Hyaluronic Acid/Viscosupplementation

Coverage decision: Covered with conditions

Conditions of Coverage

  • Hyaluronic Acid/Viscosupplementation is a covered benefit for the treatment of pain associated with osteoarthritis of the knee (OA), when all of the following conditions are met:
    • Restricted to patients who have a documented medical contraindication to other forms of non-surgical care including all of the following: NSAIDS, corticosteroid injections, and physical therapy/exercise;
    • Is limited to two courses per year with at least four months between courses; and
    • Documented evidence of clinical benefit in terms of pain and function from the prior course of treatment is required for subsequent treatment courses.
  • Hyaluronic Acid/Viscosupplementation for indications other than osteoarthritis of the knee is not covered.

 

Background Policy Information

The State Health Technology Clinical Committee (HTCC) reviewed Hyaluronic Acid/Viscosupplementation on November 15, 2013. The committee’s determination, based on a systematic review of the evidence of safety, efficacy and cost-effectiveness, is that Hyaluronic Acid/Viscosupplementation is a covered benefit with conditions.  Complete information on this HTCC determination is available here: http://www.hca.wa.gov/hta/Pages/Forms/HTA_Findings.aspx.

 
Implementation of the Determination

All requests for Hyaluronic Acid/Viscosupplementation require prior authorization.

 
For State Fund Claims

All requests will be reviewed by L&I’s occupational nurse consultant and claims manager.

  • Complete the Preauthorization Form and fax to:(360) 902-4567
  • For additional information contact the claims manager
    • To obtain the claims manager’s phone number call 1-800-831-5227
    • Attending physician, concurrent care provider or IME log into the Claims & Account Center (CAC).
For Self-Insured Claims

Please contact the self-insured employer (SIE) or their third party administrator (TPA). For a list of SIE/TPAs, go to:
http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp

 
Billing Codes

CPT ® Code: 20610
HCPCS Codes: J7321 and J7323 - J7326

Schedule of Injections

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

Trade name HCPCS Code Administered on an outpatient basis by Total injections allowed
Euflexxa J7323 intra-articular injection once per week (1 week apart) 3 injections
Gel-One J7326 intra-articular injection one time injection 1 injection
Hyalgan J7321 intra-articular injection once per week (1 week apart) 5 injections
Orthovisc J7324 intra-articular injection once per week (1 week apart) 3-4 injections
Supartz J7321 intra-articular injection once per week (1 week apart) 5 injections
Synvisc J7325 intra-articular injection once per week (1 week apart) 3 injections
Synvisc-One J7325 intra-articular injection one time injection 1 injection


For more information:
Contact information.

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