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Hyaluronates Injectable Medication Precertification Request — Coverage Criteria
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Intra-articular Hyaluronates
Initial therapy
Covered when ALL of the following are met
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Continuation / restart
Covered continuation requires documentation:
form fields for injection dates
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Requests for Medicare Advantage Part B should be submitted using the Medicare Request Form rather than the Aetna Hyaluronates Injectable Medication Precertification Request form.
Use of intra-articular hyaluronate injections without documentation of the required elements on the precertification form — including a diagnosis of knee osteoarthritis, radiographic support, documentation of required prior trials (nonpharmacologic measures, an analgesic trial and an intraarticular steroid trial of at least 3 months or documented contraindication), and evidence of functional impairment — is not supported by this precertification process and may be considered not medically necessary.
Coding, Trials, and Timing
| Administration code(s) (CPT) | Administration code(s) to be provided on form |
| 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) |
Precertification and Documentation Requirements
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 / 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
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
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
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