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    v1.0.31
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsClover Health Hyaluronan Coverage | OpenPayer
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    CurrentClover HealthPolicy 3832-A

    Jurisdiction Specific Medicare Part B Hyaluronans

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    This policy governs coverage and authorization of specified hyaluronan products administered under Medicare Part B for osteoarthritis, shoulder impingement syndrome, and other approved indications. It applies to members in the specified Medicare Administrative Contractor jurisdictions when the stated clinical criteria and applicable exclusions are satisfied.

    Policy Summary
    PayerClover Health
    PolicyJurisdiction Specific Medicare Part B Hyaluronans
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionFor an initial knee or shoulder osteoarthritis course, document inadequate response to conservative nonpharmacologic therapy and simple analgesics.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    13Listed hyaluronan products
    6 monthsStandard authorization period
    3 monthsShoulder impingement authorization
    6 monthsMinimum interval before repeat course

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1
    Maximum repeat shoulder osteoarthritis courses

    Covered Indications and Exclusions

    Osteoarthritis of the Knee

    Authorization may be granted when the applicable treatment-course criteria below are met.

    ONE of the following treatment-course pathways

    • Initial treatment course

      • Authorization of 6 months may be granted for treatment of pain associated with osteoarthritis of the knee for the first treatment course in members who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.

    • Subsequent treatment courses

      • Authorization of 6 months may be granted for subsequent treatment courses of osteoarthritis of the knee.
      • The medical record indicates the member experienced objective improvement in pain and functional capacity from the prior series of injections (i.e., reduction of symptomatology and medication usage).
      • The last injection (in a prior course) was given at least six months ago.

    Osteoarthritis of the Shoulder

    Authorization may be granted when the applicable treatment-course criteria below are met.

    ONE of the following treatment-course pathways

    • Initial treatment course

      • Authorization of 6 months may be granted for osteoarthritis of the shoulder for the first treatment course in members who have failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.

    • Subsequent treatment

      • Authorization of 6 months may be granted for subsequent treatment of osteoarthritis of the shoulder.
      • The medical record indicates the member experienced objective improvement in pain and functional capacity from the prior series of injections (i.e., reduction of symptomatology and medication usage).

    Impingement Syndrome of the Shoulder

    Authorization may be granted for the following indication.

    Authorization of 3 months may be granted for treatment of subacromial impingement syndrome of the shoulder.

    All Other Indications

    Authorization may be granted for the following indication.

    Authorization of 6 months may be granted for treatment of all other approvable indications listed in LCA A52420.

    The indications below are considered a covered benefit provided that all the approval criteria are met and the member has no exclusions to the prescribed therapy.

    Initial Treatment Requirements

    Initial Osteoarthritis Course

    Initial treatment for knee or shoulder osteoarthritis may be covered when all criteria for either the knee or shoulder indication are met.

    Knee or shoulder osteoarthritis

    • Knee osteoarthritis

      • The member has pain associated with osteoarthritis of the knee.
      • The member has failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.Authorization period: 6 months

    • Shoulder osteoarthritis

      • The member has osteoarthritis of the shoulder.

    Subsequent Treatment Requirements

    Subsequent Osteoarthritis Treatment

    Subsequent knee or shoulder osteoarthritis treatment is covered when all applicable repeat-course criteria are met.

    Knee or shoulder subsequent treatment

    • Subsequent knee osteoarthritis treatment

      • The member is being treated for osteoarthritis of the knee.
      • The medical record indicates objective improvement in pain and functional capacity from the prior series of injections, including reduction of symptomatology and medication usage.
      • The last injection in the prior course was given at least six months ago.At least 6 months since last injection

    • Subsequent shoulder osteoarthritis treatment

    Required Conservative Treatment

    StepRequired therapyRequirement
    1Conservative nonpharmacologic therapy and simple analgesicsMust be tried before the initial hyaluronan course for knee or shoulder osteoarthritis; the member must have failed to respond adequately.

