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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Monovisc injections in both knees for arthritis of both knees. She injured her knees nine years prior, resulting in a left anterior cruciate ligament tear, a left medial cruciate ligament tear, and a left medial meniscus tear. She received hyaluronic acid injections last year and the year before, with reported improvement in pain. She participates in physical therapy. She received cortisone injections earlier this year. She was re-evaluated by her orthopedist for a flare-up of bilateral anterior and medial knee pain. She complains of intermittent left knee shifting when walking down the stairs. She participated in physical therapy twice per month, a home exercise program five days per week, stationary biking twice per week, and aqua fitness once per week. X-rays show left and right medial joint space narrowing and osteophyte formation; right worse than left, and right and left patellar osteophytes with left worse than right. Examination shows quadriceps weakness and right knee tenderness, with trace effusion of the left knee. The plan was for the enrollee to continue physical therapy and receive hyaluronic acid injections in both knees. The enrollee indicates the injections work for several months to keep her knee pain at a minimum. She is concerned that without the injections the condition of her knees will worsen and she will have to consider knee replacement surgery. This enrollees range of motion is 0-130 degrees, with bilateral knee joint line tenderness. X-rays show bilateral multi-compartment degenerative joint disease. The enrollee is not yet a surgical candidate for total knee replacement. Hyaluronic acid has been used twice in the past with a good temporary pain relief response; therefore, a third injection is clinically indicated. Literature describes hyaluronic acid as a treatment for osteoarthritis individuals who have already been treated with pain relievers and other treatments that did not work well. Literature notes clinical studies, which demonstrate hyaluronic acid is effective for osteoarthritis, especially for the knee. It improves both pain and function, while avoiding anti-inflammatory treatment and corticosteroids. Individuals usually tolerate the injection well and the rate of complications is low. Literature indicates the clinical benefit of hyaluronic acid is underestimated when analyzed with conventional meta-analytic techniques. When accounting for control group effects, it can be reasonably concluded that hyaluronic acid may be effective for  many persons with knee osteoarthritis.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.