Coverage of Conditions and Treatments
Use this lookup tool to determine coverage decisions, or if prior authorization is needed for the treatment or condition. Note: For Self-insured employer claims, you must contact the employer or their claims administrator.
List also available in PDF format.
Hyaluronic acid is a naturally occurring component of synovial fluid and cartilage within our joints. Its viscous nature is thought to act as a lubricant, with its elasticity acting as a shock absorber. In patients with osteoarthritic joints, most commonly the knee(s), the availability of this substance is reduced, making them more susceptible to damage. Viscosupplementation is the act of injecting hyaluronic acid or hyaluronan as a means of treating osteoarthritic joints. These products have several brand names. This updated coverage decision adds new brand names that are currently on the market.
Conditions of Coverage
(Effective date: June 1, 2014; last updated*: February 2019).
- 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: https://www.hca.wa.gov/about-hca/health-technology-assessment.
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).