CurrentBlue Cross Blue Shield - IowaPolicy 02.01.12

Viscosupplementation (Intra‑articular hyaluronan) for Knee Osteoarthritis — Coverage Criteria

Defines coverage and authorization criteria for viscosupplementation products used to treat knee osteoarthritis for Wellmark (Blue Cross Blue Shield - Iowa) members, including preferred and targeted hyaluronate products and required prior steps before coverage.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyViscosupplementation (Intra‑articular hyaluronan) for Knee Osteoarthritis — Coverage Criteria

Policy CodePolicy 02.01.12

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateJan 1, 2026

Key ActionObtain prior authorization and document diagnostic evidence, prior conservative therapy failure, analgesic and steroid trials, and functional impairment to support a 12‑month approval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3preferred products

18targeted products

12 moapproval duration

180 dcourse interval

Coverage Criteria

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This policy may not apply to members covered under the Federal Employee Program (FEP). Benefit determinations for FEP are governed by the Federal Employee Program and exclusions, limitations, or exceptions may differ by contract. Verify individual member benefits and contract language before applying this policy.

Intra-articular hyaluronan (viscosupplementation) injections are considered not medically necessary when the patient does not meet the policy’s specified initial or continuation criteria. Authorization for continued treatment is contingent on meeting all criteria for initial approval, documented improvement in pain and function following prior injections, and at least 6 months elapsed since the last completed injection series.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Members must meet the health plan's Preferred Drug Plan Design for the specific viscosupplement product and all applicable Criteria for Initial Approval or Continuation of Therapy. Authorization may be granted for up to 12 months when criteria are met.

Authorization duration: up to 12 months when criteria met
Preferred products: Euflexxa, Synvisc, Synvisc One
Targeted (non-preferred) products require meeting Preferred Drug Plan Design exceptions (current treatment continuation or intolerance to ≥2 preferred products)

Documentation Required

Diagnostic Documentation Required

Diagnosis must be supported by radiographic evidence of knee osteoarthritis (e.g., joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts) or documentation that the member has at least five of the following signs/symptoms: 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 (agglutination); synovial fluid clear with normal viscosity and WBC < 2000/mm3. Also document that knee pain interferes with functional activities (e.g., ambulation, prolonged standing).

Documentation Required

Prior Therapy and Response Documentation

Document prior therapies and response: inadequate response, intolerance, or contraindication to non‑pharmacologic treatments (physical therapy, exercise, insoles, bracing, weight reduction); inadequate response, intolerance, or contraindication to analgesics (e.g., acetaminophen up to 3–4 g/day, NSAIDs, topical capsaicin) for at least 3 months; and inadequate response, intolerance, or contraindication to intra‑articular corticosteroid injection for at least 3 months. If requesting a targeted (non‑preferred) product based on intolerance, document adverse events to at least two preferred products (Euflexxa, Synvisc, Synvisc One).

Non‑pharmacologic therapies tried and outcome documented
Analgesic trial (≥3 months) documented or contraindication noted
Intra‑articular steroid trial (≥3 months) documented or contraindication noted
If requesting non‑preferred for intolerance, document adverse event to ≥2 preferred products: Euflexxa, Synvisc, Synvisc One

Denial Risk

Not Medically Necessary if Criteria Not Met

Intra‑articular hyaluronan injections are considered not medically necessary if the above criteria are not met (including scheduling for total knee replacement within 6 months).

