Appeal type: Medical Necessity
Decision: Overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for both knees (3 for each knee). The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollees osteoarthritis of the knees. A review of the record indicates that the enrollee has been diagnosed with osteoarthritis of the knees. The enrollee reported having bilateral knee pain. Physical examination findings included left knee medial and lateral joint line tenderness. Left knee range of motion was 0-130 degrees. Left knee strength was rated as 5 of 5. Full range of motion was noted in the right knee with no tenderness to palpation. The enrollees provider has recommended Orthovisc injections for both knees (3 for each knee) for the enrollee.The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. The European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis treatment algorithm recommends intra-articular hyaluronic acid for management of knee osteoarthritis as second-line treatment in patients who remain symptomatic despite 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%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The clinical benefit of intraarticular hyaluronic acid on knee osteoarthritis may be 2-fold: mechanical viscosupplementation of the joint (allowing lubrication and shock absorption) and the re-establishment of joint homeostasis through induction of endogenous hyaluronic acid production, which continues long after the exogenous injection, has left the joint. 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 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. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. The records documented subjective, objective, and radiographic findings that support progressive disease despite extensive conservative treatments. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As such, I find the request for Orthovisc injections of the knees to be reasonable, appropriate and medically necessary.Final Result: The reviewer determined that the requested injections 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.