Appeal type: Medical necessity
Decision: Overturned

Diagnosis: Osteoarthritis. 
Treatment: Hyaluronic Acid (Orthovisc) 15MG/ML Inj. 

The insurer denied the Hyaluronic Acid (Orthovisc) 15MG/ML Inj. 
The denial is overturned. 

The patient is a female. She has had problems associated with a diagnosis of osteoarthritis.  MR (magnetic resonance) imaging of the knee described a complete tear of the medial meniscus with marked degeneration.  Focal full-thickness chondral loss over the central weightbearing portion of the medial femoral condyle medial tibial plateau appreciable.  Marginal osteophyte was noted with findings that were suggestive be worsened from the prior exam.  Articular surface cartilage maintained lateral compartment with high-grade full-thickness chondral loss involving the patellofemoral articulation.  Focal bone marrow edema in the medial tibial plateau was suggested. 

Physical therapy indicated pain with activity 2/10, slight pain. The patient was able tolerate squatting with maximal difficulty tolerating standing less than 30 minutes.  Ambulation noted with the patient able to walk without significant difficulties less than 30 minutes.  Improvements in lower extremity strength are noted.  A degree of pain with prolonged weightbearing squatting and bending was described.  Continued therapy was recommended. 

Clinical evaluation performed noted the issues associated with a meniscal tear, right knee sprain.  This individual had undergone knee arthroscopy.  Localized osteoarthritis was also described.  The patient was utilizing nortriptyline at bedtime oxycodone 5/325 for pain.  Clinical exam described negative McMurray test.  Positive patellofemoral crepitus with crepitation noted over the medial lateral femoral condyles.  No instability was described.  Two views of the right knee described moderate to early severe degenerative changes.  Viscous supplementation was recommended for treatment of the condition. 

A note indicates the patient had undergone two prior surgeries.  Therapy for two months was undertaken thereafter.  Because of underlying knee arthritis viscous supplementation had been requested.  This was considered as a means of preventing the possibility of total knee arthroplasty.  Cortisone injection had been performed without any benefit.  Symptoms were reported to have been worsening with no benefits from anti-inflammatory medications activity modification or home exercises.

New York State external appeal application indicates that this individual had received viscous supplementation the past with significant relief. 

Yes, the requested Hyaluronic Acid is medically necessary. 

The proposed treatment is medically reasonable and necessary because of ongoing pain issues and limitations in function, as noted within the documentation and within the appeal clinical information provided. 

In denial of viscosupplementation, the health plan had acted reasonably, but yet not clearly in the best interest of the patient, given the considerations for viscosupplementation detailed within the peer-reviewed literature. 

In considering viscosupplementation for knee osteoarthritis the Journal of Clinical Orthopedic Trauma, noted in conclusion: "MRI [magnetic resonance imaging] results have confirmed the possibility to employ 7T [7 Tesla] magnets to evaluate early changes in cartilage structure in vivo. HA [hyaluronic acid] VS [viscosupplementation] has provided good clinical outcomes and an improvement in the global assessment of the knee joint, but it doesn't seem to significantly modify the cartilage over the time."  Noted is that the changes noted within the cartilage and reasonable clinical outcomes but did not modified the cartilage over time. 

Within the Journal Pain Research August it describes Visco supplementation stating the following: "Our results indicate that multiple courses of treatment are associated with greater improvements than a single course of VS [viscosupplementation], and that these improvements continue through four courses of treatment." 

Clinical Rheumatology, June noted the efficacy of Visco supplementation which stated the following: "While further research will inform the medical field regarding viscosupplementation treatment options for knee OA [osteoarthritis], these findings show that hylan G-F 20 (hyaluronic acid) at both frequencies/dosages are efficacious and generally well tolerated for long-term use." 

Given these recent articles within the peer-reviewed literature, there is a support for the use of such injections as reasonable to treat osteoarthritis of the knee.  Particularly in this young individual with changes noted over the patellofemoral and medial joints, MR (magnetic resonance) imaging supporting degenerative changes cartilage loss along with osteophyte formation uses such injection are reasonable given that totally arthroplasty would not be considered for this young individual the current time.  There was also report that this had been beneficial in the past for this individual for which would be medically reasonable for medical necessity. 

The information that has provided within the documentation reviewed indicate that the utilization of viscosupplementation would not be considered unproven. There is a reasonable medical consideration for the injections for this individual which should be provided as an ongoing treatment for knee osteoarthritis.