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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections in the right knee. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees osteoarthritis. A review of the record indicates that the enrollee has been diagnosed with osteoarthritis, gastroesophageal reflux disease, degenerative joint disease and peripheral vascular disease. A visit note reported the enrollee presented with right knee pain. The enrollee reported previous left knee viscosupplement injections provided excellent results and previous right knee cortisone injections did not work. The provider reported x-ray results of the right knee revealed moderately advanced osteoarthritis of the right knee and is recommending Euflexxa injections.At issue in this case is whether the requested Euflexxa injections in the right knee are medically necessary for treatment of the enrollees medical condition. The patient has advanced osteoarthritis of the right knee with recurrent pain that does not respond to corticosteroid injections. However, there was a history of excellent response to viscosupplementation in the past. A review of the recent literature reveals continued support for viscosupplementation for osteoarthritis of the knee as in this case. As evidenced by the history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. 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. Researchers in a systematic review of overlapping meta-analyses compare viscosupplementation with other nonoperative 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. The patient has failed treatment with non-steroidal anti-inflammatory drugs and corticosteroid injections. However, he benefitted from viscosupplementation in the past with excellent results. Therefore, the request for Euflexxa injections of the right knee is medically necessary.Final Result: The reviewer determined that the requested treatment is 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.