Appeal type: Medical necessity
Decision: Upheld

Diagnosis: osteoarthritis

Treatment: procedure code - J7324 (Hyaluronan - Orthovisc injections for joint problems

The insurer is denied coverage for procedure code - J7324 (Hyaluronan - Orthovisc injections for joint problems.

The denial is upheld. 

This female patient has a history of severe osteoarthritis.

In 2013, the AAOS [American Academy of Orthopedic Surgeons] following an extensive review of therapies for osteoarthritis of the knee concluded that "We cannot recommend studies both societies researched, a large placebo efect was seen which limited the scope of the data." using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Strong". In their orthoinfo in 2015 they stated that "The effectiveness of viscosupplementation in treating arthritis is not clear. It has been proposed that viscosupplementation is most effective if the arthritis is in its early stages (mild to moderate), but more research is needed to support this. Research in viscosupplementation and its long-term effects continues."
In 2015, Jevsevar et al. concluded, "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of HA [hyaluronic acid] treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials."          
Most recently, in a discussion of the role of intraarticular hyaluronic acid Up to Date stated "The use of any intraarticular hyaluronic acid (HA) formulation is not widely recommended and not routinely used in our practice due to the lack of robust evidence demonstrating clinically relevant benefits over intraarticular placebo [4,6,9,64]. There has been a longstanding debate and conflicting data across trials and meta-analyses regarding the benefit of viscosupplementation (ie, intraarticular HA) for the treatment of symptomatic knee OA [osteoarthritis]. The evidence from large, double-blinded, and high-quality trials indicates that intraarticular HA has a small, clinically irrelevant benefit over intraarticular placebo [75-77]. Moreover, intraarticular HA is associated with high costs and potential side effects such as pain flare-ups and joint infection, although the latter is a rare complication."     
Finally,  the  ACR [American Colloge of Radiology] guidelines state "In prior systematic reviews, apparent benefits of hyaluronic acid injections in OA have been reported. These reviews have not, however, taken into account the risk of bias of the individual primary studies. Our review showed that benefit was restricted to the studies with higher risk of bias: when limited to trials with low risk of bias, meta-analysis has shown that the effect size of hyaluronic acid injections compared to saline injections approaches zero (37). The finding that best evidence fails to establish a benefit, and that harm may be associated with these injections, motivated the recommendation against use of this treatment."                           

The health plan did act reasonably with sound medical judgment, and in the best interest of the patient.

The carrier's denial of coverage for the procedure code - J7324 (Hyaluronan - Orthovisc injections for joint problems is upheld.  The medical necessity is not substantiated.