Synvisc Injection denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that the patient has requested authorization and coverage for a Synvisc injection to the left knee. The Health Plan has denied the request indicating that the requested medication is not medically necessary.At issue, in this case, is whether the requested Synvisc injection is medically necessary for the treatment of the patient’s medical condition.According to researchers, intra-articular hyaluronic acid provides a moderate symptomatic benefit to patients with knee osteoarthritis without major safety concerns. In fact, viscosupplementation may offer one of the best benefit/risk ratios among pharmacologic options, as measured by improvements in knee osteoarthritis symptoms, the overall gain in quality of life and substantial delay in time to total knee replacement.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc injections. The Health Plan has denied this request indicating that the requested injections are not medically necessary for treatment of the enrollee’s bilateral knee osteoarthritis.At issue in this case is whether the requested Synvisc injections are medically necessary for treatment of the enrollee’s medical condition.As evidenced by the patient’s history of significant benefit from prior injections, the current literature continues to support the use of viscosupplementation for osteoarthritis of the knees.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A patient requested authorization and coverage for bilateral knee Synvisc injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patient’s osteoarthritis of the knees, bilateral. The submitted documentation does not support the medical necessity of the requested medication. The most recent guidelines for the management of knee osteoarthritis do not recommend hyaluronic acid injections. The 2014 Osteoarthritis Research Society International (OARSI) states that for Osteoarthritis (OA) of the knee, appropriate treatment modalities for all individuals with knee OA included biomechanical interventions, intra-articular corticosteroids, land-based and water-based exercise, self-management and education, strength training, and weight management.

Nature of Statutory Criteria/Case Summary: A patient requested Synvisc injections in the knees. Findings: The physician reviewer found that the medical evidence does not support repeat hyaluronic acid injections if there is no documentation of significant improvement in symptoms for six months or more. Hyaluronic acid injections in the knee are recommended as a possible option for patients with significantly symptomatic severe knee 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 evidence supports 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 Synvisc Injection, then check the rights and deadlines that apply to your plan.