CurrentCignaPolicy N/A

Hyaluronic Acid Drugs

This document is a Cigna prior authorization/coverage request form and operational guidance for hyaluronic acid intra-articular drugs used primarily for knee osteoarthritis and other joint conditions, collecting clinical, administrative and billing information required for review and fulfillment.

Policy Summary

PayerCigna

PolicyHyaluronic Acid Drugs

Policy CodePolicy N/A

Change TypeOperational prior authorization form

Effective Date

Next Review Date

Key ActionProviders must submit the completed prior authorization form with all required clinical documentation (radiologic evidence, physical therapy trial, pharmacologic therapy trials, prior HA response documentation when applicable) to Cigna via fax (855-840-1678) or online; incomplete documentation may lead to denial.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

MultipleProducts referenced

>=6 monthsMinimum re-treatment interval

2Pharmacologic therapies required

Policy overview and scope

This is an operational prior authorization form for intra-articular hyaluronic acid derivatives used primarily for knee osteoarthritis and other joint conditions. The form collects patient and prescriber identifying information (physician name, specialty, DEA/NPI/TIN, patient name, Cigna ID, DOB, addresses, and contact information) and urgency designation to enable response and processing.

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Clinical prerequisites documented on the form include radiologic confirmation of osteoarthritis (x-ray, MRI, CT, ultrasound), confirmation of at least one course of physical therapy for the affected knee, the number of prior intra-articular corticosteroid injections, and attestation that the patient has tried at least two pharmacologic therapies (from acetaminophen, tramadol, duloxetine, or NSAIDs — noting two or more NSAIDs counts as one therapy).

For repeat courses, the form requires timing information: if treating one knee, confirm that at least 6 months have elapsed since the last hyaluronic acid injection in that knee; if treating both knees, confirm at least 6 months have elapsed for both knees. For specified multi-injection products the form documents whether the product requires more than one injection to complete a course, whether the patient is starting a new course or continuing a previously started course, and — for new courses of certain listed products — whether documentation is provided that the patient has tried at least one course each of Euflexxa and Durolane or Gelsyn-3 (medical documentation must be attached).

Intended use: collected administrative, clinical, and billing information is used to review and fulfill prior authorization requests; providers must submit the completed form with required clinical documentation (radiology, PT trial, pharmacologic trials, prior HA response documentation when applicable) via fax or online and incomplete documentation may lead to denial. Fax and submission instructions are provided on the form for response and urgent requests.

Key thresholds and quick facts

Products referencedMultiple branded HA products listed

Minimum re-treatment interval>=6 months

Pharmacologic therapies required (minimum)2

Scope SummaryThis document is a Cigna prior authorization/coverage request form and operational guidance for hyaluronic acid intra-articular drugs used primarily for knee osteoarthritis and other joint conditions, collecting clinical, administrative and billing information required for review and fulfillment.

Policy SubjectHyaluronic acid intra-articular injections prior-authorization form

Authorization data requirements and clinical preconditions

Authorization Data Requirements and Clinical Preconditions

Covered when ALL of the following authorization data and clinical preconditions are provided:

ALL of the following

Patient identifiers: patient name, date of birth, Cigna ID or other plan ID, and patient contact information (phone and address).
Prescriber identifiers: prescriber name, specialty, office contact, office phone and fax, and at least one of DEA, NPI, or TIN.
Medication requested: specify product name (e.g., Durolane, Euflexxa, Gel-One, Gelsyn-3, Genvisc 850, Hyalgan, Hymovis, Hymovis-One, Monovisc, Orthovisc, Supartz FX, Synojoynt, Synvisc, Synvisc-One, Triluron, Trivisc, Visco-3) and J-code/NDC where applicable.
Injection site: laterality (left knee, right knee, or both knees) and anatomic site for injection.
Where medication will be obtained: Accredo specialty pharmacy, prescriber office stock (medical claim), retail pharmacy, home health/vendor, or other; include vendor details if applicable.
Chronic condition flag: indicate whether the medication is for a chronic/long-term condition that may be necessary for the life of the patient (Yes/No).
Diagnosis related to use: specify diagnosis (knee osteoarthritis, other OA or joint pathology, acute ankle sprain, other pathologic knee conditions, or other diagnoses) and provide ICD-10 code(s).
Initial vs repeat course: indicate whether request is for initial therapy or a repeat course. Note: a repeat course = the affected knee has previously received one or more courses of any intraarticular hyaluronic acid derivative.
Radiologic confirmation: documentation that osteoarthritis of the affected knee has been confirmed by radiologic evidence (eg, x-ray, MRI, CT, or ultrasound).
Examples of acceptable radiologic evidence: plain radiographs, MRI, CT scan, or diagnostic ultrasound.
Physical therapy trial: documentation the patient tried at least one course of physical therapy for the affected knee (Yes/No).
Number of intra-articular corticosteroid injections to the affected knee: document 0, 1, 2, or >2.
Pharmacologic therapy trials: documentation the patient tried at least two of the following classes/agents: acetaminophen; tramadol; duloxetine; oral or topical NSAID (examples: naproxen, ibuprofen, celecoxib, diclofenac solution/gel).
A trial of two or more NSAIDs (oral and/or topical) counts as one pharmacologic therapy.
Specialist supervision attestation: attestation that the product will be administered by or under the supervision of a physician specializing in rheumatology, orthopedic surgery, or physical medicine and rehabilitation (physiatrist).
If the request is for a multi-injection product and the course has already been started, documentation that the patient is continuing the same product to complete the course (so the remainder of the course may be approved).

