Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Genvisc injection (J7320).
You asked the Plan to pre-approve a Genvisc injection (J7320). You say that the requested Genvisc injection is medically necessary. The Plan denied your request. The Plan says the requested Genvisc injection does not meet criteria.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve Genvisc injections (J7320). Our reviewer says that the requested Genvisc injections do not meet criteria. Our physician reviewer found the enrollee was seen on 01/10/2020. She had multiple complaints including low back and bilateral leg pain, which was greater on the right with cramping on the left. She had an onset of symptoms of 10 years without mechanism of injury and her symptoms were progressing. Her treatments had included physical therapy and spinal injections. She had pain rated at 10/10. She was also having left greater than right knee pain rated at 10/10. She was status-post right knee arthroscopic surgery. There had been temporary relief with cortisone. She
had not had physical therapy for her knees. She also had a complaint of right shoulder pain recently treated with physical therapy with some relief. She was also having cervical spine pain and upper extremity numbness and tingling. Her relevant past medical history included hypertension. There was also a history of bilateral foot surgery. Physical examination findings included lumbar paraspinal muscle tenderness with limited range of motion. Straight leg raising was positive bilaterally at 50 degrees. Findings were positive for spinal stenosis. Lumbar facet loading was positive. Examination of the knees showed findings of crepitus and an effusion. There was medial and lateral joint line tenderness and tenderness over the saphenous nerve region, pes anserine bursa, and popliteal fossa. She had approximate range of motion from 0 to 10 degrees. She had decreased strength graded at 4/5 in flexion and extension. There were right shoulder impingement signs. She had positive O'Brien's and Yergason/Speed's test. There was supraspinatus insertion region tenderness. Diagnoses included bilateral primary osteoarthritis of the knees. An x-ray of the knee showed findings of moderate tricompartmental osteoarthritis. The treatment plan included a lumbar epidural injection and series of hyaluronic injections for the knees. A right shoulder subacromial/subdeltoid bursa injection was recommended for her shoulder impingement syndrome. Recommendations also included physical therapy/chiropractic care and there was consideration of knee unloader braces in the future. The enrollee does not meet criteria for the requested injection. There is no evidence of a failure of recommended conservative treatments as she has not had physical therapy for her knees or evidence that she is effectively performing a home exercise program. She also has not failed a trial of bracing. The injection being requested is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc injection (J7320) have not been met. Therefore, we decided that the Plan does not have to pre-approve a Genvisc injection (J7320).