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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral knee injections with Orthovisc. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.Findings: A study concluded that hyaluronic acid is an effective pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Another 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. Researchers 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. 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 bilateral knee pain that affects his work ability. Clinical examination findings have been documented and are consistent with reported bone-on-bone bilateral knee osteoarthritis. Reasonable conservative treatments, including nonsteroidal anti-inflammatory drugs, activity modification, and corticosteroid injections, have failed to provide adequate symptom relief. The records documented prior viscosupplementation injections were performed with approximately one year of pain reduction and functional improvement. 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 work ability, repeat viscosupplement injections are indicated. The evidence shows that 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. Therefore, bilateral knee Orthovisc injections have been demonstrated as medically necessary for treatment of the patients knee pain.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 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.