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

Nature of Statutory Criteria/Case Summary:The patient is a male with bilateral knee osteoarthritis. The patient had increasing pain in both knees secondary to his osteoarthritis. The patient desired to undergo another injection series with Supartz. He had continued swelling, giving way sensations, and pain. A bilateral knee examination documented good range of motion, crepitus with range of motion, medial and lateral joint line tenderness, an intra-articular effusion, no instability, and no obvious deformities. He was reporting 100% improvement with the injections to date. He had good range of motion with crepitus. One additional Supartz injection was recommended to the right knee. The patient has requested coverage for Supartz injections. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient. At issue is whether the requested Supartz injections are medically necessary for treatment of the patients medical condition. Hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to injection of intra-articular steroids. The medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for younger patients with pain that interferes with functional activities. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high-quality scientific evidence. This patient had worsening left knee pain with associated swelling and giving way. Examiner findings have been consistent with radiographic evidence of end-stage medial compartment osteoarthritis with mild varus deformity. He has failed to achieve adequate symptomatic relief with medications. Left knee Supartz injections were administered with reported excellent pain relief and improved ability to perform activities of daily living. Evidence-based literature supports the use of viscosupplementation injections for the treatment of pain in patients withosteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous excellent long-term response and to assist in delaying total knee replacement, repeat Supartz injections are indicated. Therefore, the requested Supartz injections are medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturnedCredentials/Qualifications: The 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 a similar medical condition.Findings:  The physician reviewer found that