CurrentmediviewcurativePolicy MM-PNP-022

Viscosupplementation for knee osteoarthritis (coverage criteria)

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This policy governs prior-approval, medical necessity, and coverage criteria for intra-articular viscosupplementation (hyaluronates) for knee osteoarthritis for Curative Health Plan participating providers and members.

Policy Summary

Payermediviewcurative

PolicyViscosupplementation for knee osteoarthritis (coverage criteria)

Policy CodePolicy MM-PNP-022

Change TypeNo material change

Effective DateDec 1, 2023

Next Review Date

Key ActionObtain prior approval for viscosupplementation products for participating providers and members where required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Preferred viscosupplement products named

10+Non-preferred viscosupplement examples listed

6 monthsMinimum interval between completed series

Prior approvalAdministrative requirement

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CurrentmediviewcurativePolicy MM-PNP-022

Viscosupplementation for knee osteoarthritis (coverage criteria)

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Sign up for mediviewcurative Policy MM-PNP-022 alerts

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Policy Summary

Payermediviewcurative

PolicyViscosupplementation for knee osteoarthritis (coverage criteria)

Policy CodePolicy MM-PNP-022

Change TypeNo material change

Effective DateDec 1, 2023

Next Review Date

Key ActionObtain prior approval for viscosupplementation products for participating providers and members where required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3Preferred viscosupplement products named

10+Non-preferred viscosupplement examples listed

6 monthsMinimum interval between completed series

Prior approvalAdministrative requirement

Coverage Criteria

Initial Approval

Covered when ALL of the following are met:

Initial approval criteria: Member has a diagnosis of knee osteoarthritis supported by radiographic evidence (e.g., joint space narrowing, subchondral sclerosis, osteophytes, subchondral cysts) OR the member has at least 5 of the specified signs/symptoms; member has knee pain that interferes with functional activities (e.g., ambulation, prolonged standing); member has experienced inadequate response or intolerance to non-pharmacologic treatments (e.g., physical therapy, exercise, insoles, knee bracing, weight reduction); member has experienced inadequate response, intolerance, or has a contraindication to a trial of analgesics (e.g., acetaminophen up to 3–4 g/day, NSAIDs, topical capsaicin) for at least 3 months; member has experienced inadequate response, intolerance, or has a contraindication to a trial of intra-articular corticosteroid injections for at least 3 months; member is not scheduled for total knee replacement within 6 months of starting treatment.

Signs/symptoms list: bony enlargement; bony tenderness; crepitus on active motion; ESR < 40 mm/hr; < 30 minutes morning stiffness; no palpable synovial warmth; age > 50 years; rheumatoid factor < 1:40 (agglutination); synovial fluid clear with normal viscosity and WBC < 2000/mm3.

Continuation of Therapy

Covered when ALL of the following are met:

Continuation criteria: Member meets all initial medical necessity criteria; member experienced improvement in pain and functional capacity after the previous injection series; at least 6 months have elapsed since the last injection in the prior completed series of injections.6 months

This policy identifies a number of indications for which viscosupplementation is considered experimental and investigational because effectiveness has not been established. Examples include intra‑articular polynucleotides and the use of imaging guidance (ultrasound, fluoroscopy, or knee arthrography) for viscosupplement injections. The policy also considers viscosupplementation investigational when used in combination with anesthetics, corticosteroids, mannitol/sorbitol, mesenchymal stem cells, or platelet‑rich plasma, as well as several specific product/formulation‑indication combinations and a range of non‑knee joint or disorder indications (see policy for the full list).

Curative explicitly lists numerous clinical scenarios as investigational for viscosupplementation, including use after ACL reconstruction or arthroscopic knee surgery, treatment of chondromalacia patellae, facet joint arthropathy, hemophilic arthropathy, patellofemoral syndrome, various peripheral nerve or plantar entrapment syndromes, psoriatic arthritis, and other conditions where benefit has not been established.

For medically necessary indications, Curative designates certain higher‑cost viscosupplement brands as non‑preferred when lower‑cost alternatives are available that are at least as likely to produce equivalent results. Specifically, Gel‑One, Gelsyn‑3, GenVisc 850, Hyalgan, Hymovis, Synojoynt, Synvisc, Synvisc One, Triluron, and Trivisc are identified as more costly and lack reliable evidence of superiority compared with the lower‑cost products Durolane, Supartz FX, and Visco‑3. Use of these non‑preferred products for medically necessary indications is considered not medically necessary when a lower‑cost alternative producing equivalent therapeutic results is available.

Coding and Product List

Preferred viscosupplement productsmixed

Durolane	Preferred viscosupplement product
Supartz FX	Preferred viscosupplement product
Visco-3	Preferred viscosupplement product

Non-preferred viscosupplement productsmixed

Gel-One	Non-preferred viscosupplement product
Gelsyn-3	Non-preferred viscosupplement product
GenVisc 850	Non-preferred viscosupplement product
Hyalgan	Non-preferred viscosupplement product
Hymovis	Non-preferred viscosupplement product
Synojoynt	Non-preferred viscosupplement product
Synvisc	Non-preferred viscosupplement product
Synvisc One	Non-preferred viscosupplement product
Triluron	Non-preferred viscosupplement product
Trivisc	Non-preferred viscosupplement product

Interval between completed series — continuation threshold

Minimum intervalAt least 6 months must have elapsed since the last injection in the prior completed series

Applies toContinuation of viscosupplementation therapy for knee osteoarthritis when initial criteria are met

Requirement linkageMember must have experienced improvement in pain and functional capacity following the previous injections

Provider Actions and Administrative Requirements

Prior Authorization

Prior approval required

Prior Approval of viscosupplementation products is required for all Curative participating providers and members in applicable plan designs.

Step Therapy

Step therapy — failed conservative treatments required

Members must have experienced inadequate response, intolerance, or contraindication to non‑pharmacologic treatments and to analgesics, and must also have inadequate response/intolerance/contraindication to intra‑articular steroid injections for the specified durations before initial approval.

Inadequate response or adverse effects with non‑pharmacologic options (e.g., physical therapy, exercise, insoles, knee bracing, weight reduction).
Inadequate response/intolerance/contraindication to an analgesic trial (e.g., acetaminophen up to 3–4 g/day, NSAIDs, topical capsaicin) for at least 3 months.
Inadequate response/intolerance/contraindication to intra‑articular steroid injections for at least 3 months.

Background

Viscosupplementation refers to intra‑articular injection of hyaluronate preparations as a treatment option for knee osteoarthritis. Curative recognizes these hyaluronate products as therapeutic options when coverage criteria are met and names Durolane, Supartz FX, and Visco‑3 as the preferred products based on cost‑effectiveness. The policy requires clinical and radiographic evidence of knee osteoarthritis and documentation of failed conservative therapies prior to approval, and it outlines specific clinical signs and symptoms that may support the diagnosis (for example, crepitus, limited morning stiffness duration, or radiographic findings such as joint space narrowing and osteophytes).

Definitions

Radiographic evidence of osteoarthritis of the knee — key findings

DefinitionRadiographic evidence of knee osteoarthritis includes findings such as joint space narrowing, subchondral sclerosis, osteophytes, and subchondral cysts

Alternative clinical supportDiagnosis may instead be supported by at least five specified signs/symptoms (e.g., bony enlargement, bony tenderness, crepitus, ESR < 40 mm/hr, <30 minutes morning stiffness)

Synovial fluid criteriaSynovial fluid consistent with OA: clear fluid of normal viscosity and WBC < 2000/mm3

Associated functional criterionMember has knee pain that interferes with functional activities (e.g., ambulation, prolonged standing)