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Intra-Articular Hyaluronan Injections for Osteoarthritis of the Knee

Section: Injections
Effective Date: December 01, 2019
Revised Date: November 26, 2019

Description

Intra-articular injections of hyaluronan (also known as sodium hyaluronate) act as lubricants to restore elasticity and viscosity to the arthritic knee. The procedure involves an arthrocentesis to aspirate the damaged synovial fluid or joint effusion if present from the knee as directed by product. Then the hyaluronan preparation is injected intra-articularly into the knee synovial capsule (if treatment is bilateral, a separate syringe is used for each knee.

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 U.S. Food and Drug Administration (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), SynojoyntTM (1% sodium hyaluronate), TriluronTM (Sodium Hyaluronate) and generic sodium hyaluronate 1% solution for injection.

Intra-articular hyaluronan injections may be considered medically necessary when ALL of the following are met:

  • The patient 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.

*Conservative therapy includes the following:

  • Activity modification, participation in a home exercise program implemented by a physical therapist, protective weight bearing; and
  • Non-narcotic analgesics (e.g., acetaminophen, NSAIDS) 1 gram up to four times daily, topical anti-inflammatory preparations including capsaicin cream applied to affected knee joint, and
  • Intra-articular corticosteroid injections; or
  • The individual is unable to tolerate conservative therapy because of adverse side effects or other medical condition.

Arthrocentesis and the injection of hyaluronic acid derivatives for all other body joints is considered not medically necessary.

The use of Intra-Articular Hyaluronan preparations for any other indication is considered not medically necessary.

Procedure Codes

20610     J3490 J7318 J7320 J7321  J7322 J7323
J7324 J7325 J7326 J7327 J7328 J7329 J7331
J7332

Repeat Treatment Cycles

An additional course of the previously approved viscosupplementation therapy may be considered medically necessary for treatment of painful osteoarthritis of the knee when ALL of the following are met:

  • At least six months must have elapsed since the previous injection or completion of the prior series of injections; and
  • The individual and provider have elected to continue conservative/non-surgical management of the osteoarthritis (no surgery planned within 6 months of viscosupplementation therapy); and
  • The medical record must document a reduction in the dose of analgesics or anti-inflammatory medications in the three (3) month period following the injection series (NOTE: not required if the individual requires these medications for a comorbid medical condition in addition to knee osteoarthritis); and
  • The medical record must objectively document significant improvement in pain and functional capacity of the knee joint. (e.g., an improvement in an objective measurement of pain and/or functional status Visual Analog Scale [VAS], Western Ontario and McMaster Universities Osteoarthritis [WOMAC] Index, or other validated objective measure).

Repeat treatment cycles of Intra-Articular Hyaluronan Injections are considered not medically necessary if the above criteria are not met.

Procedure Codes

20610     J3490 J7318 J7320 J7321  J7322 J7323
J7324  J7325      J7326  J7327  J7328     J7329 J7331
J7332

Imaging guidance is considered not medically necessary when performed during intra-articular hyaluronan injections for osteoarthritis of the knee.

Procedure Codes

20611 76942

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.

Diagnosis Codes

Covered Diagnosis Codes for
J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329,J7331,J7332

M17.0 M17.2 M17.4 M17.5 M17.9 M17.10 M17.11
M17.12 M17.30 M17.31 M17.32

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