Intra-Articular Hyaluronan Injections for Osteoarthritis
Coverage policy for intra-articular hyaluronan (viscosupplementation) for osteoarthritis, applicable to Commercial products of Blue Cross & Blue Shield of Rhode Island; Medicare Advantage follows CMS NCD/LCD.
No material clinical or coverage changes in this revision.
Coverage Determination
Not Medically Necessary — Commercial Products
Covered when ALL of the following are met:
Based on randomized controlled trials and meta-analyses showing mixed and generally small effects with risk of bias and publication/small-trial effects; evidence insufficient to demonstrate net health benefit.
For Commercial Products, intra-articular hyaluronan (IAHA) injections of the knee and all other joints are considered not medically necessary. The policy states the evidence is insufficient to determine the effects of the technology on health outcomes, and therefore these services are not covered for Commercial members.
If services are determined to be not medically necessary or are non-covered benefits, providers may not charge the member unless the member has been informed and has agreed in writing in advance to pay at their own expense. Verify member-specific benefits and follow the applicable participation and subscriber agreements.
The policy lists specific intra-articular hyaluronan HCPCS/J-codes that are not medically necessary for Commercial Products, including: J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, and J7332. Additionally, CPT code 20610 (arthrocentesis, aspiration and/or injection, major joint or bursa) is considered not medically necessary when billed in conjunction with one of the listed J-codes.
The policy notes that some services may be determined to be not medically necessary or non-covered; specific non-covered or not medically necessary conditions beyond the listed IAHA items are not detailed in this portion of the document. Providers should check member-specific benefits and coverage rules and obtain written member agreement before billing for non-covered services.
Coding and Billing
| J7318 | Hyaluronan or derivative, durolane, for intra-articular injection, 1 mg |
| J7320 | Hyaluronan or derivative, GenVisc 850, for intra-articular injection, 1 mg |
| J7321 | Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose |
| J7322 | Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg |
| 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, 1 mg |
| J7326 | Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose |
| J7327 | Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose |
| J7328 | Hyaluronan or derivative, Gel-syn, for intra-articular injection, 0.1 mg |
| 20610 | Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa) |
| 20611 | Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting |
Provider Responsibilities & Billing Notes
Prior Authorization
Prior authorization is not applicable for this policy. Medicare Advantage members follow CMS NCD/LCD requirements; providers should follow applicable CMS guidance for those members.
Verify benefits / Prior Authorization
Policy directs providers to verify member-specific benefits and prior authorization requirements when applicable. For member-specific benefit information, contact the provider call center or refer to the member's Benefit Booklet, Evidence of Coverage, Subscriber Agreement, or employer agreement.
- Contact the provider call center for member-specific benefits and prior authorization information.
- Benefit determinations are governed by the member's subscriber agreement, Evidence of Coverage, or employer agreement.
Check Member Benefits and Eligibility
Providers must check member benefits and eligibility prior to providing services. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement; those documents supersede this medical policy.
- Verify eligibility and benefits before scheduling services.
- If services are determined to be not medically necessary or non-covered, members may not be balance-billed unless they were informed and provided written agreement in advance.
Benefit Verification
Benefits may vary between groups and contracts. Refer to the appropriate Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable coverage details and not medically necessary benefit language.
- Benefits vary by contract — confirm specifics in the member's Benefit Booklet or Evidence of Coverage.
- This policy applies to Commercial Products only; for Medicare Advantage plans follow CMS NCD/LCD.
Not Medically Necessary Codes
Use of the following intra-articular hyaluronan HCPCS/J-codes (and CPT 20610 when billed in conjunction with these J-codes) for Commercial Products is considered not medically necessary and may be denied.
- J7318 — Hyaluronan or derivative, Durolane, for intra-articular injection, 1 mg
- J7320 — Hyaluronan or derivative, GenVisc 850, for intra-articular injection, 1 mg
- J7321 — Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose
- J7322 — Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg
- 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, 1 mg
- J7326 — Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose
- J7327 — Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose
- J7328 — Hyaluronan or derivative, Gel-syn, for intra-articular injection, 0.1 mg
- J7329 — Hyaluronan or derivative, Trivisc, for intra-articular injection, 1 mg
- J7331 — Hyaluronan or derivative, Synojoynt, for intra-articular injection, 1 mg
- J7332 — Hyaluronan or derivative, Triluron, for intra-articular injection, 1 mg
- CPT 20610 — Arthrocentesis, aspiration and/or injection, major joint or bursa (when used with the above J-codes)
Clinical Background
Knee osteoarthritis (OA) is common and a frequent cause of disability. Intra-articular hyaluronan (viscosupplementation) is proposed to restore synovial fluid viscoelasticity and thereby reduce pain and improve function; most of the available evidence pertains to the knee. Randomized trials and systematic reviews provide mixed and generally small effects with concerns about bias and publication/small-trial effects, leaving insufficient evidence of net health benefit for IAHA in the knee and other joints.
Key Terms
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