Diagnosis: Osteoarthritis
Treatment is Gel-One 30MG (milligram) /3ML (milliliter) IX PRSY
The insurer denied coverage for Gel-One 30MG/3ML IX PRSY
The denial is upheld

This is the case of an adult female with history of osteoarthritis of the knees. X-rays of the knees showed severe degenerative joint disease. Per the office visit note, the patient's right knee had been injected with viscosupplementation # (number) 1 several weeks prior, and her pain had diminished. The left knee was injected. Per the office visit note, the patient's left knee was doing somewhat better, and she was presenting for viscosupplementation of the right knee.

The scientific literature does not show difference in efficacy between formulary agent and Gel-One 30MG/3ML IX PRSY. There are no reports nor studies which recommend Gel-One 30MG/3ML IX PRSY.
The facts are the patient received the medication without use of the formulary agent. There was no report of intolerance nor failure to improve with a formulary agent.

The facts are additional injections are only prescribed if at least 6 months have passed with objective evidence of improvement. The provider has not followed the recommended guidelines for use.

In conclusion, based upon use of a non-formulary agent and an insufficient time period between injections, there would be no indication for the Gel-One 30MG/3ML IX PRSY.

The formulary drug(s) will not be likely to cause the patient an adverse reaction.

Has the formulary drug(s) been ineffective based on the patient's clinical history? NO

The requested drug will not be more effective than formulary drug.

The insurer's denial of coverage for Formulary Exception for Gel-One 30MG/3ML IX PRSY is upheld.