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

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for bilateral knee Synvisc injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients osteoarthritis of the knees, bilateral. The submitted documentation does not support the medical necessity of the requested medication. The most recent guidelines for the management of knee osteoarthritis do not recommend hyaluronic acid injections. The 2014 Osteoarthritis Research Society International (OARSI) states that for Osteoarthritis (OA) of the knee, appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, land-based and water-based exercise, self-management and education, strength training, and weight management. Treatments appropriate for specific clinical sub-phenotypes included acetaminophen (paracetamol), balneotherapy, capsaicin, cane (walking stick), duloxetine, oral non-steroidal anti-inflammatory drugs (NSAIDs); cyclooxygenase-2 selective and selective and non-selective and topical NSAIDs. Treatments of uncertain appropriateness for specific clinical sub-phenotypes included acupuncture, avocado soybean unsaponfiables, chondroitin, crutches, diacerein, glucosamine, intra-articular hyaluronic acid, opioids (oral and transdermal), rosehip, transcutaneous electrical nerve stimulation, and ultrasound. Colleagues have voted that treatments not appropriate included risedronate and electrotherapy (neuromuscular electrical stimulation). Colleagues strongly recommend nonpharmacologic modalities for the management of knee OA including aerobic, aquatic, and/or resistance exercises, as well as weight loss for overweight patients. Nonpharmacologic modalities conditionally recommended for knee OA included medial wedge insoles for valgus knee OA, subtalar strapped lateral insoles for varus knee OA, medially directed patellar taping, manual therapy, walking aids, thermal agents, tai chi, self-management programs, and psychosocial interventions. Pharmacologic modalities conditionally recommended for the initial management of patients with knee OA included acetaminophen, (oral and topical NSAIDs), tramadol, and intra-articular corticosteroid injections; intra-articular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy. This patient has bilateral knee osteoarthritis.  However, detailed information regarding the patients previous therapies were not including in the documentation submitted for review. In this case, the medical records fail to demonstrate that the patient has failed initial therapy. The 2013 American Academy of Orthopedic Surgery (AAOS) states that with regards to hyaluronic acid injections for knee osteoarthritis, we cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. According to the American Academy of Orthopaedic Surgeons clinical practice guidelines, although the records indicate that the patient has had significant benefit with previous injections, the records fail to demonstrate evidence of functional improvement. The guidelines do not recommend this therapy for knee osteoarthritis. As such, bilateral knee Synvisc injections are not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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.