Viscosupplementation Injections denials in California external review

What the reviewers wrote

Where the denial was overturned

The patient has requested authorization and coverage for injections in left knees due osteoarthritis causing chronic pain and functional difficulties. Evidence from randomized trials and current medical literature have revealed varied results as viscosupplementation may relieve some knee pain in patients with osteoarthritis. However, the evidence concerning for which individuals viscosupplementation may benefit is unknown. In an effort to establish a more effective treatment, different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma and other agents. However, guidelines indicate that confirmatory evidence is limited and inconclusive. As such, noted orthopedic organizations do not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for viscosupplementation injection for treatment of the enrollee’s osteoarthritis of knees. 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. Viscosupplementation has been found to be safe and effective. More importantly, viscosupplementation has delayed total knee replacements for patients diagnosed with osteoarthritis. The studies have also shown that viscosupplementation is more effective than corticosteroid injections. This patient was diagnosed with severe left knee osteoarthritis. He had been treated with corticosteroid injections, medications, and activity modification without sustained relief.

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: An enrollee has requested viscosupplementation injections for treatment of the enrollee’s knee osteoarthritis. Findings: The physician reviewer found that based on the available medical records, the requested viscosupplementation injections for treatment of this patient’s medical condition are not medically necessary. Additional hyaluronan injections is not supported in the evidence based literature. Further, there is a documented possibility of complications such as iatrogenic intraarticular infection and sensitivity reactions which may jeopardize future total knee arthroplasty. This patient has undergone multiple injections and with each injection and each exposure to the antigen, there is an increased risk of allergic response.

A 62-year-old female enrollee requested viscosupplementation injections (series of three) for treatment of the enrollee’s osteoarthrosis of the knee. Findings: The physician reviewer found thatThe current medical evidence does not support the requested services in this clinical setting. There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection. Additionally, there is a documented incidence of aseptic inflammatory reactions due to allergic response. This patient has had multiple injections and with each injection and exposure to the antigen, there is an increased risk of allergic response. There is also a risk of iatrogenic infection within the joint. Rutjes and colleagues performed a systematic review and meta-analysis of the efficacy of viscosupplementation.

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