Durolane Injections denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient is diagnosed with osteoarthritis of the left knee. The patient reported lateral left knee pain; the provider noted an MRI revealed evidence of degenerative arthritis of the left knee lateral compartment and a large defect of the anterior horn of the lateral meniscus. The provider noted a previous left knee steroid injection, administered it, and did not result in any improvement. The provider noted the patient had also been treated with other conservative treatments including acetaminophen, acupuncture, chiropractic treatment, physical therapy, and activity modification without substantial improvement. The physical examination revealed an antalgic gait when getting up from a seated position, and slight limitation of knee flexion. The provider recommended viscosupplementation with Durolane to the left knee.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Durolane injections into 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. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) 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.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for Durolane injection of the right knee. The enrollee has osteoarthritis of the right knee. Her physician reports she has tried and failed various treatments, including Supartz, Kenalog, and naproxen sodium. She has pain going up and down stairs. She is requesting Durolane (hyaluronic acid) injections to the right knee. The enrollee’s physician states the goal of treatment with Durolane is to decrease pain, maintain or improve joint movement, and limit the loss of joint function. The literature summarizing the hyaluronic acid injections, such as Durolane, is well documented in the American Academy of Orthopaedic Surgery guidelines.

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 Durolane Injections, then check the rights and deadlines that apply to your plan.