Hyaluronan Injections denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for hyaluronan injections for osteoarthritis of both knees. Symptoms include pain, swelling, clicking, and painful range of motion. She has difficulty walking and using the stairs. Her symptoms are exacerbated by kneeling and squatting. Past treatments include bracing, icing, physical therapy, non-steroidal anti-inflammatories, cortisone injections, and a knee aspiration. A magnetic resonance imaging scan of the left knee showed osteoarthritis and a lateral meniscal tear. She was assessed by two different orthopedists, one who recommended surgery and one who did not. The enrollee obtained a third opinion. This orthopedist discussed treatment options, including hyaluronan injections, arthroscopic surgery, and joint replacement.

Nature of Statutory Criteria/Case Summary: The patient has been diagnosed with osteoarthritis of both knees. The patient reported bilateral knee pain. Physical examination findings included tenderness over the right knee medial joint line. Patellar grind tests were positive in bilateral knees. The patient has previously been treated with cortisone injections and physical therapy, with minimal improvement. The provider noted that the previous hyaluronic acid injections provided good results for the patient. The patient has requested authorization and coverage for Hyaluronan (Euflexxa) injections (J7323) in both knees. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for hyaluronan/derivative Euflexxa IA injection per dose for treatment of the enrollee’s hip pain. Findings: The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. Piccirilli and colleagues performed a systematic review and meta-analysis regarding hyaluronic acid (HA) injections in hip disorders. The authors concluded that there is a lack of standardization of HA injections for hip conditions. Their results suggested that this is the best conservative therapy before surgery and it can act on pain relief and function. However, the authors noted “there is no evidence to prove its ability to modify the morphological structure of the pathological hip and the natural history of the disease.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections for the right knee. According to the current practice guidelines for knee arthritis from the American Academy of Orthopaedic Surgeons (AAOS), hyaluronic acid is no longer a recommended treatment for knee arthritis. Fourteen hyaluronic acid (HA) studies were analyzed, and it was noted that a few individual trials found statistically significant treatment effects, but when combined in a meta-analysis, the evidence did not meet the minimum clinically important improvement (MCII) thresholds. It was conceded that there might be some subgroup of responders who could be helped by HA, but that subgroup has not yet been identified. In this case, there is no rationale presented in the submitted clinical documentation to support an approach that is contrary to AAOS 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 Hyaluronan Injections, then check the rights and deadlines that apply to your plan.