Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Knee Pain
Treatment: intra-articular lidocaine in combination with corticosteroids
The insurer denied intra-articular lidocaine in combination with corticosteroids.
The determination is overturned.

This is a patient who was diagnosed with bilateral knee arthritis. There is a request regarding intra-articular injection of lidocaine and corticosteroid. A clinical progress note documents that the patient is presenting regarding bilateral knee pain. They report much improvement following corticosteroid injections previously. Symptoms in both knees have been slowly worsening over time and are fairly significant. The patient reports swelling with activity. Studies have shown degenerative changes of the knees. The patient has a body mass index (BMI) of 48.78. An exam of the bilateral knees documented effusion, joint line tenderness, and pain at terminal flexion. A diagnostic ultrasound demonstrated mild effusion and arthritis. The provider states that the patient would like to continue conservative treatment and recommended corticosteroid injections which were provided at the office visit utilizing lidocaine and Kenalog. A clinical progress note states that the patient presented regarding knee pain and is currently in physical therapy. A progress note documented that the patient had persistent knee pain despite an exercise program and oral anti-inflammatories.
At issue is whether the intra-articular lidocaine in combination with corticosteroids is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes, the provided intra-articular injection of lidocaine with corticosteroids is more beneficial than other standard treatments or treatments for the patient's knee arthritis.
As noted in the article in the Journal of Arthroplasty, intra-articular corticosteroid injection is considered standard of care for the treatment of knee arthritis and is supported every 3 months if efficacious. The below article in Arthroscopy indicates that intra-articular steroid injections are most likely the best injection treatment for symptomatic knee arthritis. The American College of Rheumatology/Arthritis Foundation Guidelines support corticosteroid injections for the treatment of symptomatic arthritis after failure of initial conservative care. The documentation provided indicates that the patient has bilateral knee arthritis not improved with anti-inflammatories, physical therapy, and an exercise program. The patient underwent a corticosteroid injection  which provided relief and the pain returned. Repeat corticosteroid injections were provided with Kenalog and lidocaine.
When noting that the corticosteroid injections are considered standard of care for the treatment of knee arthritis when efficacious and after other conservative treatments have failed, and when noting that the patient had prior efficacy with corticosteroid injections, failed initial conservative care, and is not a candidate for arthroplasty due to an elevated BMI, a repeat corticosteroid injection would be considered more beneficial than other standard treatments as initial conservative care has failed. Additionally, it should be noted that corticosteroids are provided in conjunction with an anesthetic such as lidocaine at the time of injection to reduce irritation of the synovium and provide a larger quantity of medication to ensure proper injection.
Intra-articular injection of lidocaine and corticosteroids are supported for the treatment of symptomatic knee arthritis.