CurrentAloha CarePolicy RXMP-10

Hyaluronic Acids (Intra‑articular Knee Injections)

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This policy governs prior authorization, coverage criteria, quantity limits, and Medicare/Medicaid step therapy for hyaluronic acid (hyaluronan) intra‑articular knee injections for Aloha Care members.

Policy Summary

PayerAloha Care

PolicyHyaluronic Acids (Intra‑articular Knee Injections)

Policy CodePolicy RXMP-10

Change TypeNo material change

Effective DateApr 6, 2019

Last ReviewSep 26, 2025

Next Review DateSep 26, 2025

Key ActionPrior authorization required; initial approval duration 6 months; one treatment per 180 days; quantity limits specified per product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/180 daysQuantity limit / approval frequency

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CurrentAloha CarePolicy RXMP-10

Hyaluronic Acids (Intra‑articular Knee Injections)

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Policy Summary

PayerAloha Care

PolicyHyaluronic Acids (Intra‑articular Knee Injections)

Policy CodePolicy RXMP-10

Change TypeNo material change

Effective DateApr 6, 2019

Last ReviewSep 26, 2025

Next Review DateSep 26, 2025

Key ActionPrior authorization required; initial approval duration 6 months; one treatment per 180 days; quantity limits specified per product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1/180 daysQuantity limit / approval frequency

Coverage Criteria for Hyaluronic Acid Injections

Osteoarthritis of the knee coverage criteria

Covered when ALL of the following criteria are met:

ALL of the following

Diagnosis is osteoarthritis (OA) of the knee
Clinical support (one of)
- Radiologic evidence confirming osteoarthritis of the knee (e.g., joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts)
- Documentation of at least 5 of the following: bony enlargement; bony tenderness; crepitus on active motion; ESR < 40 mm/hr; < 30 minutes of morning stiffness; no palpable warmth of synovium; age > 50 years; rheumatoid factor < 1:40; synovial fluid clear with normal viscosity and WBC < 2000/mm3
Medication prescribed by or in consultation with a Rheumatologist, Orthopedics, or pain management specialist
Documentation of pain interfering with functional activities (e.g., ambulation, prolonged standing)
Tried and failed, intolerant of, or contraindicated to at least two oral analgesics (e.g., acetaminophen, NSAIDs) for ≥3 months (or documented contraindication/intolerance) AND one topical NSAID (diclofenac 1% gel); medication samples/coupons/discount cards do not count as trials
Tried and failed, intolerant of, or contraindicated to a cortisone (intra‑articular) injection (verified by paid claims, fax/caller confirmation, or chart notes); medication samples/coupons/discount cards do not count as trials
No knee surgery planned within the next 6 months (as documented in chart notes or confirmed by caller/fax); if chart notes do not mention surgery, it is acceptable to assume no surgery is planned
Member does not have coexistent active inflammatory arthritis in the targeted knee (e.g., rheumatoid arthritis, spondylitis, gouty arthritis) and does not have a history of total knee arthroplasty in the targeted knee

Medicare-specific requirement

For Medicare members initiating many non-preferred hyaluronan agents, trial and inadequate response, intolerance, or contraindication to two (2) preferred hyaluronan agents (Durolane, Euflexxa, or Gelsyn-3) is required; medication samples/coupons/discount cards do not count as trials

Medicaid-specific requirement

For Medicaid members initiating non-preferred agents, trial and inadequate response or intolerance to one (1) preferred hyaluronan agent (e.g., Durolane or Euflexxa) is required; medication samples/coupons/discount cards do not count as trials

Renewal (continuation) criteria

Diagnosis remains osteoarthritis (OA) of the knee
Continuation of therapy with prior authorization on file (verified by paid claims)
Prescribed by or in consultation with a Rheumatologist, Orthopedics, or pain management specialist
Documentation of improvement in functional activities (e.g., ambulation, prolonged standing) with hyaluronic acid treatment
Previous treatment was at least 6 months from the planned treatment date
No knee surgery planned within the next 6 months (as documented in chart notes or confirmed by caller/fax)

Operational notes

Medication samples, coupons, or discount cards do not qualify as evidence of a prior trial
Verification of prior therapies or continuation may be via paid claims, chart notes, or fax/caller confirmation

