Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Knee Pain
Treatment: intra-articular lidocaine in combination with corticosteroids
The insurer denied intra-articular lidocaine in combination with corticosteroids
The determination is overturned.

The patient has a history of bilateral knee pain. A progress report revealed presentation for bilateral knee pain. The patient reported much improvement following corticosteroid injections, but the symptoms of both knees had been slowly worsening. The symptoms were fairly significant. The patient had intermittent swelling with activity. The provider stated prior studies showed degenerative change of the knees. The physical examination of the bilateral knees revealed effusion, mild medial and lateral tenderness, and pain at terminal flexion. Bilateral knee diagnostic ultrasounds were performed with evidence of mild intra-articular  effusions with degenerative joint disease. There is an assessment of osteoarthritis of the knees, bilateral. Bilateral knee corticosteroid injections consisting of 1 cubic centimeter (cc) of Kenalog 40 milligrams (mg) and 9 cc of 1% lidocaine were performed.
A letter of medical necessity indicates that the patient presented with bilateral knee pain. The symptoms were present for approximately one year, and they were slowly worsening. There was a denial of an injury. The symptoms correlated with increasing activities, including using a rowing machine. The pain was worse with ambulation and improved with rest. There was pain with stairs and deep flexion. The pain was located in the posterior aspect of the knees. The pain was moderate in severity. There was associated mild intermittent swelling. The prior treatment included physical therapy and anti-inflammatories with little improvement. The patient also had Orthovisc injections and corticosteroid injections with improvement. The provider indicated that the patient was treated with an exercise program and with anti-inflammatories with continued symptoms. They noted corticosteroid injections are useful and can help with the symptoms by reducing inflammation and pain in the joint, and the services are medically necessary to assist the individual to achieve or maintain maximum functional capacity in performing daily activities.
At issue is whether intra-articular lidocaine in combination with corticosteroids is likely to be more beneficial than any standard treatment or treatments for the insured's life threatening or disabling condition or disease.

Yes. The provided documentation indicates the patient was seen with recurrent bilateral knee pain in the setting of osteoarthritis confirmed on imaging. He had persistent pain despite treatment with an exercise program and anti-inflammatory medications. Bilateral knee corticosteroid injections were performed. As noted in the referenced article from the Orthopedic Journal of Sports Medicine, intra-articular corticosteroid injections are a favored treatment for knee osteoarthritis. As noted in the referenced article from the Journal of Functional Morphology and Kinesiology, intra-articular corticosteroid injections are effective for short to medium-term treatment of joint pain in osteoarthritis of the knee. Per the referenced article from Clinics in Sports Medicine, corticosteroid injections are a mainstay of osteoarthritis treatments with studies showing that they provide short-term and can be used for osteoarthritis flares. Given the osteoarthritis flare, the performed corticosteroid injections were in accordance with accepted standards of practice. The alternatives to the injections included therapeutic exercise and anti-inflammatory medications which the patient had already failed. The treatment of intra-articular lidocaine in combination with corticosteroids was likely to be more beneficial than these failed standard treatments.