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/about-hca/health-technology-assessment/health-technology-reviews.
Implementation of the Determination
All requests for Hyaluronic Acid/Viscosupplementation require prior authorization. Hyaluronic Acid/Viscosupplementation may be used only for care of a condition accepted on the claim.
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: C9471, J7321 and J7323 - J7328
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 |
| Gel-Syn | J7328 | intra-articular injection once per week (1 week apart) | 3 injections |
| Hyalgan | J7321 | intra-articular injection once per week (1 week apart) | 5 injections |
| Hymovis | C9471 | intra-articular injection once per week (1 week apart) | 2 injections |
| Monovisc | J7327 | intra-articular injection one time injection | 1 injection |
| 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.
