CurrentUnitedHealthcarePolicy CSIND0081.05

Sodium Hyaluronate (for Indiana Only)

Defines UnitedHealthcare Community Plan medical benefit drug policy for intra-articular sodium hyaluronate products for members in Indiana; describes covered products, coding references, and reliance on InterQual criteria for medical necessity.

Policy Summary

PayerUnitedHealthcare

PolicySodium Hyaluronate (for Indiana Only)

Policy CodePolicy CSIND0081.05

Change TypeRoutine reviewno material changes

Effective DateJul 1, 2025

Next Review Date

Key ActionObtain prior authorization when required and submit appropriate procedure and J‑codes with requests that meet InterQual clinical criteria.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes.

Indiana-onlystate applicability

>=13products referenced

InterQualcriteria source

CSIND0081.05policy id

2025-07-01effective

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

InterQual-governed medical necessity

Covered when the InterQual clinical coverage criteria for intra-articular sodium hyaluronate are met.

InterQual-based coverage: Intra-articular injections of sodium hyaluronate are proven and medically necessary for the treatment of conditions outlined within the InterQual criteria.

Refer to the current release of InterQual for full clinical eligibility, specific indications, and exclusions.

Policy application is subject to applicable federal, state, or contractual benefit plan requirements which may differ from the provisions of this document. In the event of a conflict, the federal, state, or contractual requirements for benefit plan coverage govern. This policy is provided for informational purposes and does not constitute medical advice or override applicable benefit contract terms.

Services that do not meet the InterQual clinical coverage criteria for intra-articular sodium hyaluronate are not considered medically necessary under this policy.

Procedure and Drug Coding

Procedure CPT CodesCPT

20605	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); without ultrasound guidance.
20606	Arthrocentesis, aspiration and/or injection, intermediate joint or bursa (e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa); with ultrasound guidance; with permanent recording and reporting.
20610	Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance.
20611	Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); with ultrasound guidance, with permanent recording and reporting.

HCPCS J-CodesHCPCS

J3490	Unclassified drugs.
J7318	Hyaluronan or derivative, Durolane, for intra-articular injection, 1 mg.
J7320	Hyaluronan or derivative, GenVisc 850, for intra-articular injection, 1 mg.
J7321	Hyaluronan or derivative, Hyalgan, Supartz or Visco-3, for intra-articular injection, per dose.
J7322	Hyaluronan or derivative, Hymovis, for intra-articular injection, 1 mg.
J7323	Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose.
J7324	Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose.
J7325	Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg.
J7326	Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose.
J7327	Hyaluronan or derivative, Monovisc, for intra-articular injection, per dose.

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Provider Requirements, Prior Auth, and Billing

Prior Authorization

Prior Authorization and InterQual Criteria

Coverage determined using InterQual® criteria. Coverage for intra-articular sodium hyaluronate injections is determined using the current InterQual clinical criteria. Providers should obtain prior authorization when required by plan or local contract and ensure documentation supports InterQual requirements.

Prior authorization may be required per plan or contract — confirm with payer.
Services not meeting InterQual criteria may be considered not medically necessary and subject to denial.

Denial Risk

InterQual‑Guided Denial Risk

Services not meeting InterQual criteria may be denied. If the submitted clinical information does not meet the InterQual-guided medical necessity criteria for intra‑articular sodium hyaluronate, the service may be adjudicated as not medically necessary and denied.

Documentation Required

Coding & Claim Documentation

Coding and claim documentation requirements. Use applicable CPT and HCPCS/J‑codes when submitting claims and include clinical documentation to support medical necessity per InterQual. Ensure documentation of diagnosis, prior conservative therapy, symptom duration and functional impact, and site of injection are included in the medical record and available on request.

Covered/commonly used CPT codes: 20605, 20606, 20610, 20611 (arthrocentesis/ injection codes).
Relevant HCPCS/J‑codes: J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, J7332, and J3490 (unclassified drug) as applicable.
Include documentation of product administered (brand name and amount), route/site of administration, and linkage to InterQual criteria.

Billing Rule

Provider action: Confirm prior authorization and submit complete clinical documentation aligned to InterQual; use the applicable CPT and J‑codes listed on the policy when billing.

Background

Sodium hyaluronate products are viscoelastic hyaluronans formulated for intra-articular injection to treat joint conditions, commonly knee osteoarthritis. Examples referenced by this policy include Durolane, Euflexxa, Gel-One, Gelsyn-3, GenVisc 850, Hymovis, Monovisc, Orthovisc, Supartz, and Synojoynt. UnitedHealthcare uses the current release of the InterQual clinical criteria to determine medical necessity for intra-articular sodium hyaluronate injections; providers should refer to InterQual for specific eligibility and exclusions.

Definitions and Product Examples

Sodium hyaluronate products referenced by policy

DurolaneDurolane®

EuflexxaEuflexxa® (1% sodium hyaluronate)

Gel-OneGel-One® (cross-linked hyaluronate)

Gelsyn-3Gelsyn-3™ (sodium hyaluronate)

GenVisc 850GenVisc 850® (sodium hyaluronate)

HymovisHymovis® (high molecular weight viscoelastic hyaluronan)

MonoviscMonovisc® (high-molecular-weight hyaluronan)

OrthoviscOrthovisc® (high-molecular-weight hyaluronan)

SupartzSupartz™ (sodium hyaluronate)

SynojoyntSynojoynt™ (1% sodium hyaluronate)

SynviscSynvisc (Hylan G-F 20)

TriluronTriluron (sodium hyaluronate)

TriViscTriVisc (sodium hyaluronate)

Visco-3Visco-3 (sodium hyaluronate)

InterQual (policy definition)

InterQual definitionInterQual®: third-party clinical coverage criteria used by UnitedHealthcare to determine medical necessity for intra-articular sodium hyaluronate injections; refer to the current release of the InterQual guideline for full clinical eligibility and exclusions.

Role in coverageCoverage for intra-articular sodium hyaluronate is governed by InterQual criteria; services that do not meet InterQual criteria are not considered medically necessary per this policy.

Provider actionProviders should refer to the current release of InterQual for specific medical necessity criteria and obtain prior authorization as required by the plan.