Diagnosis: Osteoarthritis of the knee (knee pain)
Treatment: Second dose of Zilretta 32 mg (milligrams)
The insurer denied the second dose of Zilretta 32 mg.
The denial is upheld.

This patient is an adult female with bilateral knee pain. She had been diagnosed with osteoarthritis. She received bilateral Zilretta injections 8 months ago. She was evaluated by a nurse practitioner 5 months ago, who recommended additional injections. Additional injections were provided on that date. The patient's body mass index was 45.

The Second dose of Zilretta was not medically necessary.

The health plan notes that repeat injections have not been reported to be effective or indicated. The package insert and current literature support this claim. Therefore, the Second dose of Zilretta was not medically necessary.