Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
The following United States Food and Drug Administration (U.S. FDA) approved hyaluronan preparations are available:
Synvisc
®
(hylan G-F 20), Synvisc-One
®
(hylan G-F 20), Euflexxa
®
(sodium hyaluronate), Hyalgan
®
or Supartz
™
(sodium hyaluronate), Orthovisc
®
(high molecular weight hyaluronic acid), Gel One
®
(cross-linked hyaluronate), Monovisc
®
(lightly cross-linked high molecular weight hyaluronic acid), GelSyn-3
™
(hyaluronic acid), GenVisc 850
®
(sodium hyaluronate), Hymovis
®
(high molecular weight viscoelastic hyaluronan), Durolane
®
(hyaluronic acid), TriVisc
®
(sodium hyaluronate), Synojoynt
™
(1% sodium hyaluronate), Triluron
™
(sodium hyaluronate), and Visco-3
™
(sodium hyaluronate).
Intra-articular hyaluronan injections may be considered medically necessary when ALL of the following are met:
-
The individual has documentation of diagnosis of symptomatic painful osteoarthritis of the knee and there is no evidence of inflammatory arthritis (e.g., rheumatoid arthritis);
and
-
There is documentation of failure to respond adequately to at least three (3) months of *conservative therapy;
and
-
There are no contraindications to the hyaluronan injections;
and
-
There is documentation that the pain interferes with functional activities (e.g., ambulation, prolonged standing);
and
-
Cause of pain cannot be attributed to other forms of joint disease;
and
- The injections are performed by a licensed medical professional (e.g., MD, DO, PA or CRNP). Injections cannot be performed by nursing or other medical personnel. Injections are for medial and lateral aspect of the knee and not patellar. Patellar injections would be not medical necessary.
*Conservative therapy includes the following:
-
Activity modification, participation in a home exercise program, protective weight bearing;
and
-
Non-narcotic analgesics (e.g., acetaminophen, NSAIDS) for a period of time adequate to assess therapeutic benefit, topical external analgesic preparations including capsaicin cream applied to affected knee joint, topical anti-inflammatory preparations applied to affected knee joint;
and
- Intra-articular corticosteroid injections; or
- The individual is unable to tolerate conservative therapy due to adverse side effects or other medical condition.
The use of Intra-Articular Hyaluronan preparations for all other indications not listed in this policy or for any other body joint other than the knee is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Injections are for medial and lateral aspect of the knee and not patellar. Patellar injections would be not medical necessary.
Procedure Codes
| 20610 | J7318 | J7320 | J7321 | J7322 | J7323 | J7324 |
| J7325 | J7326 | J7327 | J7328 | J7329 | J7331 | J7332 |
