Appeal type: Medical Necessity
Decision: Insurer Denial Upheld

Summary Reviewer

The patient is a 41-year-old female with an onset of right knee pain on 7/04/16 due to a fall.  On 7/06/16, right knee x-ray documented minimal degenerative changes. Findings documented the joint spaces were well-maintained, with sharpening of the posterior superior patellar margin suggesting early degenerative change.  On 7/20/16, right knee magnetic resonance imaging (MRI) documented chondromalacia patella with mild diffuse articular cartilage loss of the patellar apex, medial patella facet, and medial trochlea. There was focal inflammation of the suprapatellar fat.  On 12/19/16, the records noted persistent anterior knee pain with associated swelling. Conservative treatment had included physical therapy and corticosteroid injection with temporary relief. Right knee examination documented retropatellar tenderness, range of motion 0 to 120 degrees with patellofemoral crepitation, no instability, and negative meniscal signs. Review of the prior MRI revealed chondromalacia patella with a mild diffuse cartilage loss and focal inflammation in the suprapatellar fat pad. The diagnosis was chondromalacia patella, right knee, and rule-out inflammatory arthritis. She had significant anterior knee pain likely related to chondromalacia. There was evidence of synovial inflammation, and rheumatology consultation was recommended for further evaluation. On 1/30/17, second opinion orthopedic report cited persistent right knee pain. The diagnosis was right knee patellofemoral chondromalacia status post fall. She had previously undergone treatment, including medical management, physical therapy, and corticosteroid injection. She had not experienced lasting improvement with treatment to date. The treatment plan recommended a viscosupplementation injection series. The patient has requested coverage for Supartz FX 25 mg/2.5 ml syringe 10 mg. The Health Insurer has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.  This denial is the subject of this appeal and determination.  The submitted documentation fails to demonstrate the medical necessity of the requested services.  Evidence-based medical guidelines state that hyaluronic acid injections in the knee, such as Supartz, are recommended as a possible option for severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments, to potentially delay total knee replacement. There is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patella-femoral syndrome (kneecap pain), or osteochondritis dissecans. This patient presents with persistent right anterior knee pain with swelling. Functional difficulty was reported in activities of daily living and work activities. Clinical examination findings were consistent with imaging evidence of right knee chondromalacia patella. Conservative treatment has included medications, activity modification, physical therapy, and corticosteroid injection, without sustained improvement. The current medical guidelines and peer-reviewed literature does not support the use of Supartz injections for a diagnosis of chondromalacia patella or patellofemoral arthritis since the effectiveness of hyaluronic acid injections for these indications has not been established. Therefore, the requested Supartz FX 25 mg/2.5 ml syringe 10 mg is not medically indicated for the treatment of this patient. Therefore, the requested services are not medically necessary for treatment of the patients medical condition. The Health Insurers denial should be upheld.