Misc Drugs denials: what the review data shows

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Durolane injection to the right knee. Evidence from randomized trials and current medical literature has revealed varied results, as viscosupplementation may relieve some knee pain in individuals with osteoarthritis. However, the evidence concerning which individuals may benefit from viscosupplementation 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 from the leading experts indicate that confirmatory evidence is limited and not conclusive. As such, the leading experts do not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees.

Findings: The physician reviewer found that a patient has requested authorization and coverage for Durolane injections in both knees. Evidence from systematic reviews and randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data have not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on the safety and efficacy of viscosupplementation remain inconclusive, and it is not recommended as routine treatment. Viscosupplementation is generally reserved for patients with a history of lasting benefit from prior injections or when remaining options are limited.

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 Misc Drugswhen you appeal: reviewers routinely find that denials like yours didn’t hold up.