Response to Prior HA Therapy (Repeat Course Documentation)

When requesting a repeat course (additional therapy) of an intraarticular hyaluronic acid derivative for the same knee, ALL of the following must be documented:

ALL of the following

Documentation of prior HA therapy: record of the previous course(s) of intraarticular hyaluronic acid derivative given to the affected knee, including product name(s), dates of injections, and number of injections per course.
Clinical response to prior HA therapy: prescriber documentation that the patient had a positive response to the previous course (examples: reduced joint pain, decreased tenderness, reduced morning stiffness, or improved mobility).
Timing since last injection: for requests treating a single knee, documentation that at least 6 months have elapsed since the last injection with any hyaluronic acid derivative in the affected knee; for requests treating both knees, documentation that at least 6 months have elapsed since the last injection in both knees (select and document appropriately).
If less than 6 months have elapsed, the repeat course does not meet timing criteria for a new repeat course approval.

Product-specific multi-injection course & step requirements

Covered when the following product-specific multi-injection course and step requirements are met:

ALL of the following

Applicable products
- Gel-One
- GenVisc 850
- Hyalgan
- Hymovis
- Hymovis-One
- Monovisc
- Orthovisc
- Supartz FX
- Synojoynt
- Synvisc
- Synvisc-One
- Triluron
- Trivisc
- Visco-3
Multi-injection product administrative requirements
- Provider must indicate whether the requested product requires more than one injection to complete a course (Yes/No).
  Examples: GenVisc 850, Hyalgan, Hymovis, Orthovisc, Supartz FX, SynoJoynt, Synvisc, Triluron, Trivisc, Visco-3 are typically multi-injection products.
- Provider must state whether the request is for starting a new course or continuing a previously started course (Starting a new course vs Continuing a course).
  If a course has already been started, continuation with the same product to complete the course is allowed without meeting the Preferred Product trial requirement for that ongoing course.
- Provider must attach patient-specific documentation to support the request. Documentation may include chart notes, claims records, prescription receipts, imaging reports, or other medical records and must include patient identifying information.
  Requests lacking attached documentation may be denied.
- Provider must specify the site of injection (left knee, right knee, both, or other), the source/vendor of the product (e.g., Accredo specialty pharmacy, prescriber office stock, retail pharmacy, home health/vendor), and the intended billing method (medical claim billing from office stock vs pharmacy claim).
Step requirement for new courses
- For patients starting a new course with one of the listed multi-injection products, the patient must have had prior trials of BOTH: A) Euflexxa (1% sodium hyaluronate) AND B) Durolane OR Gelsyn-3.
  Medical documentation specific to these prior trials must be attached (chart notes, prescriptions, claims, or receipts).
- If the patient is continuing a course that was previously started with the same product, the continuation to complete that course is allowed without first trying the Preferred Product; however, after completing that course, further therapy will require trial of a Preferred Product as described above.

Step Therapy

Step therapy summary

Step therapy requirement: For certain multi-injection hyaluronic acid products, a prior trial of Euflexxa AND either Durolane or Gelsyn-3 is required when starting a new course. Continuation of an already-started course with the same product to complete that course is permitted without meeting this step. Attach patient-specific documentation and specify injection site, product sourcing, and billing method with the request.

Affected products: Gel-One; GenVisc 850; Hyalgan; Hymovis; Hymovis-One; Monovisc; Orthovisc; Supartz FX; Synojoynt; Synvisc; Synvisc-One; Triluron; Trivisc; Visco-3.
Provider action: Attach patient-specific documentation (chart notes, claims, prescription receipts, imaging) — documentation must include patient identifiers.
Provider action: Specify injection site, where medication will be obtained (e.g., Accredo specialty pharmacy, prescriber office stock, retail pharmacy, home health vendor), and intended billing method (medical claim/J-code vs pharmacy/NDC).

Code references and billing method

J-codes referenced on form (to be provided by requestor)HCPCS

No codes listed

Diagnosis codes to be provided by requestorICD-10

No codes listed

Billing Rule

Specify medication source and billing site

The form requires indication of where the medication will be obtained and how it will be billed. Options include Accredo Specialty Pharmacy (Cigna's nationally preferred specialty pharmacy), prescriber's office stock (billing on a medical claim), retail pharmacy, home health/home infusion vendor, or other. Indicate the selected site/source on the form for proper billing.

What providers must submit and risks

Prior Authorization

Submit completed prior authorization with required documentation

Providers must submit the completed prior authorization form with all required clinical documentation (including radiologic evidence, documentation of a physical therapy trial, pharmacologic therapy trials, and prior hyaluronic acid response when applicable) to Cigna via fax to 855-840-1678 or submit online. Incomplete submissions or missing required documentation may result in denial.

Documentation Required

Attach patient-specific medical documentation

Attach patient-specific medical documentation (chart notes, test results, claims records, prescription receipts) that include patient identifiers. This is required especially when documenting prior trials of specific products (Euflexxa and Durolane or Gelsyn-3) for certain multi-injection products.

Documentation Required

Specialist supervision attestation required

Therapy must be administered by or under the supervision of a physician who specializes in rheumatology, orthopedic surgery, or physical medicine and rehabilitation (physiatry). The form requires the provider to attest Yes/No to this supervision.

Denial Risk

Denial risk for missing documentation or unmet step requirements

Requests may be denied if required documentation is not attached or if step-therapy requirements for specified multi-injection products are not met (i.e., lack of documented trials of Euflexxa and Durolane or Gelsyn-3 when starting a new course).

Policy Summary

PayerCigna

PolicyHyaluronic Acid Drugs

Policy CodePolicy N/A

Change TypeOperational prior authorization form

Effective Date

Next Review Date

SourceLink

On This Page

OpenPayer

Hyaluronic Acid Drugs

Policy overview and scope

Authorization data requirements and clinical preconditions

Repeat course timing requirements

Product-specific multi-injection course & step requirements

Code references and billing method

What providers must submit and risks

Definitions

Document changes and review dates