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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Synvisc-One injections to the knees. The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees bilateral knee osteoarthritis.At issue in this case is whether the requested bilateral Synvisc-One injections to the knees are medically necessary for treatment of the enrollees medical condition.The medical records have been reviewed, along with recent medical literature with regard to the benefits of viscosupplementation for individuals who are deemed too young for total joint arthroplasties, yet have severe osteoarthritis with associated pain. As evidenced by the history of significant benefit from prior injections, the current literature continues to support the use of vicsosupplementation for osteoarthritis of the knees.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 lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around two years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be twofold: (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. An article referenced a systematic review of overlapping meta-analyses comparing 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 that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, the request for Synvisc-One injections of the knees is medically necessary.Final Result: The reviewer determined that the requested procedures 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.