Knee Osteoarthritis denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that the patient has requested authorization and coverage for a Synvisc injection to the left knee. The Health Plan has denied the request indicating that the requested medication is not medically necessary.At issue, in this case, is whether the requested Synvisc injection is medically necessary for the treatment of the patient’s medical condition.According to researchers, intra-articular hyaluronic acid provides a moderate symptomatic benefit to patients with knee osteoarthritis without major safety concerns. In fact, viscosupplementation may offer one of the best benefit/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.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee’s knee pain. A review of the record indicates that the enrollee has been diagnosed with osteoarthritis, essential hypertension, and morbid obesity. A visit note dated 11/2/18, reported the enrollee presented with bilateral knee pain, right more than left. The provider reported previous magnetic resonance imaging of the right knee revealed significant diffuse meniscus tear of the medial meniscus; and chondromalacia to the medial compartment, mild to moderate chondromalacia to the patella and a partial tear of the anterior cruciate ligament (ACL).

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for (1) bilateral platelet-rich plasma injections (to both knees, (2) platelet-rich plasma injections to left knee, and (3) bilateral platelet-rich plasma injections every six months to both knees. Researchers report, “Among patients with symptomatic mild to moderate radiographic knee osteoarthritis, intra-articular injection of platelet-rich plasma, compared with injection of saline placebo, did not result in a significant difference in symptoms or joint structure at 12 months. These findings do not support use of platelet-rich plasma for the management of knee osteoarthritis.” Researchers explain that platelet-rich plasma works by delivering a supraphysiologic amount of growth factors and cytokines contained within platelets.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The parent of a patient has requested authorization and coverage for (1) immediate scheduling of a total knee replacement (TKR) for the right knee, or in the alternative, (2) an arthroscopic procedure for repair of tibia fracture, core decompression of marrow edema, preservation and debridement of anterior cruciate ligament and/or repair of the meniscus, and if so, (3) immediate scheduling of the arthroscopic procedure. The patient is requesting TKR surgery or arthroscopic surgery to be performed urgently with immediate scheduling. However, this is not supported as medically necessary as the patient was recommended to continue conservative measures examination, indicating that these conservative modalities have not been exhausted.

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 knee osteoarthritis, then check the rights and deadlines that apply to your plan.