Orthovisc Injections denials in California external review
In the California DMHC record, independent physician reviewers decided 223 published external-review cases involving Orthovisc Injectionsand overturned the plan’s denial in 76.7%. That is a historical result among cases that reached this program, not a forecast for an individual appeal.
By condition
| Condition | Decisions | Overturned |
|---|---|---|
| Osteoarthritis Of The Knee | 119 | 84.9% |
| Knee Osteoarthritis | 51 | 58.8% |
| Osteoarthritis | 15 | 73.3% |
What the insurer actually argued
| Reason given | Decisions | Overturned |
|---|---|---|
Medical Necessity The plan said the care wasn’t medically necessary. The most common fight, and the most winnable. | 205 | 81.5% |
Experimental/Investigational The plan called the treatment unproven. These turn on published evidence, so the appeal is a literature argument. | 18 | 22.2% |
What the reviewers wrote
Where the denial was overturned
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for both knees (3 for each knee). The Health Plan has denied this request indicating that the requested procedures are not medically necessary for treatment of the enrollee’s osteoarthritis of the knees. A review of the record indicates that the enrollee has been diagnosed with osteoarthritis of the knees. The enrollee reported having bilateral knee pain. Physical examination findings included left knee medial and lateral joint line tenderness. Left knee range of motion was 0-130 degrees. Left knee strength was rated as 5 of 5. Full range of motion was noted in the right knee with no tenderness to palpation.
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections to the knees. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollee’s bilateral knee osteoarthritis. A review of the record indicates that the enrollee has been diagnosed with bilateral knee osteoarthritis. In a report, the enrollee’s provider noted knee pain. The provider noted prior viscosupplementation provided 4 to 4.5 months of significant improvement. The enrollee’s provider has recommended Orthovisc injections to the knees for the enrollee.Four prior series of injections resulted in significant benefit to the enrollee.
Where the denial was upheld
Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections to the left shoulder, once a week for four weeks. The patient was being treated for primary localized osteoarthritis of the shoulder. The patient underwent a left shoulder arthroscopy. The patient reported pain and discomfort at the anterior aspect of the left shoulder due to arthritic changes. The patient attempted treatment with physical therapy exercises without success. Upon physical examination, the medical records indicated that the left shoulder demonstrated near normal range of motion with improved rotator cuff strength. The provider recommended a hyaluronic acid injection series to treat the arthritic changes seen in the operative site in the left shoulder.
Findings: The physician reviewer found that the patient has history of right knee osteoarthritis who is requesting reimbursement for Orthovisc injections. In the medical literature, researchers 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. All treatments except acetaminophen showed clinically significant improvement from baseline pain. In addition, another research reported that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis, which failed conservative treatment, was efficacious during a 54-month follow-up period.
Figures and quotations on this page come from 42,749 published decisions in the California DMHC Independent Medical Review dataset. These are California external-review outcomes. Other state and federal programs have different eligibility rules, processes, and current availability; the rates here do not transfer to those programs or predict an individual result. Excerpts are quoted verbatim from the public record and describe this treatment generally, not any individual case.
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 Injections, then check the rights and deadlines that apply to your plan.
SOURCE: CALIFORNIA DMHC INDEPENDENT MEDICAL REVIEW OUTCOMES (CHHS OPEN DATA) · AGGREGATES + DEIDENTIFIED DECISION EXCERPTS/REFERENCE IDS · METHODOLOGY