Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Patellofemoral Osteoarthritis; Knee Pain. 
Treatment:  Hyaluronan Injections. 

The insurer denied the Hyaluronan Injections. 
The denial is upheld. 

The patient is a female. This is for an appeal for hyaluronic injections. There is an appeal letter from the patient. The injections were not approved because it did not meet the standard of care for the treatment of joint problems. It was denied is not medically necessary. 

The patient is a female who presented for a postop visit following left knee arthroscopy.  The patient reported intermittent left knee pain with flexion and extension of the knee.  The patient reported knee locking up when getting from a seated position and walking.  She was wearing a brace for support and taking Motrin when necessary. Her pain scale was four to ten. The patient's exam showed the sutures were left in place. There was moderate effusion and tenderness to palpation of the medial joint line. There was tenderness to palpation of the lateral joint line. Her range of motion was zero to 20 degrees. X-ray of the left knee showed adequate medial and lateral joint space and alignment. There was no fracture or dislocation. 

The patient has a body mass index (BMI) of 27.81. The patient is status post arthroscopic meniscectomy, chondroplasty, synovectomy aspiration and injection. She has patellofemoral osteoarthritis and may require patellofemoral arthroplasty for definitive treatment. The request is for left knee hyaluronic acid injections to address residual patellofemoral osteoarthritis post-arthroscopy. The patient will continue topical anti-inflammatories as needed for pain. She was referred to physical therapy. A magnetic resonance image (MRI) shows mild early osteoarthritis in the patellofemoral compartment. 

The proposed treatment is not medically necessary. 
The request is for an injection for the knee. 

Per the health plan policy, document number: ING-GC-006: "Requests for hyaluronan injections for all joints including but not limited to the knee, ankle, shoulder, hip, temporomandibular joint, or thumb may not be approved." 

Based on current orthopedic and reviewed orthopedic literature, there is a lack of evidence showing improved patient outcomes and efficacy of viscosupplementation injections for osteoarthritis of the patellofemoral joint.  Viscosupplementation injections are not currently recommended by the American Academy of Orthopedic Surgeons and the American College of Rheumatology for osteoarthritis of the knee. 

The health plan acted reasonably based on the current orthopedic literature and specialty siding recommendations. 

From the American Academy of Orthopedic Surgeons (AAOS) Clinical Policy Guideline (CPG) Osteoarthritis of the Knee: "Hyaluronic acid intra-articular injection(s) is not recommended for routine use in the treatment of symptomatic osteoarthritis of the knee." 

From the American College of Rheumatology Clinical Practice Guidelines (CPG) Osteoarthritis Guidelines: "Intraarticular hyaluronic acid injections are conditionally recommended against in patients with knee and/or first CMC (carpometacarpal) joint OA (osteoarthritis) and strongly recommended against in patients with hip OA (osteoarthritis)." 

From Journal of Bone and Joint Surgery (JBJS) Systematic Review: "Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of HA (hyaluronic) treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials." 

Yes, the health plan acted reasonably, with sound medical judgment and in the best interest of the patient.