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

Findings:  The physician reviewer found that the patient has requested authorization and coverage for a Synvisc injection to the left knee. The Health Plan has denied the request indicating that the requested medication is not medically necessary.At issue, in this case, is whether the requested Synvisc injection is medically necessary for the treatment of the patients medical condition.According to researchers, intra-articular hyaluronic acid provides a moderate symptomatic benefit to patients with knee osteoarthritis without major safety concerns. In fact, viscosupplementation may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis symptoms, the overall gain in quality of life and substantial delay in time to total knee replacement. Research showed that treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as a second-line treatment in patients who remain symptomatic, despite the use of non-steroidal anti-inflammatory drugs. This recommendation is based upon accumulating evidence that intraarticular hyaluronic acid provides a significant benefit in knee osteoarthritis. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular 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 percent, and suggests that there may be a delay in the need for total knee replacement of around two years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be two-fold: (1) mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and (2) the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection has left the joint. Another research completed a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. This review showed that the current highest level of evidence suggests that intraarticular 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. Intra-articular hyaluronic acid has a good safety profile and its use should be considered in patients with knee osteoarthritis. The medical records document subjective, objective, and radiographic imaging findings consistent with osteoarthritis of the knee. The patient has failed conservative treatment, including cortisone injections. The recent literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Therefore, the Synvisc injection to the left knee is medically necessary.Final Result: The reviewer determined that the requested medication 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.