Viscosupp Injection denials in California external review

What the reviewers wrote

Where the denial was overturned

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.

Findings: The physician reviewer found that the enrollee has been diagnosed with right knee primary osteoarthritis. The enrollee reported right anterior knee pain and grinding, which limited her activities. Her prior treatment included activity modification and over-the-counter medications. Previous viscosupplementation resulted in long-term pain relief and an improved activity level. The patient underwent a platelet-rich plasma (PRP) injection and reported no substantial benefit. Her current medications included Cymbalta and Mobic. Right knee examination demonstrated patellofemoral tenderness to palpation, especially at the lateral facet. Normal strength and no instability were noted. Radiographs demonstrated mild to moderate lateral patellofemoral compartment joint space narrowing consistent with early to moderate patellofemoral osteoarthritis.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Hymovis injections. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollee’s osteoarthritis. At issue in this case is whether the requested treatment, Hymovis injections, is medically necessary for treatment of the enrollee’s medical condition.Hyaluronic acids (HA) are naturally occurring connective tissue materials that help cushion and lubricate joints. Intra-articular injection of avian-derived or synthetic HA, also called viscosupplementation, can decrease osteoarthritis (OA) symptoms in some but not all patients; with sustained improvements in pain and functional outcomes, and few adverse events.

Nature of Statutory Criteria/Case Summary: The patient with a diagnosis of chronic low back, bilateral hip, and bilateral shoulder pain. The patient rated pain a 7 out of 10 without medications. She was taking Vicodin and ibuprofen without relief. She reported that she was having a lot of bilateral shoulder pain, alternating between the right and left, with an associated cracking sound. She reported pain and difficulty performing activities of daily living. She reported that her hip pain was constant and making it difficult for her to walk, stand, sit or move. She had physical therapy but felt like it made the pain worse. Her symptoms had improved after a corticosteroid injection into the hips. Bilateral shoulder and hip examinations were not documented.

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