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.
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:
*Conservative therapy includes the following:
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.
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:
Repeat treatment cycles of Intra-Articular Hyaluronan Injections for any other indication are considered not medically necessary.
Imaging guidance is considered not medically necessary when performed during intra-articular hyaluronan injections for osteoarthritis of the knee.
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.
Covered Diagnosis Codes for: J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332