Osteoarthritis Of Both Knees: when insurers say no, reviewers often say yes

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Orthovisc injections in both knees. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Several studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents, to increase its effectiveness. Current medical guidelines indicate that the data on the safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Euflexxa injections, one a week for 3 weeks. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee’s osteoarthritis. A review of the records indicates that the enrollee is diagnosed with primary osteoarthritis of both knees, and is status post bilateral arthroscopic partial lateral Meniscectomy. Progress notes indicated the enrollee had presented with bilateral knee pain, and is unable to perform activities of daily living comfortably now due to her condition. The enrollee reported that past lubricant injections had provided pain relief lasting 6 months. The provider recommended bilateral knee Euflexxa injections, weekly, for 3 weeks.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for enrollment into the bariatric Options Program. The Health Plan has denied this request indicating that the requested service is not medically necessary for treatment of the enrollee’s morbid obesity and osteoarthritis of both knees. At issue in this case is whether the requested enrollment into a bariatric Options Program is medically necessary for treatment of the enrollee’s medical condition.Findings: The physician reviewer found that in order to justify participation in a bariatric program in general, one must show that they are consistently working and successfully implementing long-term dietary changes conducive to weight loss. Post-bariatric program and surgery results strongly depend on these habits.

These outcomes come from California’s external review program — an independent physician panel whose decision binds the insurer. Every state has an equivalent, and internal appeals succeed even more often. If your care for osteoarthritis of both knees was denied, the published record says the denial is worth fighting.