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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Orthovisc injections for the right knee due to osteoarthritis. Her treatment history includes arthroscopy; rest, ice, compress, and elevate (RICE); activity modification, and previous cortisone injections. She has also tried a brace and rehabilitation. She takes one Norco per day to help her sleep. She complains of pain and discomfort in the knee that has been persistent and somewhat progressive in nature. The soreness appears to have some mechanical characteristics with instability. However, mainly there is activity-related pain. Her walking distance has been directly limited. The enrollee received an intra-articular injection of Depo-Medrol and Marcaine without epinephrine into the right knee with no complications. There is continued evidence of pain and inflammation secondary to arthritis, refractory to treatment by multiple anti-inflammatories, steroid injections and rehabilitation exercises. The enrollees orthopedic surgeon has prescribed hyaluronic acid injections for her right knee. The enrollee indicates she has received injections for her left knee the last one and a half years, which have improved her mobility and lessened the pain in her left knee. She indicates aside from the injections, knee replacement is her only option. The enrollee's right knee has failed to improve with arthroscopic debridement or steroid injections. She is not yet a candidate for a total knee replacement. Therefore, viscosupplementation is the next logical step; especially since the use of viscosupplementation in her left knee has been successful. The medical literature indicates there was a review of a group of studies that evaluated pharmacological or medical device interventions for treating knee arthritis, and to assess the placebo effect on intra-articular injection therapies. The strongest evidence supports clinically important and significant treatment effects with intra-articular hyaluronic acid (HA) formulations between 1,500 and >6,000 kilodaltons (kDa). A study of elderly patients treated with knee arthroplasty (KA)n showed a longer time span between the diagnosis of osteoarthritis (OA) and surgical treatment with KA in those patients who had received intra-articular HA. The scientific literature support for the requested treatment, hyaluronic acid injection, including Orthovisc, for knee osteoarthritis is controversial. Although there is some debate between societies, a number of recent studies have shown hyaluronic acid to be a viable treatment option showing longer-term improvement in both pain and function in some cases. This enrollee has limited options and has reported improvement in left knee pain with this treatment. Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.