Supartz Injection denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary:The patient is a male with bilateral knee osteoarthritis. The patient had increasing pain in both knees secondary to his osteoarthritis. The patient desired to undergo another injection series with Supartz. He had continued swelling, giving way sensations, and pain. A bilateral knee examination documented good range of motion, crepitus with range of motion, medial and lateral joint line tenderness, an intra-articular effusion, no instability, and no obvious deformities. He was reporting 100% improvement with the injections to date. He had good range of motion with crepitus. One additional Supartz injection was recommended to the right knee. The patient has requested coverage for Supartz injections. The Health Plan denied the request and reported that the requested services are not medically necessary for the treatment of this patient.

Nature of Statutory Criteria/Case Summary: This patient is a 55-year-old female with a diagnosis of osteoarthritis, hypertension and diabetes. A review of records documented the patient had a history of bilateral knee pain. The records noted constant moderate bilateral knee pain, right greater than left. Her pain was worse with motion and walking, and better with rest. The diagnosis was primary osteoarthritis of both knees. The patient had tried and failed conservative options, including corticosteroid injections and anti-inflammatory medication. The treatment plan recommended Supartz series. The patient has requested authorization and coverage for Supartz injections for both knees. The Health Plan has denied this request and reported that the requested services are not medically necessary for the treatment of this patient.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested Supartz injections for treatment of the enrollee’s hip pain. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested medication. There is limited peer-reviewed literature supporting Supartz injections for the treatment of osteoarthritis of the hip. Migliore and colleagues noted that sodium hyaluronate ultrasound guided injection seemed to delay total hip replacement in the context of overall management of symptomatic hip osteoarthritis patients.

Nature of Statutory Criteria/Case Summary: An enrollee has requested Flector (diclofenac epolamine) patches and bilateral knee Supartz injections for treatment of her medical conditions. Findings: The physician reviewer found that the Flector patch and bilateral knee Supartz injections are not medically necessary for treatment of the patient’s medical conditions. Flector is a topical non-steroidal anti-inflammatory drug (NSAID). Researchers performed a systematic review to address and summarize the evidence of effectiveness and safety in topical NSAIDs. The authors concluded that topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects, based on the formulation chosen. In acute and chronic low back pain, widespread musculoskeletal pain and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical NSAIDs.

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