Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: This patient is a 55-year-old female with a diagnosis of osteoarthritis, hypertension and diabetes. A review of records documented the patient had a history of bilateral knee pain. The records noted constant moderate bilateral knee pain, right greater than left. Her pain was worse with motion and walking, and better with rest. The diagnosis was primary osteoarthritis of both knees. The patient had tried and failed conservative options, including corticosteroid injections and anti-inflammatory medication. The treatment plan recommended Supartz series. The patient has requested authorization and coverage for Supartz injections for both knees. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient. This denial is the subject of this appeal and determination.At issue is whether Supartz injections to both knees are medically necessary for treatment of the patients medical condition. Evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic severe knee osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to exercise, nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroid injections. Guidelines support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The medical literature suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients, but questions remain about the most effective formulations, which populations benefit most, and whether hyaluronic acid injections should be combined with other agents to increase effectiveness. This patient has a history of chronic bilateral knee pain, right greater than left. Functional limitations are noted in walking and daily activities. Clinical examination findings are consistent with radiographic evidence of moderate degenerative joint disease with decreased medial joint space and osteophyte formation. The patient has reportedly failed corticosteroid injections and oral anti-inflammatory medications. Evidence based medical guidelines support hyaluronic acid injections in the setting of significantly symptomatic severe osteoarthritis, which is documented in this case. Therefore, the requested Supartz injections to both knees are medically necessary for treatment of the patients medical condition. 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.