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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections. The Health Plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollees bilateral knee osteoarthritis.At issue in this case is whether the requested Synvisc injections are medically necessary for treatment of the enrollees medical condition.As evidenced by the patients history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation 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 percent; and suggests that there may be a delay in the need for total knee replacement of around 2 years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be two-fold: mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection, has left the joint. Researchers provide 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 injections of the knees is medically necessary for this patient.Final Result: The reviewer determined that the requested injections 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.