Hyaluronic acid

Coverage Decision

L&I or self-insurer covers the use of Hyaluronic acid (HA) when osteoarthritis is the accepted condition or is retarding recovery from an accepted condition. Under those circumstances, one course of Hyaluronic acid may be considered medically necessary.

Hyaluronic acid injections for indications other than osteoarthritis of the knee are considered experimental and will not be paid.

Hyaluronic acid is a complex sugar chain substance with viscous properties. It is approved as a device by the Food and Drug Administration (FDA) for the treatment of osteoarthritis of the knee. HA injections are only for intra-articular injections into the knee to treat osteoarthritis. HA is a natural component of synovial fluid; inflammation from osteoarthritis reduces the viscoelasticity of the joint's synovial fluid. A series of HA injections may increase the viscoelasticity of the synovial fluid in a knee with osteoarthritis.

The schedule of injections varies with the FDA-approved product used. One course of the currently approved products consists of:

Trade name Administered on an outpatient basis by Total injections allowed
Euflexxa intra-articular injection once per week (1 week apart) 3 injections
Gel-One intra-articular injection one time injection 1 injection
Hyalgan intra-articular injection once per week (1 week apart) 5 injections
Orthovisc intra-articular injection once per week (1 week apart) 3-4 injections
Supartz intra-articular injection once per week (1 week apart) 5 injections
Synvisc intra-articular injection once per week (1 week apart) 3 injections
Synvisc-One intra-articular injection one time injection 1 injection

Coverage criteria for hyaluronic acid injections

When osteoarthritis is the accepted condition or is retarding recovery from an accepted condition, one course of HA may be considered medically necessary. Prior authorization is required for hyaluronic acid injections.

The requesting provider must provide the insurer with documentation of the existence of osteoarthritis of the knee and that the patient has failed to benefit from or is unable to tolerate all of the following therapies recommended by the American College of Rheumatology:

  1. Non-pharmacological therapies (e.g., physical therapy),
  2. Non-opioid analgesics (e.g., acetaminophen) and
  3. Treatment with non-steroidal anti-flammatory drugs (NSAIDs). Intolerance and therapeutic failure must be documented with at least a 1 week trial of 2 formulary products from different NSAID classes.

If osteoarthritis is retarding recovery of the accepted medical condition, temporary treatment may be authorized when the requirements of bullets 1-3 above are met, and these additional requirements below are documented to the insurer:

  1. The occupational disease or industrial injury is not stable.
  2. Osteoarthritis is directly retarding recovery of the accepted occupational disease or industrial injury.
Additional courses of hyaluronic acid

Under rare circumstances, the insurer will pay for an additional course of HA treatment. Additional courses may be considered only when osteoarthritis is the accepted medical condition on the claim, not when it is the condition retarding recovery.

In order for additional courses of HA injections to be considered medically necessary:

  1. You must request prior authorization in writing.
  2. The request must include documentation of return of pain complaints and evidence of functional improvement for the patient following a prior course of treatment.
Billing and payment information

You may bill the insurer for the use of HA at a frequency of 1 service unit per day, per knee with the codes listed below. The insurer will pay each of these codes according to the treatment protocol and the current L&I Fee Schedule.

HCPCS Code Description
J7321 Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose.
J7323 Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose.
J7324 Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose.
J7325 Hyaluronan or derivative, Synvisc, for intra-articular injection, per milligram (mg).
J7325 Hyaluronan or derivative, Synvisc-One, for intra-articular injection, per milligram (mg).
J7326 Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose.

For more information:
WAC 296-20-055 - Limitation of treatment and temporary treatment of unrelated conditions when retarding recovery.

 

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