Effective August 30, 2016, Blue Cross Blue Shield of North Carolina will no longer cover steroid injections for osteoarthritis for the knee.
BCBS of North Carolina Deems Knee Steroid Injections Investigational
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Secondary
Under a new coverage policy adopted in May, the insurer says intra-articular glucocorticoids for the treatment of individuals who have knee osteoarthritis are considered investigational. The insurer also determined that subacromial glucocorticoids for the treatment of adults who have shoulder impingement syndrome are considered investigational.
However, intra-articular glucocorticoid for the treatment of adults who have frozen shoulder may be considered medically necessary.
Evidence Judgement
According to the insurer, the evidence for intra-articular glucocorticoids in individuals who have knee osteoarthritis includes, “randomized controlled trials (RCTs), systematic reviews of RCTs, and observational studies and surveys assessing potential harms. Relevant outcomes are symptoms, functional outcomes, health status measures, and treatment-related morbidity. The evidence is consistent with short-term improvement in pain and function following intra-articular glucocorticoids.”
However, the insurer claims conclusions are, “limited by suboptimal trial quality. In addition, mean improvements reported are not large and of questionable clinical importance.” Furthermore, the insurer says short-term adverse events appear to occur infrequently. “The long-term effects are unclear, particularly whether there are important beneficial or possibly harmful, long-term effects with repeated injections. The evidence is insufficient to determine the effects of the technology on health outcomes.”
Blue Cross Blue Shield of North Carolina has issued controversial policies limiting coverage for certain spine fusion procedures. Now it looks like the insurer is taking on knees.
The American Academy of Orthopaedic Surgeons told us the organization plans to issue a response to the coverage policy.
The new policy may present opportunities for alternative injection therapies for osteoarthritis in the knee that are in the FDA approval pipeline.
To read the entire policy document, click here.
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Discussion
This is a fascinating development. In my practice we've seen similar outcomes with the revised protocol. The key differentiator seems to be patient selection criteria. Has anyone else noticed the correlation with BMI thresholds?
Great point. I'd push back slightly on the conclusion, the sample size in the cited study is too small to draw population-level inferences. That said, the directional signal is compelling and worth a larger RCT.
We implemented a similar approach last year. Early results are promising but we're still gathering 12-month follow-up data. Happy to share our protocol if anyone is interested.
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