Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: The enrollee is requesting Synvisc One injections in both knees. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  The enrollee has a history of osteoarthritis of both knees with bilateral knee pain. Examination findings revealed evidence of medial femoral condylar tenderness, patellar grind, and radiographic evidence of tricompartmental osteoarthritis. The patient has tried and failed non-invasive treatment and has done well with viscosupplementation over the last several years. Viscosupplementation is noted to have reduced his pain level and the need for large doses of nonsteroidal anti-inflammatory drugs.  The Health Plan has denied the request for Synvisc injections in both knees as not medically necessary. At issue is whether the requested medication, Synvisc injections in both knees are medically necessary.This patient is not a candidate for total knee arthroplasties due to his age. He has been treated with various non-operative treatments and has derived substantial benefit from repeat injections of Synvisc One over the last several years. A study found that intra-articular hyaluronic acid provides a moderate symptomatic benefit to knee osteoarthritis patients without major safety concerns. The study noted that viscosupplementation may offer one of the best benefit-to-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. 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. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be two-fold: mechanical viscosupplementation of the joint allowing lubrication and shock absorption, as well as the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production. A systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis shows that the current highest level of evidence suggests that an intraarticular hyaluronic acid is a viable option for knee osteoarthritis. Moreover, improvements in knee pain and function can persist for up to 26 weeks. Based upon its efficacy and safety profile, the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. This patient has documented benefit from repeat viscosupplementation over several years. The current medical evidence suggests that additional injections are likely to provide similar results. As such, the requested Synvisc One injections of both knees are medically necessary for treatment of this patients knee osteoarthritis.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.