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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Orthovisc injections. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees right knee pain.Findings: There is sufficient support in the medical literature for the requested injections in this clinical setting. A study concluded that hyaluronic acid is an effective pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. The study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Another study concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay total knee replacement in patients with knee osteoarthritis who failed conservative treatment was found efficacious during a 54-month follow up period. The literature also states that hyaluronic acid injections in the knee are recommended as possible options for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. This patient presents with recurrent right knee pain that affects his ambulatory ability. Clinical examination findings have been documented consistent with x-ray findings of osteoarthritis. Reasonable conservative treatment, including nonsteroidal anti-inflammatory drugs, activity modification, and corticosteroid injections has been documented. Conservative therapy has failed to provide adequate symptom relief. Records documented prior viscosupplementation had been performed on two occasions with six months of pain reduction and functional benefit. Evidence based medical peer reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis 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 response and to assist in delaying total knee replacement and improving performance of activities of daily living, repeat viscosupplement injections are medically indicated. Therefore, the requested Orthovisc injections have been demonstrated as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested injections are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/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.