Diagnosis: Osteoarthritis of right knee

Treatment: Monovisc

The insurer denied coverage for Monovisc. The denial was upheld.

This patient is a female with osteoarthritis of the right knee. She was evaluated by an orthopedic surgeon. Her pain increases with walking. She has tried ice, rest, and over the counter (OTC) medications. The physical examination was significant for patellofemoral tenderness, crepitus, and medial joint line tenderness. An x-ray report revealed marked degenerative arthritis medially. Her physician provided a cortisone injection. Authorization was also requested for Monovisc. The denial was based upon this medication not being on the preferred list.

The medical record demonstrates that the patient has osteoarthritis and has failed conservative treatment. There is documentation that physical therapy, injections, and medications have been tried and failed. The criteria for use of viscosupplementation have been established. However, there is no evidence of contraindications or inability to tolerate formulary viscosupplementation. There is no evidence of reactions, problems, or medical contraindications for formulary viscosupplementation. There is insufficient evidence in the medical record to support the use of Monovisc vs. formulary sodium hyaluronate alternatives. There were no extenuating circumstances reported to support the use of Monovisc.

The health care plan acted reasonably and with sound medical judgment and in the best interest of the patient. Monovisc is not medically necessary.

Based on the above, the medical necessity for Monovisc is not substantiated. The insurer's denial is upheld.