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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Orthovisc injections. The Health Plan has denied this request. The Health Plan indicates that the requested medication injections are not medically necessary for treatment of the enrollees degenerative joint disease and osteoarthritis of the knees.At issue in this case is whether the requested Orthovisc injections are medically necessary for treatment of the patients medical condition.Researchers noted the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis; as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intraarticular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function; a reduction in use of concomitant analgesia by up to 50 percent; and suggests that there may be a delay in the need for total knee replacement. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be two-fold: (i) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and (ii) the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. Researchers in a systematic review of overlapping meta-analyses compared viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. This shows that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. The patient has osteoarthritis of both knees associated with varus deformities and tenderness to palpation. He has benefitted from viscosupplementation in the past. The recent literature with regard to use of viscosupplementation for management of osteoarthritis of the knees continues to support the use of viscosupplementation for osteoarthritis of the knees. In this case it has clearly been beneficial for the patient in the past. As such, the request for Orthovisc injections of the knees is medically necessary.Final Result: The reviewer determined that the requested medication injections are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.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.