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Coverage criteria policies

Intra-articular Hyaluronan (Viscosupplementation)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for Intra-articular hyaluronan when request is for a covered indication (see below).

Off-label uses are considered investigational and not covered. Coverage is provided for select agents in this class.

The provider and facility will be liable for payment of intra-articular hyaluronans not eligible for coverage unless:

  1. The provider notifies the member that a specific service has been determined by HealthPartners to be cosmetic and
  2. The member signs a waiver agreeing to pay for the specific non-covered service being rendered and
  3. The claim has been billed with a GA modifier indicating such. If the member has signed a waiver agreeing to pay for the specific service then the member will be liable for payment.

Coverage

Coverage for intra-articular hyaluronan is subject to the indications listed below, and per your plan documents.

No prior authorization is required when used in the following manner:

  1. After failure to respond to both of the following conservative therapy approaches:
    1. Simple analgesics such as NSAIDs unless there is a contraindication to use, and
    2. Conservative nonpharmacologic therapy such as strengthening, low-impact aerobic exercises, and neuromuscular education.
  2. Repeat courses in patients with a documented response to previous intra-articular viscosupplementation and with courses spaced at least six months apart.

Use in joints other than the knee is considered investigational.

Coverage will only be provided for Synvisc, Synvisc One and Euflexxa. No coverage will be provided for Gel-One, Hyalgan, Monovisc, Orthovisc, Supartz, Gen-Visc 850, Gel-Syn, and Hymovis.

This policy does not address sodium hyaluronate use for other conditions or procedures.

Definitions

All viscosupplements are FDA-approved for treatment of pain in osteoarthritis (OA) of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy, and to simple analgesics, e.g., acetaminophen.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

HCPCS Codes

Covered:

Codes

Description

J7323

Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose (20mg/2 mL)

J7325

Hyaluronan or derivative, Synvisc or Synvisc One, for intra-articular injection, 1 mg

Not Covered:

Codes

Description

J7321

Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose (Hyalgan dose is 20mg/2 mL and Supartz dose is 25mg/2.5 mL)

J7324

Hyaluronan or derivative, OrthoVisc, for intra-articular injection, per dose (30mg/2 mL)

J7326

Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose

J7328

Hyaluronan or derivative, Gel-Syn, for intra-articular injection, 0.1 mg

J7327

Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose

J7322

Hyaluronan or derivative, Hymovis, for intra-articular injection, 1mg

J7320

Hyaluronan or derivative, Genvisc 850, for intra-articular injection, 1 mg

ICD-10-CM Codes

Prior authorization is not required for the following diagnosis codes:

Codes

Description

M17.0

Bilateral primary osteoarthritis of knee

M17.10 – M17.12

Unilateral primary osteoarthritis, unspecified knee; unspecified, right knee or left knee

M17.2

Bilateral post-traumatic osteoarthritis of knee

M17.30 – M17.32

Unilateral post-traumatic osteoarthritis of knee; unspecified, right knee, or left knee

M17.4

Other bilateral secondary osteoarthritis of knee

M17.5

Other unilateral secondary osteoarthritis of knee

M17.9

Osteoarthritis of knee, unspecified

NDC Codes

Covered:

Codes

Description

55566410001

20mg/2 mL multiple dose syringe pack, Euflexxa

58468009001

8mg/mL multiple dose syringe pack, Synvisc

66267092103

8mg/mL multiple dose syringe pack, Synvisc

35356003401

8mg/mL single dose syringe, Synvisc

58468009003

8mg/mL single dose syringe, Synvisc One

Not Covered:

