CurrentHawaii Medical Service Association (HMSA)Policy N/A

Hyaluronate (intra-articular) products for knee osteoarthritis — Coverage Criteria

Prior authorization and coverage criteria for hyaluronate injections for treatment of knee osteoarthritis under the HMSA/CVS Caremark prescription benefit; applies to providers requesting authorization for these products for HMSA members.

Policy Summary

PayerHawaii Medical Service Association (HMSA)

PolicyHyaluronate (intra-articular) products for knee osteoarthritis — Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization to CVS Caremark with diagnosis, requested product, prior hyaluronate treatment dates, and documentation of conservative therapy failure or intolerance to preferred products.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4preferred hyaluronate products listed

6 monthsminimum interval between courses

prior authadministrative requirement

NSAID + nonpharmconservative therapy required

Coverage Criteria for Hyaluronate Injections

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Initial and repeat therapy

Covered when ALL of the following are met:

Primary diagnosis: Diagnosis is osteoarthritis of the knee.

Document ICD-10 code

Conservative therapy failure or contraindication: Patient has had inadequate response to non‑pharmacologic treatments (exercise/strength training/physical therapy and/or weight management counseling, if appropriate) AND inadequate response to an oral or topical NSAID, OR has a contraindication or history of intolerance to NSAIDs.

If intolerance or adverse event to NSAIDs, acetaminophen, or tramadol is claimed, provide reason and supporting documentation

Acetaminophen/tramadol trial or intolerance: If inadequate response to NSAIDs is not documented, patient has had an inadequate response to acetaminophen or tramadol, or has contraindication/intolerance to them.

Document intolerance or contraindication if applicable

Product selection and preferred products: If a non‑preferred hyaluronate product is requested, provider must document inability to use preferred products (Durolane, Euflexxa, Gelsyn‑3, Supartz FX), prior treatment with the requested product within the past 365 days, or that coverage is required to complete a current course.

Attach supporting chart notes for intolerable adverse events to preferred products

Prior hyaluronate treatment timing and effectiveness: If prior intra‑articular hyaluronate was given in the same joint, the start of the next treatment course must be planned at least 6 months after the date of the last injection of the previous completed treatment course; if the previous course was ineffective or caused an adverse event, authorization may not be approved for the same product.>= 6 months between courses

Provide date of last injection and response

Requests for diagnoses other than osteoarthritis of the knee are not pursued further on the prior authorization form. The form directs the user to select the diagnosis at question #2 (or #7) and routes any selection of “Other” to “No Further Questions,” halting authorization processing for non‑knee OA indications.

The request is not advanced when the form documents that the patient has not had an inadequate response to required conservative measures or when a prior hyaluronate course was ineffective. Specifically, the questionnaire requires evidence of failure of non‑pharmacologic treatments (exercise/strength training/physical therapy/weight management) at question #9 and failure of an oral or topical NSAID at question #10; answers indicating no inadequate response or an ineffective prior hyaluronate course lead to “No Further Questions” and the request is not continued.

Diagnosis and Coding

Diagnosis codesICD-10

ICD-10

Provider must supply the ICD-10 code for the diagnosis (e.g., osteoarthritis of the knee)

inv-05: Repeat injection interval — minimum interval between treatment courses.

Minimum interval between completed treatment courses>= 6 months from the date of the last injection of the previous completed treatment course

Action required on formProvide date of the last injection of the previous treatment course (MM/DD/YYYY) to demonstrate interval

When not metIf next course is planned < 6 months after last injection, the form continues to questions that may lead to denial (No, No Further Questions)

Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required for hyaluronate products administered under the patient’s prescription benefit. Providers must submit the CVS Caremark prior authorization form with an accurate diagnosis and all supporting documentation (including prior hyaluronate treatment dates and affected joint). Fax the completed form to CVS Caremark toll-free at 1-866-237-5512. For prior authorization questions contact CVS Caremark at 1-808-254-4414; for eligibility, copay, or medication delivery questions contact CaremarkConnect at 1-800-237-2767.

Fax: 1-866-237-5512
Prior auth questions: 1-808-254-4414
CaremarkConnect (eligibility/cost/delivery): 1-800-237-2767

Step Therapy

Preferred Product Step Therapy

A preferred-product step-therapy pathway applies. The plan’s preferred hyaluronate products are Durolane, Euflexxa, Gelsyn-3, and Supartz FX. If a non-preferred product is requested for osteoarthritis of the knee, prescribers must indicate whether the patient can be switched to one of the preferred products. If the patient cannot be switched, document prior use of the requested product within the past 365 days, ongoing treatment that must be completed, or a documented intolerable adverse event to all preferred products with supporting chart notes.

Preferred products: Durolane, Euflexxa, Gelsyn-3, Supartz FX
If switch possible: indicate which preferred product (Durolane, Euflexxa, Gelsyn-3, or Supartz FX)
If non-preferred requested: document prior injection date within 365 days or attach intolerance/adverse-event chart notes

Documentation Required

Required Documentation

Providers must complete and submit the prior authorization form with clinical responses to the Clinical Criteria Questions (e.g., current treatment status, diagnosis, prior hyaluronate course dates, response to prior therapy, prior nonpharmacologic and NSAID trials, and any contraindications or intolerances). Attach supporting documentation (chart notes) when requesting exception for adverse events or intolerance to preferred products.

Clinical criteria required on form: current treatment status; diagnosis (osteoarthritis of the knee or other); date of last injection and whether ≥6 months since prior course; prior nonpharmacologic therapies and NSAID trials; contraindications/intolerances; reason for requesting a different product
Attach supporting chart notes if claiming intolerable adverse events to preferred products

Background

Intra‑articular hyaluronate injections are used for symptomatic management of osteoarthritis of the knee. This prior authorization policy focuses on documenting the knee OA diagnosis, prior hyaluronate treatment dates and response, adherence to conservative therapy trials (non‑pharmacologic measures and oral/topical NSAIDs), and product selection. The form routes providers through questions that confirm diagnosis, prior injection timing (including the minimum 6‑month interval between completed courses), effectiveness of prior courses, and whether a non‑preferred product is being requested due to adverse events or prior use.

Definitions

inv-11: Repeat treatment interval — A new course should be planned at least 6 months after the last injection of a previous completed treatment course.

Planned timing for new courseA new course should be planned at least 6 months after the last injection of a previous completed treatment course

Documentation neededProvide the date of the last injection of the previous treatment course on the prior authorization form

Effect of prior course effectivenessIf the previous course was ineffective, authorization may not be approved for the same product

Adverse event handlingIf a different hyaluronate product is requested due to an adverse event with the previous course, the form routes to denial questions to document the adverse event