Hyaluronic Acid 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 Hyaluronic injections. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee has left knee osteoarthritis. A review of the record indicates that the enrollee has been diagnosed with left knee osteoarthritis. The enrollee reported having left knee pain and swelling. The enrollee is 9 months post-left knee surgery. The enrollee was noted to have been on high dose non-steroidal anti-inflammatory drugs (NSAIDs) for months and had received a left knee cortisone injection. The enrollee’s provider has recommended Hyaluronic injections.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for Monovisc injections in both knees for arthritis of both knees. She injured her knees nine years prior, resulting in a left anterior cruciate ligament tear, a left medial cruciate ligament tear, and a left medial meniscus tear. She received hyaluronic acid injections last year and the year before, with reported improvement in pain. She participates in physical therapy. She received cortisone injections earlier this year. She was re-evaluated by her orthopedist for a flare-up of bilateral anterior and medial knee pain. She complains of intermittent left knee shifting when walking down the stairs. She participated in physical therapy twice per month, a home exercise program five days per week, stationary biking twice per week, and aqua fitness once per week.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested hyaluronan injections for treatment of the enrollee’s hip pain. Findings: Three physician reviewers found that this patient is requesting authorization and coverage for hyaluronic acid injection for treatment of left hip pain attributed to osteoarthrosis. Viscosupplementation with hyaluronan is performed frequently for painful knee osteoarthritis, but the benefits are limited. The hyaluronan injection treatment proposed is approved by the Food and Drug Administration for treatment of painful osteoarthritis of the knee and injection in the hip is an off label usage. However, there have been very limited studies as to the superior efficacy of hyaluronic injections for treatment of hip pain related to hip osteoarthritis.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for viscosupplement/hyaluronic acid injections. The submitted documentation does not support the medical necessity of the requested medication. The evidence-based peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with severe osteoarthritis of the knee who have failed conservative treatment, including corticosteroid injections. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. In this case, the patient has been diagnosed with advanced osteoarthritis of the right knee. However, the patient recently completed physical therapy with improvement noted, and underwent a recent corticosteroid injection, with no documentation of inadequate response.

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