Synvisc denials in California external review

What the reviewers wrote

Where the denial was overturned

Nature of Statutory Criteria/Case Summary: An enrollee has requested Synvisc injections for treatment of the enrollee’s chronic knee pain. Findings: The physician reviewer found that Evidence-based medical peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.

The enrollee is requesting authorization and coverage for Hyaluronan Injections (Synvisc) in both knees. The enrollee has bilateral knee osteoarthritis. Previous cortisone injections provided one week of benefit. An x-ray showed mild medial and patellofemoral compartment joint space narrowing and spurring. Her provider recommended hyaluronic acid injections (Synvisc) injections to her bilateral knees due to the enrollee’s mild degree of osteoarthritis and her decreased benefit from the cortisone injections. The enrollee notes she has finally found a treatment that worked and it has changed her quality of life. She is now able to squat with less pain to her knees, and going up and down the stairs is tolerable after the hyaluronic acid (Synvisc) injections. This enrollee is too young for total knee replacement surgery. The enrollee has tried and failed steroid injection therapy.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Synvisc (hyaluronan) injections for treatment of the enrollee’s bilateral knee pain. Findings: The physician reviewer found that colleagues concluded that there is a general lack of reliable evidence that any specific brand is superior to others. However, some clinically important reductions in pain have been noted, after closer review of systematic reviews and meta-analyses, using higher molecular weight and cross-linked formulations. Synvisc and Synvisc One are crosslinked with molecular weight 5-6 M (million Daltons). Euflexxa (2.4-3.6 M) and Orthovisc (1-2.9M) are not cross-linked.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for injection, Synvisc, for both knees. The enrollee is diagnosed with bilateral primary osteoarthritis of the knees, chronic neck pain, and chronic tension type headache. His orthopedist administered bilateral Synvisc injections for his knee pain. He was prescribed hydrocodone/acetaminophen and hydromorphone, as part of his pain management. He was seen for follow up and was referred back to an orthopedist for continuation of care with Synvisc injections. An x-ray, of the right knee was negative and the left knee showed minimal patellar spurring. His physician prescribed one Synvisc injection to each knee. Review of the medical records indicates the x-rays do not show arthritis of the knee.

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