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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Hyaluronic injections. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee has left knee osteoarthritis. A review of the record indicates that the enrollee has been diagnosed with left knee osteoarthritis. The enrollee reported having left knee pain and swelling. The enrollee is 9 months post-left knee surgery. The enrollee was noted to have been on high dose non-steroidal anti-inflammatory drugs (NSAIDs) for months and had received a left knee cortisone injection. The enrollees provider has recommended Hyaluronic injections. A review of the recent literature with regard to use of vicsosupplementation for management of osteoarthritis of the knees indicated that the current literature continues to support the use of vicsosupplementation for osteoarthritis of the knees. This is particularly important in this case due to the relatively young age of the patient, harmful effects of frequent corticosteroid injections, involvement of only one compartment, and inability to tolerate NSAIDs due to gastritis. The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intra-articular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intra-articular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long lasting as compared with intra-articular corticosteroids. Evidence from real-life studies of repeat courses of intra-articular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The clinical benefit of intra-articular hyaluronic acid on knee osteoarthritis may be allowing lubrication and shock absorption and the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection, has left the joint. Researchers provided a systematic review of overlapping meta-analyses comparing vicsosupplementation with other non-operative treatment modalities for knee osteoarthritis. This shows that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Its use results in improvements in knee pain and function that can persist for up to 26 weeks. Vicsosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. As such, I find the request for Hyaluronan (Orthovisc) injections of the left knee to be reasonable, appropriate and medically necessary.Final Result: The reviewer determined that the requested treatment is 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.