Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Knee Pain
Treatment: Hyaluron injection
The insurer denied the Hyaluron injection.
The determination is overturned.


The patient is diagnosed with unilateral primary osteoarthritis of the right knee and recommended for Hyaluronan injection. A progress report  reveals her presentation with knee pain. The pain had improved since the last visit, but the patient is still having pain. The current medication list includes Duexis. The patient uses icy hot ointment to alleviate the pain and also uses Tylenol as needed for the pain. The patient does not use nonsteroidal anti-inflammatory drugs (NSAIDs) due to a renal cyst. The provider reported that a right knee x-ray showed degenerative change in the lateral compartment. A right knee corticosteroid injection was performed. The provider stated that the patient has diclofenac gel which may be applied as directed.
The patient has been using cannabidiol [CBD] cream, but continued to have pain at the knee. The physical examination of the right knee revealed 15 degree () valgus deformity, pain in the lateral joint line, and crepitus on motion. There is a diagnosis of primary osteoarthritis with valgus deformity right knee. A right knee corticosteroid injection was performed. The provider indicated that the patient still wanted to pursue viscosupplementation. The provider reported that this would be helpful, particularly since she cannot take NSAIDs because of a renal condition. The provider discussed the possibility of eventual total knee replacement. The patient would like to avoid this.
At issue is the medical necessity of Hyaluronan injection.

The Hyaluronan injection is medically necessary. The provided documentation indicates that the patient has chronic right knee pain in the setting of osteoarthritis. The knee pain persists despite treatment with simple analgesics, nonpharmacological therapy that has included a home exercise program, and multiple corticosteroid injections. The patient wants to avoid total knee arthroplasty. The provider has recommended treatment with Hyaluronan injection. Hyaluronan injections are Food and Drug Administration (FDA) approved for the treatment of pain in osteoarthritis of the knee in patients who have not adequately responded to nonpharmacologic therapy and simple analgesics, so the request is for an FDA approved indication.
Additionally, there is an abundance of support in the medical literature for hyaluronan injections for pain in osteoarthritis of the knee. As noted in the referenced meta-analysis from Arthroscopy, hyaluronic acid is appropriate for treatment of patients with knee osteoarthritis. As noted in the 2020 level 1 meta-analysis from Knee Surgery, Sports Traumatology, Arthroscopy, viscosupplementation injection was the only treatment to surpass the MID (minimum important difference) for both pain and function outcomes when compared to other treatments, including corticosteroid and platelet rich plasma injections. As noted in the 2018 level 1 review article from the Journal of Bone and Joint Surgery, while many nonoperative treatments demonstrated significant improvements in pain, the greatest effect estimates were in intra-articular treatments, and the strongest current evidence supports clinically important and significant treatment effects of intra-articular hyaluronic acid formulations. As noted in the referenced article from Clinics in Sports Medicine, despite some debate between societies, a large number of recent studies have shown hyaluronic acid to be a viable treatment option in knee osteoarthritis, showing longer-term improvement in both pain and function. As noted in the 2021 referenced article from Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders, intra-articular hyaluronic acid injections are associated with delay to total knee arthroplasty.
Given the failure of first-line therapies, the request for Hyaluronan injection is consistent with the standard of care. Based on the available information, the requested health service/treatment of hyaluronan injection is medically necessary for this patient.