Do not authorize if member is scheduled for total knee replacement within 6 months of starting treatment

Procedure / Billing Codes & Course Interval

Procedure/Billing Codesmixed

C9465	Hyaluronan or derivative, Durolane, for intra-articular injection, per dose
J7318	Hyaluronan or derivative, Durolane, for intra-articular injection, 1mg
J7320	Hyaluronan or derivative, Genvisc 850, for intra-articular injection, 1mg
J7321	Hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection, per dose
J7322	Hyaluronan or derivative, Hymovis, for intra-articular injection, 1mg
J7323	Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose
J7324	Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose
J7325	Hyaluronan or derivative, Synvisc or Synvisc One®, for intra-articular injection, 1mg
J7326	Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose
J7327	Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose

1–10 of 16

1/2

Course interval

Course intervalPer treatment course defined generally as 180 days

Authorization periodAuthorization of 12 months for initial or continuation when criteria met

Quantity limits referenceQuantity limits for specific products are applied per 180-day course (see product-specific entries)

Requirement	Details
{"text":"Completion of current course","status":""} \| {"text":"Member is currently undergoing treatment and coverage is required to complete the current course of treatment.","status":""}
{"text":"Intolerable adverse events to preferred products","status":""} \| {"text":"Member has tried and experienced an intolerable adverse event to at least two of the preferred products: Euflexxa, Synvisc, or Synvisc One.","status":""}

Quantity Limits by Product

Durolane

ProductDurolane

Limit1 injection (60 mg per 3 mL) per 180-day course

Alternative listing noteAlso listed as 1 injection (3 mL each; 3 mL total) per course in quantity limits section

Synvisc-One

ProductSynvisc-One

Limit1 injection (6 mL each; 6 mL total) per 180 day course

Preferred product statusSynvisc One is listed as a preferred product

Synvisc

ProductSynvisc

Limit3 injections (2 mL each; 6 mL total) per 180 day course

Preferred product statusSynvisc is listed as a preferred product

Hyalgan

ProductHyalgan

Limit3 to 5 injections (2 mL each; 10 mL total) per 180 day course

ClassificationTargeted product (non-preferred)

Hymovis

ProductHymovis

Limit2 injections (3 mL each; 6 mL total) per 180 day course

ClassificationTargeted product (non-preferred)

Euflexxa

ProductEuflexxa

Limit3 injections (2 mL each; 6 mL total) per 180 day course

Preferred product statusEuflexxa is listed as a preferred product

Gel-One

ProductGel-One

Limit1 injection (3 mL each; 3 mL total) per 180 day course

Targeted product noteGel-One is listed among targeted (non-preferred) products

Gelsyn-3

ProductGelsyn-3

Limit3 injections (2 mL each; 6 mL total) per 180 day course

ClassificationTargeted product (non-preferred)

GenVisc 850

ProductGenVisc 850

Limit3 to 5 injections (2.5 mL each; 12.5 mL total) per 180 day course

ClassificationTargeted product (non-preferred)

Monovisc

ProductMonovisc

Limit1 injection (4 mL each; 4 mL total) per 180 day course

ClassificationTargeted product (non-preferred)

Orthovisc

ProductOrthovisc

Limit3 or 4 injections (2 mL each; 8 mL total) per 180 day course

ClassificationTargeted product (non-preferred)

Supartz FX

ProductSupartz FX

Limit3 to 5 injections (2.5 mL each; 12.5 mL total) per 180 day course

ClassificationTargeted product (non-preferred)

Durolane (alternate listing)

ProductDurolane (alternate listing)

Limit1 injection (3 mL each; 3 mL total) per course

NoteAlternate volume listing appears in quantity limits section

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyViscosupplementation (Intra‑articular hyaluronan) for Knee Osteoarthritis — Coverage Criteria

Policy CodePolicy 02.01.12

Change TypeNo material changes

Effective DateJan 1, 2024

Next Review DateJan 1, 2026

Key ActionObtain prior authorization and document diagnostic evidence, prior conservative therapy failure, analgesic and steroid trials, and functional impairment to support a 12‑month approval.

SourceLink

On This Page

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Viscosupplementation (Intra‑articular hyaluronan) for Knee Osteoarthritis — Coverage Criteria

Coverage Criteria

Initial Therapy

Continuation of Therapy

Provider Actions & Requirements

Procedure / Billing Codes & Course Interval

Step Therapy / Product Selection

Quantity Limits by Product

Background

Definitions