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

Nature of Statutory Criteria/Case Summary: The patient with a diagnosis of chronic low back, bilateral hip, and bilateral shoulder pain. The patient rated pain a 7 out of 10 without medications. She was taking Vicodin and ibuprofen without relief. She reported that she was having a lot of bilateral shoulder pain, alternating between the right and left, with an associated cracking sound. She reported pain and difficulty performing activities of daily living. She reported that her hip pain was constant and making it difficult for her to walk, stand, sit or move. She had physical therapy but felt like it made the pain worse. Her symptoms had improved after a corticosteroid injection into the hips. Bilateral shoulder and hip examinations were not documented. Magnetic resonance imaging (MRI) of the shoulders showed bilateral osteoarthritis and rotator cuff tendinosis with a right shoulder labral tear. Hyalgan injections were performed to the left hip.  The patient presented with 7 out of 10 for low back pain, bilateral hip pain, and bilateral shoulder pain without medications. She reported that the hyaluronan injections were helpful and made it 30% better, but she was still in pain and any movement increased her pain. Right shoulder examination documented pain and clicking with right shoulder external rotation and active abduction, passive elevation caused crepitus but little pain, and there was pain with extension into the anterior shoulder. The patients diagnoses included primary osteoarthritis of the left hip and bilateral shoulders. The treatment plan indicated that the patient might need corticosteroid or hyaluronate injections into the left hip and right hip, and noted consideration of right shoulder hyaluronate injections. The patient has requested authorization and coverage for Hyalgan injections for both shoulders. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. At issue in this case is whether the requested Hyalgan injections for both shoulders are medically necessary for treatment of the patients medical condition.Viscosupplementation has been most frequently studied in osteoarthritis of the knee. There is a paucity of well-designed studies in other joints to be able to confidently conclude benefit. Researchers concluded that a numeric advantage, but without statistical significance, was found for hyaluronic acid intent-to-treat patients with glenohumeral osteoarthritis. Although data for a subset of hyaluronic acid patients without concomitant pathologies reached statistical significance, additional randomized trials are needed to confirm the clinical implication of this outcome. In this case, the patient presented with 7 out of 10 left hip pain and right shoulder pain with associated clicking. Functional limitations were interfering with activities of daily living. She reported temporary improvement with prior corticosteroid injection to the hip and no benefit with physical therapy. She had some relief with medications. Right shoulder examination documented painful range of motion with clicking. She has been diagnosed with left hip and bilateral shoulder osteoarthritis. Hyalgan injections were recommended. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of Hyalgan injections for the shoulders. Therefore, the requested Hyalgan injections to both shoulders are not medically necessary for the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.