Appeal type: Medical Necessity
Decision: Upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees medical condition.Findings: Nationally recognized evidence based medical guidelines state that hyaluronic acid injections (Orthovisc) in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. If there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to administer another series. There is no maximum amount of injections established by high quality scientific evidence. However, while medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions including patella-femoral arthritis, chondromalacia patella, patella-femoral syndrome (kneecap pain), or osteochondritis dissecans. Peer reviewed literature generally supports the use of hyaluronic acid injections for chronic moderate symptomatic osteoarthritis of the knee but states that application in sports related chondropathy has yet to be fully assessed. The ideal indication in the knee seems to be moderate femorotibial osteoarthritis without swelling.This patient presents with complaints of bilateral knee pain, persistent swelling and limited range of motion. Clinical examination findings have been consistent with recent imaging evidence of right knee chondromalacia patella. Prior x-rays and MRI of the left knee did not reveal evidence of any medial or lateral compartment osteoarthritis. There is evidence of long term nonsteroidal anti-inflammatory drug use, corticosteroid injections to both knees, and prior Synvisc and Orthovisc injections. Records documented prior Orthovisc injections with no clear evidence of significant pain improvement, but reported pain relief to both knees. There is no clear evidence of moderate medial and/or lateral osteoarthritis in the submitted medical records. Evidence based medical guidelines and literature does not support the use of Orthovisc injections for patellofemoral osteoarthritis, or for mild femorotibial osteoarthritis. Therefore, in this patients case, Orthovisc has not been established as medically necessary for the treatment of this patients bilateral knee pain.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.