Synvisc-one Injection 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 Synvisc One injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee’s osteoarthritis of both knees.There is sufficient support in the medical literature for the requested medication in this clinical setting. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. A study concluded that hyaluronic acid is an effective 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.

Nature of Statutory Criteria/Case Summary: The enrollee is requesting Synvisc One injections in both knees. Findings: The physician reviewer found that the requested services are medically necessary for treatment of the patient’s medical condition. Therefore, the Health Plan’s denial should be overturned. The enrollee has a history of osteoarthritis of both knees with bilateral knee pain. Examination findings revealed evidence of medial femoral condylar tenderness, patellar grind, and radiographic evidence of tricompartmental osteoarthritis. The patient has tried and failed non-invasive treatment and has done well with viscosupplementation over the last several years. Viscosupplementation is noted to have reduced his pain level and the need for large doses of nonsteroidal anti-inflammatory drugs.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One bilateral knee injections. This patient is being treated for bilateral knee osteoarthritis. The provider noted that the patient’s pain is getting progressively worse, and it is associated with mechanical symptoms and locking. A request was made for bilateral Synvisc One injections. The U.S. Food and Drug Administration (FDA) approved viscosupplementation as a conservative technique for the management of osteoarthritis. There is adequate support for the use of viscosupplementation injections for knee osteoarthritis. The use of exogenous intra-articular viscosupplementation is based on the concept that it may restore the viscoelastic properties of the osteoarthritic joint with the added benefit of potential analgesic and anti-inflammatory properties.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc-One injection to the left knee. 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 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 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-one Injection, then check the rights and deadlines that apply to your plan.