Gelsyn-3 Injection denials: what the review data shows

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for bilateral GelSyn-3 (hyaluronic) series knee injections.Evidence from randomized trials and current medical literature have revealed varied results as viscosupplementation may relieve some knee pain in individuals with osteoarthritis. However, the evidence concerning for which individuals viscosupplementation may benefit is unknown. In an effort to establish a more effective treatment, different studies have tried mixing hyaluronic acid with corticosteroids, platelet-rich plasma, and other agents. However, guidelines indicate that confirmatory evidence is limited and not conclusive. As such, research does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral Gelsyn-3 injections. 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. Professional study guidelines indicate that the data on the safety and efficacy of viscosupplementation remain inconclusive. As such, the study does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees.

These are outcomes from California’s external review program — an independent physician panel that binds the insurer. Every state has an equivalent process, and internal appeals succeed even more often. Cite the outcome record for Gelsyn-3 Injectionwhen you appeal: reviewers routinely find that denials like yours didn’t hold up.