Osteoarthritis Of The Knee denials in California external review
In the California DMHC record, independent physician reviewers decided 783 published external-review cases involving osteoarthritis of the kneeand overturned the plan’s denial in 79.4%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
Most-fought treatments for osteoarthritis of the knee
| Treatment | Decisions | Overturned |
|---|---|---|
| Euflexxa Injection | 125 | 97.6% |
| Orthovisc Injections | 119 | 84.9% |
| Synvisc-one Injection | 87 | 92% |
| Monovisc Injections | 57 | 98.2% |
| Synvisc Injection | 45 | 86.7% |
| Supartz Injection | 38 | 73.7% |
| Durolane Injections | 33 | 100% |
| Hyaluronan Injections | 19 | 94.7% |
| Gel-one Injection | 15 | 100% |
| Euflexxa | 15 | 80% |
| Hyalgan Injections | 13 | 61.5% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 725 | 84.1% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 58 | 20.7% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Euflexxa injections for treatment of the enrollee’s chronic 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 and 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 bilateral Synvisc One injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s osteoarthritis of both knees.There is sufficient support in the medical literature for the requested medication in this clinical setting. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. A study concluded that hyaluronic acid is an effective 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.
Where the denial was upheld
Physician 1: The patient is a 54-year-old female who when seen in July 2005, had a four-month history of severe bilateral knee pain, right greater than left, and problems with knee locking without reported falls or trauma. She also complained of back pain, which began two to three months after the onset of the knee pain. There was medial joint line tenderness of the right knee and she had worn an unloader brace, which was breaking down and required a replacement. The patient had taken a number of medications including Valium, Baclofen, Norco, Kadian and Fentanyl and had Kenalog and Lidocaine injections into both knees. In August 2005 surgery with arthroscopy or knee replacement was discussed in the event that conservative management failed.
Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for cryoablation of the anterior femoral cutaneous nerve and infrapatellar branch of the saphenous nerve of the right knee. Findings: The physician reviewer found that While there is some support for the requested treatment modality for patients who have failed standard medical therapy, there is a paucity of controlled studies in current medical literature supporting this treatment as more beneficial than standard treatments.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this condition generally, not any individual case.
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 osteoarthritis of the knee, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY