Bilateral Knee Osteoarthritis denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monovisc injection per knee for treatment of the enrollee’s bilateral knee pain. Findings: The physician reviewer found that evidence based medical peer reviewed literature supports the use of repeat viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Bannuru colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections to the knees. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee’s bilateral knee osteoarthritis. A review of the record indicates that the enrollee has been diagnosed with bilateral knee osteoarthritis. In a report, the enrollee’s provider noted knee pain. The provider noted prior viscosupplementation provided 4 to 4.5 months of significant improvement. The enrollee’s provider has recommended Orthovisc injections to the knees for the enrollee.Four prior series of injections resulted in significant benefit to the enrollee.

Where the denial was upheld

Findings: The physician reviewer found that An enrollee has requested authorization and coverage for platelet-rich plasma (PRP) injections administered to bilateral knees. The records provided for review document that this patient has been treated for bilateral knee osteoarthritis. The patient has previously undergone conservative treatment including physical therapy, physician-directed home exercise, NSAIDs, cortisone injection, and viscosupplementation injection. During a telehealth visit with the provider, the patient noted bilateral knee pain. The patient was last seen over two years ago at which time had completed bilateral knee PRP injections, which provided relief. However, detailed documentation is not evident to support the requested PRP injections administered to bilateral knees as likely to be more effective than standard available alternatives.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One bilateral knee injections. This patient is being treated for bilateral knee osteoarthritis. The provider noted that the patient’s pain is getting progressively worse, and it is associated with mechanical symptoms and locking. A request was made for bilateral Synvisc One injections. The U.S. Food and Drug Administration (FDA) approved viscosupplementation as a conservative technique for the management of osteoarthritis. There is adequate support for the use of viscosupplementation injections for knee osteoarthritis. The use of exogenous intra-articular viscosupplementation is based on the concept that it may restore the viscoelastic properties of the osteoarthritic joint with the added benefit of potential analgesic and anti-inflammatory properties.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving bilateral knee osteoarthritis, then check the rights and deadlines that apply to your plan.