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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.

In adopting this HTCC coverage determination, the Department has concluded that the determination does not conflict with any state statute. Any coverage for investigational treatment would be considered per WAC 296-20-02850. Any coverage for health technologies that have a FDA Humanitarian Device Exemption status would be considered per RCW 70.14.120 (1) (b).

In February 2019, the Department updated the coverage decision to include four new products (Durolane, GenVisc 850, TriVisc and Visco-3). The Department also removed the product and billing information from the coverage decision and moved it to Fee Schedules and Payment Policies (MARFS). Please refer to MARFS for any product and coding update in the future.

 
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 billing information, please refer to L&I Fee Schedules and Payment Policies (MARFS).
 
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.

 

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