CurrentHighmark Blueshield NenyPolicy N/A

Outpatient intra-articular hyaluronan (viscosupplementation) injections

Policy governs authorization and documentation requirements for outpatient intra-articular hyaluronan injections for knee osteoarthritis for Highmark BlueShield members, including preferred and non-preferred products and criteria for medical necessity.

Policy Summary

PayerHighmark Blueshield Neny

PolicyOutpatient intra-articular hyaluronan (viscosupplementation) injections

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionDocument at least 3 months of conservative therapy and attach clinical evidence when requesting a non-preferred hyaluronan product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4Preferred product HCPCS codes listed

13Non-preferred product HCPCS codes listed

3 moConservative therapy duration

AppliesMedicare exception

Medical Necessity and Coverage Criteria

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Non-Preferred Product Medical Necessity

Non-preferred product considered medically necessary when ALL of the following are met:

Member indication: Member has symptomatic painful osteoarthritis of the knee with no evidence of inflammatory arthritis

Conservative therapy: Member has failed to respond adequately to at least 3 months of conservative therapy defined as activity modification; participation in a home exercise program implemented by a physical therapist; protective weight bearing; adequate trial of non-narcotic analgesics/topical agents at FDA or compendia recommended doses; and intra-articular corticosteroid injections3 months

Tolerance/contraindication: Member is unable to tolerate conservative therapy due to adverse side effects or other medical conditions (if applicable)

Provider: Injections will be performed by a licensed medical professional (e.g., MD, DO, PA, or CRNP)

Documentation and step therapy: Documentation attached demonstrating prior trials/failures of ALL preferred products (Euflexxa J7323; Supartz/Hyalgan/Visco-3 J7321; GelSyn-3 J7328; Durolane J7318). Medicare members currently established on a non-preferred therapy are exempt from the requirement to try preferred products

Attach dates of prior series, conservative therapy documentation, and objective measures of pain/function when available

Coverage for viscosupplementation is limited to treatment of symptomatic knee osteoarthritis. If the member's knee pain can be attributed to other forms of joint disease (for example, inflammatory arthritis or another non‑osteoarthritis joint disorder), this excludes coverage for viscosupplementation for the osteoarthritis indication. Providers must confirm the diagnosis of symptomatic painful osteoarthritis of the knee with no evidence of inflammatory arthritis when requesting authorization.

A request for a non‑preferred hyaluronan product will not be supported unless there is documentation that the member has experienced documented drug therapy failure after an adequate trial, intolerance, or a contraindication to ALL preferred products. The form requires documentation of trials (including dates) for each preferred product (Euflexxa J7323, Supartz/Hyalgan J7321, GelSyn‑3 J7328, Durolane J7318). An exception applies to Medicare members already established on a non‑preferred therapy; those members are not required to try preferred options.

HCPCS Codes, Coding Notes, and Therapy Duration

Preferred HCPCS CodesHCPCSCovered

J7323	Euflexxa
J7321	Supartz
J7328	GelSyn-3
J7318	Durolane

Non-Preferred HCPCS CodesHCPCS

J7325	Synvisc / Synvisc-One
J7320	GenVisc 850
J7322	Hymovis
J7327	Monovisc
J7331	Synojoynt
J7326	Gel One
J7332	Triluron
J7321	Hyalgan / Visco-3
J7324	Orthovisc
J7329	TriVisc

inv-06: Conservative therapy duration — required duration before considering non-preferred products

Required durationAt least 3 months of conservative therapy prior to considering a non-preferred hyaluronan product

Components of the 3-month trialActivity modification/home exercise program with PT, protective weight bearing, adequate trial of non-narcotic analgesics/topical agents, and intra-articular corticosteroid injections

ExceptionMedicare members already established on a non-preferred product are exempt from the trial of preferred products (no requirement to retry preferred agents)

Consequence of no documentationFailure to document at least 3 months of conservative therapy may trigger denial of a non-preferred product request

Prior Authorization, Documentation, and Step Therapy

Prior Authorization

Prior Authorization Required for Non-Preferred Products

Preferred products (Euflexxa, Supartz, GelSyn-3, Durolane) do not require prior authorization. Non-preferred products require prior authorization and must include documentation of prior trials of all preferred products, unless an exception applies (see step therapy and exceptions).

