Euflexxa Injection 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 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.

Findings: The physician reviewer found that the enrollee has been diagnosed with right knee primary osteoarthritis. The enrollee reported right anterior knee pain and grinding, which limited her activities. Her prior treatment included activity modification and over-the-counter medications. Previous viscosupplementation resulted in long-term pain relief and an improved activity level. The patient underwent a platelet-rich plasma (PRP) injection and reported no substantial benefit. Her current medications included Cymbalta and Mobic. Right knee examination demonstrated patellofemoral tenderness to palpation, especially at the lateral facet. Normal strength and no instability were noted. Radiographs demonstrated mild to moderate lateral patellofemoral compartment joint space narrowing consistent with early to moderate patellofemoral osteoarthritis.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee requested authorization and coverage for Euflexxa injections. Findings: The physician reviewer found that the enrollee has a history of bilateral knee pain and instability of the patella as well as subluxations and pain rated between 0/10 and 8/10. Patella grind and patella apprehension are both positive. Imaging is negative on x-rays for joint space narrowing. An MRI showed an anterior cruciate ligament (ACL) tear on the right knee, mild chondromalacia and patella alta. An MRI of the left knee showed a degenerative meniscus tear and mild cartilage loss. Treatments for her patella instability include activity modification, and steroid injections. She reports this has helped her, as has her physical therapy treatments.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections for treatment of the enrollee’s knee pain. Findings: The physician reviewer found that The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. The medical evidence supports hyaluronic acid injections in the knee as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids.

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 Euflexxa Injection, then check the rights and deadlines that apply to your plan.