Initial Therapy Requirements

Continuation / Renewal Criteria

HCPCS Codes and Volume Limits

HCPCS codes for hyaluronan productsHCPCSCovered

J7318	Durolane, hyaluronan or derivative, durolane, for intra-articular injection, 1 mg
J7323	Euflexxa, hyaluronan or derivative, euflexxa, for intra-articular injection, per dose
J7328	Gelsyn-3, hyaluronan or derivative, gelsyn-3, for intra-articular injection, 0.1 mg
J7326	Gel-One, hyaluronan or derivative, gel-one, for intra-articular injection, per dose
J7320	Genvisc 850, hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg
J7321	Hyalgan/Supartz/Visco-3, hyaluronan or derivative, hyalgan, supartz or visco-3, for intra-articular injection, per dose
J7322	Hymovis, hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg
J7327	Monovisc, hyaluronan or derivative, monovisc, for intra-articular injection, per dose
J7324	Orthovisc, hyaluronan or derivative, orthovisc, for intra-articular injection, per dose
J7325	Synvisc or Synvisc-One, hyaluronan or derivative, synvisc or synvisc-one, for intra-articular injection, 1 mg

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Volume per 180 days (both knees) — product examples

Durolane16 mL per 180 days (both knees)

Euflexxa12 mL per 180 days (both knees)

Gel-One6 mL per 180 days (both knees)

Genvisc 85025 mL per 180 days (both knees)

Trivisc15 mL per 180 days (both knees)

Quantity Limits and Product-specific Restrictions

Product-specific mL limits per 180 days (examples)

Durolane (60 mg/3 mL)16 mL per 180 days

Euflexxa12 mL per 180 days

Gelsyn-312 mL per 180 days

Gel-One (30 mg/3 mL)6 mL per 180 days

Genvisc 850 (25 mg/2.5 mL)25 mL per 180 days

All covered hyaluronic acid products — treatment frequency

Treatment frequency limitOne treatment per 180 days for all covered hyaluronic acid products

Step Therapy Requirements

Requirement	Details
Medicare step therapy requirement
For Medicare new starts of many non-preferred hyaluronan agents, member must have inadequate response to, intolerable adverse event to, or a contraindication to two (2) preferred hyaluronan agents: Durolane, Euflexxa, or Gelsyn-3.
Medicaid step therapy requirement
For Medicaid, non-preferred agents require a trial and inadequate response or intolerance to one (1) preferred hyaluronan agent (e.g., Durolane or Euflexxa).
{"text":"Definition of "failure/intolerance/contraindication"","status":""}
Failure/intolerance/contraindication is documented by paid claims, stated on the fax or caller confirmed, or via chart notes; medication samples/coupons/discount cards are excluded from consideration as a trial.

Provider Actions and Authorization Rules

Prior Authorization

Prior authorization required; 6‑month approval and 1 treatment/180 days

Prior authorization is required for hyaluronic acid intra‑articular knee injections. Initial authorization duration is 6 months; renewal duration is 6 months. Policy allows one treatment per 180 days and enforces product-specific quantity limits (volume mL per 180 days) as listed in the policy.

Prior authorization required.
Initial approval duration: 6 months; Renewal: 6 months.
Limit: one treatment per 180 days.
Product-specific mL quantity limits apply per 180 days.

Documentation Required

Medicare 90‑day transition for new members

For new Medicare members a 90‑day transition period applies. If the member is currently on an active course of the requested treatment (including when furnished by an out‑of‑network provider), Coverage and Step Therapy do not apply during the first 90 days of enrollment.

Definitions and Reference Documents

LCD — Local Coverage Determination for intra-articular knee injections

Referenced LCDLocal Coverage Determination: Intraarticular Knee Injections of Hyaluronan (L39529)

Review requirementReview using the most current applicable LCD, NCD, or LCA for the Hawaii region

CMS resourceLCD/NCD/LCA searchable at https://www.cms.gov/medicare-coverage-database/search.aspx

Medicare Part B 90-Day Transition Period — definition

DefinitionA 90-day transition period for new Medicare members during which coverage and step therapy do not apply if the member is on an active course of the requested treatment

ScopeApplies to new Medicare members, including treatments furnished by out-of-network providers

Site of Care / Administration

Note

Administer per FDA intra‑articular knee dosing; site of care not restricted

Hyaluronic acid products are administered as intra‑articular injections to the knee per FDA dosing; the policy does not place an explicit restriction on site of care.

Administration: intra‑articular injection to the knee using FDA‑listed dosing per product (see dosing table).
Site of care: not explicitly restricted in policy.