Preferred: Euflexxa (J7323), Supartz (J7321), GelSyn-3 (J7328), Durolane (J7318)
Non-preferred: Synvisc/Synvisc-One (J7325), GenVisc 850 (J7320), Hymovis (J7322), Monovisc (J7327), Synojoynt (J7331), Gel One (J7326), Triluron (J7332), Hyalgan/Visco-3/Orthovisc/TriVisc (J7321/J7324/J7329)

Step Therapy

Step Therapy Requirement for Non-Preferred Products

Non-preferred products will be considered only after an adequate trial, intolerance, or contraindication to ALL preferred products is documented. Medicare members already established on a non-preferred therapy are exempt from the preferred product trial requirement.

A documented drug therapy failure, intolerance, or contraindication to ALL preferred products is required before approval of a non-preferred product.
Medicare members currently established on a non-preferred therapy do not need to try preferred options.

Denial Risk

Denial Risk: Non-Preferred Product Without Preferred Trial

If the request is for a non-preferred product without documentation of trials/failure/intolerance to all preferred products, the request may be denied. Providers should include dates and outcomes of prior preferred product trials and the clinical rationale for requesting a non-preferred product.

Provide dates of prior therapy and dates of prior series for preferred products (Yes/No with dates for each preferred product).
Include clinical rationale explaining why a non-preferred product is requested (e.g., adverse reaction to preferred agents, documented lack of efficacy).
Attach supporting clinical documentation (progress notes, medication history, objective pain/functional measures).

Documentation Required

Documentation Required for Prior Authorization

Attach documentation demonstrating at least 3 months of conservative therapy (unless intolerance/contraindication) and any objective measures of improvement following prior injections. Failure to document conservative therapy or testable outcomes may affect approval.

Document at least 3 months of conservative therapy (activity modification, PT/home exercise, weight bearing protection).
Document trials of non-narcotic analgesics/topical agents and intra-articular corticosteroid injections, with dates.
Provide objective measures of pain/function (e.g., VAS, WOMAC) showing response or lack thereof.
Attach all pertinent clinical information.

Denial Risk

Denial Risk: Lack of Documented Conservative Therapy

If there is no documented conservative therapy trial of at least 3 months, coverage may be denied. Ensure documentation explains intolerance or contraindication if conservative therapy was not possible.

At least 3 months of conservative non-surgical management is expected prior to viscosupplementation unless documented intolerance/contraindication.
If conservative therapy was not tolerated, include explanation and supporting clinical notes.

Definitions and Conservative Therapy Components

inv-13: Conservative therapy — activity modification, home exercise program, protective weight bearing, non-narcotic analgesics/topicals

Activity modification/home exerciseParticipation in a home exercise program implemented by a physical therapist and activity modification

Protective weight bearingMeasures to limit weight-bearing stress on the affected knee (protective weight bearing)

Non-narcotic analgesics/topicalsAdequate trial of non-narcotic analgesics (e.g., acetaminophen, NSAIDs) at FDA or compendia-recommended doses and topical agents such as capsaicin or topical anti-inflammatory preparations

Intra-articular corticosteroidsTrial of intra-articular corticosteroid injections as part of conservative management

OpenPayer

Outpatient intra-articular hyaluronan (viscosupplementation) injections

Medical Necessity and Coverage Criteria

HCPCS Codes, Coding Notes, and Therapy Duration

Prior Authorization, Documentation, and Step Therapy

Policy Background and Scope

Definitions and Conservative Therapy Components