL reconstruction, the authors conclude, This study demonstrates the importance of restoration of the anatomic insertion point of the MPFL when performing MPFL reconstruction and proposes that this procedure should not be performed in isolation in patients with high-grade trochlear dysplasia. Nwachukwu and colleagues note, Surgical treatment of first time patella dislocation in children and adolescents is associated with a lower risk of recurrent dislocation and higher health-related quality of life and sporting function. There is a paucity of evidence on MPFL reconstruction for first time traumatic patella dislocation in this population. Frings and colleagues state, The risk of recurrent dislocation after primary patellar dislocation is increased by a number of risk factors, and even more so when multiple such risk factors are present. Published stratification models enable an assessment of the individual risk profile. Patients at low risk can be managed conservatively; surgery should be considered for patients at high risk. In assessing the effects of surgical versus non-surgical interventions for treating people with primary or recurrent patellar dislocation, Smith and colleagues conclude, Although there is some evidence to support surgical over non-surgical management of primary patellar dislocation in the short term, the quality of this evidence is very low because of the high risk of bias and the imprecision in the effect estimates. We are therefore very uncertain about the estimate of effect. No trials examined people with recurrent patellar dislocation. Adequately powered, multi-centre, randomised controlled trials, conducted and reported to contemporary standards, are needed. To inform the design and conduct of these trials, expert consensus should be achieved on the minimal description of both surgical and non-surgical interventions, and the anatomical or pathological variations that may be relevant to both choice of these interventions and the natural history of patellar instability. Furthermore, well-designed studies recording adverse events and long-term outcomes are needed.In this case, the patient reported a right patellar dislocation approximately one month prior when he went from a standing to a sitting position, and that his mother was able to put it back in place. The patient reported another dislocation about two weeks prior that self-reduced. He reported no pain. An examination of the right knee was limited by the patients willingness to cooperate with the examination. The patient was noted as having a range of motion from zero to 180 degrees without significant J sign. He did not tolerate palpation of his knee or patellar apprehension testing due to anxiety. X-rays of the right knee reported patellar trochlear dysplasia. There was markedly shallow trochlea bilaterally, the patella was centered in the groove, and the right knee showed a joint effusion suggesting there had been a subluxation. Physical therapy notes report that the patient is scheduled for 12 physical therapy sessions over the next six weeks. Given that recent, reasonable, and comprehensive less invasive conservative care measures, including physical therapy, should be trialed prior to surgical intervention, the requested service is not medically indicated. Therefore, medial patellofemoral ligament (MPFL) reconstruction is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is 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 orthopedic surgery 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.