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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees knee pain. A review of the record indicates that the enrollee has been diagnosed with osteoarthritis, essential hypertension, and morbid obesity. A visit note dated 11/2/18, reported the enrollee presented with bilateral knee pain, right more than left. The provider reported previous magnetic resonance imaging of the right knee revealed significant diffuse meniscus tear of the medial meniscus; and chondromalacia to the medial compartment, mild to moderate chondromalacia to the patella and a partial tear of the anterior cruciate ligament (ACL). The provider reported the enrollee has difficulty walking and standing, is very young for a total joint replacement, and has failed cortisone injections. The provider has requested Euflexxa injections.At issue in this case is whether the requested Euflexxa injections are medically necessary for treatment of the enrollees medical condition. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Nationally recognized 2010 evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis; who have not responded adequately to recommended conservative treatments for at least 3 months, including failure to respond adequately to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The American Medical Society for Sports Medicine recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and is more effective than corticosteroid injections. In this case, the patient has severe bilateral knee pain, right greater than left. Significant functional limitations are noted in walking and weight bearing tolerance. Clinical examination findings are consistent with imaging and x-ray evidence of right knee medial compartment osteoarthritis. She is reported to be too young to consider total knee replacement. She has failed to respond adequately to other conservative treatment, including corticosteroid injection. Therefore, the requested Euflexxa injections for the right knee are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested treatment is 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.