CurrentAetnaPolicy N/A

Hyaluronates Injectable Medication Precertification Request — Coverage Criteria

Precertification request form and requirements for Aetna coverage of intra‑articular hyaluronate/hyalaluronic acid injections, primarily for knee osteoarthritis; applies to providers submitting requests to Aetna in North Carolina.

Policy Summary

PayerAetna

PolicyHyaluronates Injectable Medication Precertification Request — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionRequest precertification from Aetna using the form (or Medicare form for Medicare Advantage Part B) prior to or at the start of treatment with intra‑articular hyaluronate products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18product options

3precert contact methods

≥3 moanalgesic/steroid trials

6 morepeat-series interval

Coverage Criteria for Intra-articular Hyaluronates

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Initial therapy

Covered when ALL of the following are met

Diagnosis: Patient has diagnosis of osteoarthritis (OA) of the knee

checkbox on form

Radiographic evidence: Diagnosis supported by radiographic evidence of knee OA (e.g., joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts)

checkbox on form

Clinical signs/symptoms: At time of diagnosis patient has at least 5 specified OA signs and symptoms from the checklist (e.g., bony enlargement, bony tenderness, crepitus, ESR <40 mm/hr, morning stiffness <30 minutes, no palpable synovial warmth, age >50, rheumatoid factor <1:40, synovial fluid clear with WBC <2000/mm3)>=5 signs

checkboxes on form

Functional impairment: Knee pain interferes with functional activities (e.g., ambulation or prolonged standing)

checkbox on form

Prior conservative therapy: Inadequate response or adverse effects with nonpharmacologic treatments (physical therapy, exercise, insoles, bracing, weight reduction)

checkbox on form

Analgesic trial: Inadequate response or intolerance to an analgesic trial (e.g., acetaminophen up to 3–4 g/day, NSAIDs, topical capsaicin) for at least 3 months, or documented contraindication>=3 months

checkbox on form

Intraarticular steroid trial: Inadequate response or intolerance to intraarticular steroid injections for at least 3 months, or documented contraindication>=3 months

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Timing relative to knee replacement: Patient is not scheduled for total knee replacement within 6 months of starting treatment

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Continuation / restart

Covered continuation requires documentation:

Ongoing series: If patient is in the middle of therapy with the requested product, provide date(s) of previous injection(s)

form fields for injection dates

Restart series interval: If restarting as a new series, prior series must have been completed at least 6 months prior to this request>=6 months since prior series

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Clinical benefit from prior series: Documentation that prior injections resulted in improvement in pain and functional capacity

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Coding, Trials, and Timing

Administration codesmixed

Administration code(s) (CPT)

Administration code(s) to be provided on form

Diagnosis codesICD-10

Primary ICD Code	Primary diagnosis ICD code (to be specified by provider)
Secondary ICD Code	Secondary diagnosis ICD code (to be specified by provider)
Other ICD Code	Other ICD code (to be specified)

Analgesic and steroid trial duration — at least 3 months

Required durationAnalgesic and intraarticular steroid trials must be for at least 3 months (e.g., acetaminophen up to 3–4 g/day, NSAIDs, topical capsaicin)

Acceptable analgesic examplesAcetaminophen up to 3–4 g/day, NSAIDs, topical capsaicin

Documentation neededRecord inadequate response or intolerance to the ≥3-month trial or document a contraindication

Minimum interval to consider previous series completed before new series — at least 6 months

Minimum intervalA prior series must have been completed at least 6 months before a new (re-start) series is requested

Documentation requiredEnter date of last injection from prior series and indicate whether the previous series was completed ≥6 months before the request

Clinical benefitDocument whether patient experienced improvement in pain and functional capacity after prior injections

Precertification and Documentation Requirements

Prior Authorization

Prior Authorization Required

Precertification is required for hyaluronate injectable medications. Complete the Hyaluronates Injectable Medication Precertification Request form in full (all fields must be legible) and submit to Aetna Precertification Notification by phone or fax. For Medicare Advantage Part B members, use the Medicare Request Form.

Aetna Precertification Phone: 1-866-752-7021 (TTY: 711)
Fax: 1-888-267-3277
All required sections (clinical, diagnosis, prior treatment history) must be completed

Step Therapy

Step Therapy / Required Prior Trials

Step therapy / required prior trials must be documented on the precertification form. The request must show inadequate response, intolerance, or contraindication to conservative and pharmacologic therapies before hyaluronate injections will be approved.

Documentation of inadequate response or intolerance to non-pharmacologic measures (e.g., physical therapy, regular exercise, insoles, knee bracing, weight reduction)
Documentation of inadequate response or intolerance to analgesics (e.g., acetaminophen up to 3–4 g/day, NSAIDs, topical capsaicin) after at least 3 months, or documentation of contraindication to these agents
Documentation of inadequate response or intolerance to intraarticular corticosteroid injections after at least 3 months, or documentation of contraindication to steroid injections
If patient is scheduled for total knee replacement within 6 months, indicate this on the form

Documentation Required

Required Documentation — Precertification Form and Supporting Items

Complete clinical and diagnosis sections for all requests. For continuation requests, include dates of prior injections and documentation of benefit if restarting a series. Indicate product-specific history (e.g., prior Orthovisc, Monovisc, Synvisc One) and any documented intolerance or contraindication.

Primary and any secondary ICD-10 diagnosis codes
Radiographic evidence of knee osteoarthritis and at least 5 supporting signs/symptoms where applicable (select items on form)
Whether knee pain interferes with functional activities
For continuation: dates of prior injections and whether the patient is mid-series
For re-start of a new series: date of last injection, whether prior series completed at least 6 months earlier, and whether prior injections improved pain and function

Denial Risk

Potential Denial Triggers

Incomplete forms or missing clinical documentation (including lack of documented prior trials or missing prior injection dates) may result in denial or delay of authorization.

Missing documentation of prior non-pharmacologic or pharmacologic trial failures
No documentation of prior intraarticular steroid trial or contraindication
Absence of prior injection dates for continuation requests
Unclear product history or lack of documented intolerance/contraindication for specific products

Background

This precertification form is used to document the clinical indication and prior treatments for use of intra-articular hyaluronate products for osteoarthritis of the knee. It requires completion of the clinical information section, including whether the patient had inadequate response or intolerance to nonpharmacologic measures, whether the patient completed a trial of analgesics (e.g., acetaminophen up to 3–4 g/day, NSAIDs, topical capsaicin) for at least 3 months or has a contraindication, whether the patient had an intraarticular steroid trial for at least 3 months or a contraindication, and whether the patient is scheduled for total knee replacement within 6 months of starting treatment. The form also captures prior product use, intolerance or contraindication to specific hyaluronate products, and dates of prior injections for continuation or restart considerations.

Definitions and Clinical Criteria

Radiographic evidence of knee OA

DefinitionOsteoarthritis of the knee documented by radiographic evidence such as joint space narrowing, subchondral sclerosis, osteophytes, or subchondral cysts.

Form requirementCheckbox on the form: ‘Is the diagnosis supported by radiographic evidence…?’ must be completed

UseRadiographic support is required for all precertification requests for hyaluronate injections

OA clinical signs/symptoms checklist

Required countAt the time of diagnosis the patient must have at least 5 of the listed signs/symptoms (select all that apply)

Included signs/symptomsBony enlargement; bony tenderness; crepitus on active motion; ESR <40 mm/hr; morning stiffness <30 minutes; no palpable synovial warmth; age >50; rheumatoid factor <1:40 titer; synovial fluid clear with normal viscosity and WBC <2000/mm3

Form useChecklist provided on the precertification form must be completed and support clinical diagnosis