Codes

Description

87541030091

30mg/3ml syringe, Gel-One

50653000601

25mg/2.5ml syringe, GenVisc 850

59676036001

15mg/mL, 2mL single dose syringe, OrthoVisc

35356003501

15mg/mL, 2mL multiple dose syringe pack, OrthoVisc

54569554300

20mg/2 mL single dose syringe, Hyalgan

89122072412

20mg/2 mL 2 mL vial, Hyalgan

89122072420

20mg/2 mL 2 mL syringe, Hyalgan

89122049663

8mg/1mL, 3mL multiple dose syringe pack, Hymovis

59676082001

88mg/4mL, 4mL syringe, Monovisc

89130444401

25mg/2.5mL single dose syringe, Supartz FX

89130311101

16.8mg/2mL 2mL syringe, Gelsyn-3

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Stitik TP, Levy JA. Viscosupplementation (biosupplementation) for osteoarthritis. Amer J Phys Med Rehab 2006;85(Suppl):S32-S50.
  2. American Academy of Orthopeaedic Surgeons. Treatment of osteoarthritis of the knee (non-arthroplasty). Rosemont (IL): American Academy of Orthopaedic Surgeons; 2013 May 18.
  3. Hochberg MC et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis Care & Research 2012;64(4):465-747.
  4. Agency for Healthcare Research and Quality. Clinician’s guide: three treatments for osteoarthritis of the knee: evidence shows lack of benefit. 2009 April.
  5. National Institute for Health and Clinical Excellence (NICE). Osteoarthritis. The Care and Management of Osteoarthritis in Adults. NICE Clinical Guideline 59. London, UK: NICE; February 2008.
  6. Zhang W, Nuki G, Moskowitz RW, et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009.
  7. Jordan KM et al. EULAR recommendations 2003: an evidence based approach to the management of knee osteoarthritis: report of a task force of the standing committee for international clinical studies including therapeutic trials (ESCISIT). Ann Rheum Dis 2003;62:1145-1155.
  8. Rutjes AWS et al. Viscosupplementation for osteoarthritis of the knee. Ann Intern Med 2012;157:180-191.
  9. Bannuru RR, Natov NS, Obadan IE, Price LL, Schmid CH, McAlindon TE. Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Arthritis Care & Research 2009;61(12):1704-11.
  10. Bellamy N, Campbell J, Welch V, Gee TL, Bourne R, Wells GA. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006;(2):CD005321.
  11. Reichenbach S, Blank S, Rutjes AWS, Shang A, King EA, Dieppe PA, Jüni P, Trelle S. Hylan versus hyaluronic acid for osteoarthritis of the knee: a systematic review and meta-analysis. Arthritis & Rheumatism 2007;57(8):1410-18.
  12. Jüni P et al. Efficacy and safety of intraarticular hylan or hyaluronic acids for osteoarthritis of the knee. Arthritis & Rheumatism. 2007;56(11):3610-19.
  13. Kirchner M, Marshall D. A double-blind randomized controlled trial comparing alternate forms of high molecular weight hyaluronan for the treatment of osteoarthritis of the knee. Osteoarthritis Cartilage 2006;14(2):154-62.
  14. Navarro-Sarabia F et al. A 40-month multicenter, randomised placebo-controlled study to assess the efficacy and carry-over effect of repeated intra-articular injections of hyaluronic acid in knee osteoarthritis: the AMELIA project. Ann Rheum Dis 2011;70(11):1957-1962.
  15. Hyalgan PI. Fidia Pharma USA Inc. Revised May 2014.
  16. Supartz PI. Seikagaku Corporation. Revised 28 April 2015.
  17. Euflexxa PI. Ferring Pharmacueticals Inc. Revised July 2016.
  18. Orthovisc PI. DePuy Mitek Inc. June 2005.
  19. Synvisc PI. Genzyme Biosurgery. Revised September 2014.
  20. Synvisc One PI. Genzyme Biosurgery. Revised September 2014.
  21. Gel-One PI. Zimmer. Issued 20 May 2011.
  22. Hymovis PI, Fidia Pharma USA Inc. Revised October 2015.
  23. GenVisc 850 PI OrthogenRx, Inc.Revised January 2015.
  24. Gel-Syn PI Bioventus Revised February 2016.

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Policy activity

  • 04/01/1998 - Date of origin
  • 01/01/2017 - Effective date
Review date
  • 08/2017
Revision date
  • 08/08/2016

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