Monovisc Injections 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 Monovisc injection per knee for treatment of the enrollee’s 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 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 Nature of Statutory Criteria/Case Summary: The patient’s parent has requested authorization and coverage for Monovisc injection to the left knee. 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. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on the safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injections. The ERCI Institute’s Health Technology Assessment for Viscosupplementation for Treating Osteoarthritic Knee Pain concluded that evidence remains inconclusive on which patient populations are likely to benefit most from hyaluronic acid injections. Evaluation of eight systematic reviews and six randomized controlled trials suggests intra-articular hyaluronic acid injections may relieve osteoarthritic knee pain in some patients, but questions remain about the most effective formulations and whether hyaluronic acid injections should be combined with other agents to increase effectiveness.

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Monovisc injections to both knees. A study noted that currently, controversy persists in the medical community regarding the optimal therapies to treat patients with knee osteoarthritis. A variety of medications including non-steroidal anti-inflammatory drugs (NSAIDs) and opioids can cause severe side effects with limited benefits. Total knee arthroplasty has been associated with risks such as postoperative infections, the need for revisions, and chronic pain. Newer injectable therapies are gaining attention as alternatives to medications as less invasive alternatives with excellent side effect profiles when compared to joint replacement.

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 Monovisc Injections, then check the rights and deadlines that apply to your plan.