CurrentNew Hampshire Department of Health and Human ServicesPolicy N/A

Hyaluronic Acid Derivatives - Injection Criteria

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This policy governs New Hampshire Medicaid Fee-for-Service coverage and prior authorization for hyaluronic acid derivative injections used to treat osteoarthritis symptoms. It applies to providers requesting initial approval or renewal for covered knee injections.

Policy Summary

PayerNew Hampshire Department of Health and Human Services

PolicyHyaluronic Acid Derivatives - Injection Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document that all five clinical criteria are met before administering the requested product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16Listed hyaluronic acid derivative products

KneeFDA-approved treatment area

5Required approval criteria

180 daysDose interval per knee

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CurrentNew Hampshire Department of Health and Human ServicesPolicy N/A

Hyaluronic Acid Derivatives - Injection Criteria

Customize your policy alerts

Sign up for all New Hampshire Department of Health and Human Services policy alerts

Know when New Hampshire Department of Health and Human Services releases new policies or updates existing guidance.

Monitor payer policy activity

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Policy Summary

PayerNew Hampshire Department of Health and Human Services

PolicyHyaluronic Acid Derivatives - Injection Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document that all five clinical criteria are met before administering the requested product.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

16Listed hyaluronic acid derivative products

KneeFDA-approved treatment area

5Required approval criteria

180 daysDose interval per knee

4One-time injection products

6Explicit denial conditions

Coverage Criteria

Initial Approval and Renewal Criteria

Covered when ALL of the following criteria are met:

ALL required criteria

Evidence of severe bone-on-bone osteoarthritis of the knee.
Trial and failure or contraindication to non-pharmacologic therapy, such as use of a cane, walker, physical therapy, or brace.
Trial and failure or contraindication to simple analgesics, such as NSAIDs (non-steroidal anti-inflammatory drugs) and acetaminophen.
Trial and failure or contraindication to aspiration and injection of intra-articular steroids.
Pain reported with functional activities, such as ambulation or prolonged sitting.

Coverage is denied for individuals with hypersensitivity to hyaluronan or any component of the product.

Coverage is denied when there are infections or skin diseases in the area of the injection site or joint.

Repeat approval is denied when less than a six-month interval has elapsed from the initial approval.

Administration and Interval Rules

Administration interval

Dose or administration limitOne dose or administration

IntervalPer 180 days

Applies perKnee

Prior Authorization and Documentation

Prior Authorization

Approval and Renewal Requirements

Prior authorization requires documentation that all five approval criteria are met. Initial approval and renewal are limited to one dose or administration per knee per 180 days (six months), according to the requested product's labeled injection schedule.

Durolane®, Gel-One®, Monovisc®, and Synvisc-One®: one-time injection.
Euflexxa®, GelSyn-3®, Synvisc®, Triluron®, TriVisc®, and Visco-3™: weekly intervals for a total of 3 injections.
Hymovis®: weekly intervals for a total of 2 injections.
Orthovisc®: weekly intervals for a total of 4 injections.
GenVisc®850®, Hyalgan®, and Supartz/FX®: weekly intervals for a total of 5 injections.
SynoJoynt™: weekly intervals for a total of 3 injections.

Documentation Required

Required Conservative-Treatment Failures

Policy Background

This policy addresses hyaluronic acid derivative injections for symptoms associated with knee osteoarthritis. Coverage is considered in the context of severe bone-on-bone osteoarthritis of the knee, with the required clinical documentation and treatment history.

Clinical Terms

Non-pharmacologic therapy

CaneExample of non-pharmacologic therapy

WalkerExample of non-pharmacologic therapy

Physical therapyExample of non-pharmacologic therapy

BraceExample of non-pharmacologic therapy

Simple analgesics

NSAIDsNon-steroidal anti-inflammatory drugs; an example of a simple analgesic

AcetaminophenExample of a simple analgesic

Policy Summary

PayerNew Hampshire Department of Health and Human Services

PolicyHyaluronic Acid Derivatives - Injection Criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization and document that all five clinical criteria are met before administering the requested product.

SourceLink

On This Page

Document a trial and failure or contraindication to each required conservative treatment before requesting approval.

Non-pharmacologic therapy, such as use of a cane, walker, physical therapy, or brace.
Simple analgesics, including NSAIDs (non-steroidal anti-inflammatory drugs) and acetaminophen.
Aspiration and injection of intra-articular steroids.

Documentation Required

Clinical Evidence Supporting Approval

Support the request with clinical documentation establishing severe knee osteoarthritis and clinically meaningful symptoms, together with the relevant treatment history.

Evidence of severe bone-on-bone osteoarthritis of the knee.
Pain reported with functional activities, such as ambulation or prolonged sitting.
Records showing the required conservative-treatment trials, failures, or contraindications.

Denial Risk

Required Trials or Diagnosis Not Established

The request is at risk for denial when severe bone-on-bone knee osteoarthritis is not established or when required treatment trials, failures, or contraindications are not documented.

No evidence of severe bone-on-bone osteoarthritis of the knee.
No documented trial and failure or contraindication to non-pharmacologic therapy.
No documented trial and failure or contraindication to simple analgesics.
Required treatment history, including aspiration and intra-articular steroid injection, is absent or insufficient.

Denial Risk

Product Hypersensitivity

Do not request approval when the member has hypersensitivity to hyaluronan or any component of the requested product.

Hypersensitivity to hyaluronan.
Hypersensitivity to any component of the requested product.

Denial Risk

Injection-Site Infection or Skin Disease

Approval is at risk for denial when infection or skin disease is present in the area of the injection site or joint.

Infection at the injection site or joint.
Skin disease in the area of the injection site or joint.

Denial Risk

Premature Repeat Approval

A repeat request is at risk for denial when fewer than six months have elapsed since the initial approval. Initial approval and renewal are limited to one dose or administration per knee per 180 days.

Confirm that at least six months have elapsed since initial approval before submitting a repeat request.

CategorySimple analgesics

Pain with functional activities

AmbulationPain during walking or other movement from place to place

Prolonged sittingPain during extended periods of sitting

General definitionPain reported with functional activities