Appeal type: Medical Necessity
Decision: Overturned

Findings:  The physician reviewer found that the enrollee has been diagnosed with right knee primary osteoarthritis. The enrollee reported right anterior knee pain and grinding, which limited her activities. Her prior treatment included activity modification and over-the-counter medications. Previous viscosupplementation resulted in long-term pain relief and an improved activity level. The patient underwent a platelet-rich plasma (PRP) injection and reported no substantial benefit. Her current medications included Cymbalta and Mobic. Right knee examination demonstrated patellofemoral tenderness to palpation, especially at the lateral facet. Normal strength and no instability were noted. Radiographs demonstrated mild to moderate lateral patellofemoral compartment joint space narrowing consistent with early to moderate patellofemoral osteoarthritis. A previous magnetic resonance imaging scan confirmed patellofemoral osteoarthritic changes. The patient has requested coverage for Euflexxa injections. The Health Plan denied this request and reported the requested services are not medically necessary for the treatment of this patient.  At issue in this case is whether the requested Euflexxa injections are medically necessary for treatment of the patients medical condition. The submitted documentation supports the medical necessity of the requested services. Researchers performed a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. The researchers reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months. Per the medical evidence, 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. This patient had increased right knee pain and grinding that limited her activities of daily living. She had failed to achieve adequate relief with activity modification, medications, and PRP injection. A previous Euflexxa injection provided significant long-term pain relief and improved her activity levels. Clinical examination findings are consistent with imaging evidence of early to moderate right knee osteoarthritis with patellofemoral joint space narrowing. Evidence-based 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. Due to the patients previous long-term pain relief and functional improvement, repeat Euflexxa injections are indicated. Therefore, the requested Euflexxa injections are medically necessary for the treatment of this patient. 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 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.