Appeal type: Experimental/Investigational
Decision: Overturned

Physician 1:  The patient is a 46-year-old woman who is a right above-the-knee amputee status post a motor vehicle accident. She underwent an open reduction internal fixation procedure on the left knee. She is requesting reimbursement for a microprocessor-controlled knee for the right leg that she obtained for the stated purposes of improved stability and function. The Health Plan has denied the patients request on the basis that the prosthetic device at issue is investigational in this setting.Upon review of the submitted documentation including review of the patients functional status and her activity level, it is not likely the patient will experience superior results with a microprocessor-controlled knee. The prosthetic device at issue has not been shown to be superior or offer more functional benefit than a standard custom fitted prosthesis in the orthotic management of high functioning patients. A standard custom fitted prosthesis would have provided an adequate level of function for this patient. Accordingly, I have determined that the prosthetic device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Physician 2:  The patient is a 46-year-old female who was injured in a motor vehicle accident in December 2004. She sustained a grade-3B fracture and eventually underwent an above-the-knee amputation. She also sustained a tibial plateau fracture of the left knee, which was treated by open reduction internal fixation. The patient was fitted for a microprocessor-controlled knee. She is seeking reimbursement from the Health Plan for the cost of the prosthetic device.Review of the available scientific data supports the conclusion that the patients functional status will be greater with a microprocessor-controlled knee prosthesis compared to a standard construct. The variable nature of a microprocessor-controlled knee is necessary to accommodate the patients active lifestyle. Thus, the prosthetic device at issue is clinically appropriate and should be covered by the Health Plan. For the reasons set forth above, I have determined that the prosthetic device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 3:  The patient is a 46-year-old female who is status post a motor vehicle accident in which she sustained severe trauma to both legs. She underwent a right above-the-knee amputation and left tibial plateau ORIF with subsequent left total knee replacement. Her ankle required pinning due to fracture and eventual triple arthrodesis. She has received a microprocessor-controlled knee for which she is seeking coverage from the Health Plan. The Health Plan has denied her request on the basis that the prosthetic device at issue is considered experimental/investigational.This patient will benefit functionally from the microprocessor-controlled, variable damping prosthetic knee. The computer controlled prosthetic knee is not considered experimental and there is documented evidence of its efficacy in the literature. Due to the patients injury of her left lower extremity with biomechanical deficits, her prosthetic training has been arduous and painful. The microprocessor-controlled knee will provide greater stability and function than a standard prosthesis. Accordingly, I have determined that the prosthetic device at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.