    Authorization and Documentation Guidance

    Prior Authorization

    Knee Osteoarthritis Authorization

    Request authorization for a six-month treatment period for pain associated with knee osteoarthritis. The first treatment course requires inadequate response to conservative nonpharmacologic therapy and simple analgesics; subsequent courses require the repeat-treatment criteria below.

    • First course: member failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.
    • Subsequent courses: document objective improvement in pain and functional capacity from the prior injection series and confirm the last injection was at least six months ago.
    Prior Authorization

    Shoulder Osteoarthritis Authorization

    Request authorization for a six-month treatment period for shoulder osteoarthritis. The first treatment course requires inadequate response to conservative nonpharmacologic therapy and simple analgesics; subsequent treatment is subject to repeat-course restrictions.

    • First course: member failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.

    Policy Context

    Hyaluronan products are injectable viscosupplementation therapies used for selected musculoskeletal conditions. This Medicare Part B policy addresses coverage for specified uses, including osteoarthritis and shoulder conditions, when the applicable approval criteria are met and no exclusion applies.

    Key Terms

    Subacromial impingement syndrome of the shoulder
    DefinitionA shoulder condition involving subacromial impingement.
    Compendial uses
    DefinitionUses recognized by Medicare-approved compendia but not necessarily included among the specifically listed FDA-labeled indications.
    Policy Summary
    PayerClover Health
    PolicyJurisdiction Specific Medicare Part B Hyaluronans
    Policy CodePolicy N/A
    Change TypeNo material change
    Effective DateN/A
    Next Review DateN/A
    Key ActionFor an initial knee or shoulder osteoarthritis course, document inadequate response to conservative nonpharmacologic therapy and simple analgesics.
    SourceLink
    On This Page
    Covered Indications and ExclusionsInitial Treatment RequirementsSubsequent Treatment RequirementsRequired Conservative TreatmentAuthorization and Documentation GuidancePolicy ContextKey Terms
    The last injection (in a prior course) was given at least six months ago.
  1. The member has received only one previous course of treatment. Repeat injections for shoulder arthritis are limited to a single repeat course.
  2. The member has failed to respond adequately to conservative nonpharmacologic therapy and simple analgesics.Authorization period: 6 months

    3. Shoulder Impingement Course

    Initial treatment may be covered when the member has subacromial impingement syndrome of the shoulder.

    Shoulder impingement therapy

    • The member has subacromial impingement syndrome of the shoulder.Authorization period: 3 months
    • The member is being treated for osteoarthritis of the shoulder.
    • The medical record indicates objective improvement in pain and functional capacity from the prior series of injections, including reduction of symptomatology and medication usage.
    • The last injection in the prior course was given at least six months ago.At least 6 months since last injection
    • The member has received only one previous course of treatment.Maximum one previous course

      Repeat injections for shoulder arthritis are limited to a single repeat course.

  3. Subsequent treatment: document objective improvement in pain and functional capacity and confirm the last injection was at least six months ago.
  4. Shoulder arthritis injections are limited to one repeat course; only one previous course may have been received.
    5. Prior Authorization

    Shoulder Impingement Authorization

    Request authorization for a three-month treatment period when treating subacromial impingement syndrome of the shoulder.

    • Indication: subacromial shoulder impingement syndrome.
    Prior Authorization

    Other Approvable Indications

    Request authorization for a six-month treatment period for other approvable indications listed in Medicare Billing and Coding article LCA A52420.

    • Indications must be listed in LCA A52420.

    Unsupported block type: documentation

    Unsupported block type: documentation

    Unsupported block type: documentation

    Unsupported block type: prior_auth

    Denial Risk

    Repeat-Course Restrictions

    Repeat treatment may be denied when the record does not document objective improvement from the prior injection series, when the required six-month interval has not elapsed, or when treatment-course limits are exceeded.

    • Knee and shoulder osteoarthritis: the last injection in the prior course must have been at least six months ago.
    • Knee and shoulder osteoarthritis: objective improvement in pain and functional capacity is required.
    • Shoulder osteoarthritis: repeat injections are limited to one repeat course; deny requests exceeding this limit.