Orthovisc 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 bilateral knee injections with Orthovisc. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s medical condition.Findings: A study concluded that hyaluronic acid is an effective pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Orthovisc three (syringes) 2 mL each. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient’s unilateral primary osteoarthritis, left knee. The submitted documentation supports the medical necessity of the requested medication. There is significant evidence supporting the requested medication in the presence of unilateral primary osteoarthritis of the knees with failed non-operative treatment, and in the presence of patients who have shown significant benefit from prior injections.

Where the denial was upheld

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for the injection, Orthovisc, for the right knee for a diagnosis of primary osteoarthritis. An MRI revealed chondromalacia patella. She has grinding in both knees. She underwent right knee surgery for a meniscus tear and cyst. She has previously completed an Orthovisc series and reported good results. She contacted her orthopedic surgeon’s office reporting a return of right knee pain. Imaging studies of the right knee show mild patellofemoral osteoarthritis. She denies injuries or major changes since her last visit. She wishes to postpone knee replacement surgery for as long as possible. The orthopedic surgeon has ordered an Orthovisc series. The record indicates the patient has a history of mild osteoarthritis of the knees; most pronounced in the patellofemoral compartment.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee’s medical condition.Findings: Nationally recognized evidence based medical guidelines state that hyaluronic acid injections (Orthovisc) in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature support hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities.

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