Highmark Medical Policy Bulletin
Section: Miscellaneous
Number: G-25
Topic: Intra-Articular Hyaluronan Injections (e.g., Synvisc, Hyalgan) for Osteoarthritis of the Knee
Effective Date: September 17, 2001
Issued Date: September 17, 2001
Date Last Reviewed: 09/2001

General Policy Guidelines

Osteoarthritis is the most common form of arthritis. Pathologically, it is characterized by deterioration and loss of articular cartilage, subchondral sclerosis and osteophyte formation. Since there are no curative therapies for osteoarthritis at this time, the overall goals of existing therapies are to reduce pain, prevent disability, and postpone the need for total knee replacement surgery.

Conservative methods of therapy for osteoarthritis may include the use of simple analgesics, (e.g., acetaminophen), nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular corticosteroid injections. For patients who fail to respond to these conservative therapies, there is yet another form of treatment for the osteoarthritic knee called intra-articular injections of hyaluronan. Brand name examples of hyaluronan are Synvisc (code J7320), Hyalgan (code J7315), or Supartz (code 90799).

Intra-articular injections of hyaluronan act as lubricants to restore elasticity and viscosity to the arthritic knee. The procedure involves an arthrocentesis to aspirate the bad or damaged synovial fluid from the knee. Then, to replace the fluid, the hyaluronan preparation (Synvisc, Hyalgan, or Supartz) is injected.

Intra-articular hyaluronan injections should be reported under code 20610 (arthrocentesis, major joint) to represent the aspiration/injection procedure, and code J7320 (Synvisc), J7315 (Hyalgan), or 90799 (Supartz) to represent the specific preparation used.

When therapeutic injections are a benefit of a member's contract, intra-articular hyaluronan injections are eligible when all of these criteria have been met:

  1. The patient has symptomatic osteoarthritis of the knee (715.16, 715.26, 715.36, 715.96);
  2. The patient has failed to respond to conservative therapy (analgesics, NSAIDs or intra-articular corticosteroid injections), or is unable to tolerate therapy, (e.g., NSAIDs), because of adverse side effects;
  3. There are no contraindications to the hyaluronan injections;
  4. The hyaluronan product is FDA-approved for intra-articular injections of the knee. Synvisc, Hyalgan, and Supartz are FDA-approved.

If the arthrocentesis and the injection are performed for reasons other than those stated in criteria 1, 2, 3 and 4, deny both the arthrocentesis and the preparation as not medically necessary. They are not covered. A participating, preferred, or network health care professional cannot bill the member for the denied services.

When therapeutic injections are not a benefit of a member's contract, deny the preparation administered and the arthrocentesis as noncovered services. However, the arthrocentesis will pay on initial processing.

Note:
Intra-articular hyaluronan injections, (e.g., Synvisc, Hyalgan, Supartz), for osteoarthritis of the knee are classified as therapeutic injection procedures under medical-surgical benefits. They are not subject to the pharmacy benefit.

When arthrocentesis is performed as a stand-alone procedure, see Medical Policy Bulletin S-31 for guidelines.

Do not apply S-31 guidelines to intra-articular hyaluronan injections.

Following are the frequency requirements for Synvisc, Hyalgan, and Supartz:

  • Synvisc - one injection per week for three weeks.
  • Hyalgan - one injection per week for three or five weeks.
  • Supartz - one injection per week for five weeks.

Repeated treatment cycles, (i.e., any further injections over and above the specified frequency requirements), for patients who have responded to the previous courses of treatment may be given individual consideration for coverage under these circumstances:
  • At least 6 months must have elapsed since the prior series of injections.
  • The medical record must objectively document significant improvement in pain and functional capacity of the knee joint.


NOTE:
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Procedure Codes

2061090799J7315J7320  

Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

Comprehensive/Wraparound/PPO Guidelines

Refer to General Policy Guidelines

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines

Publications

PRN References

10/1998, Intra-articular hyaluronan injection coverage varies with patient benefits
02/1998, Intra-articular hyaluronan injections for osteoarthritis, not covered
02/1999, New reporting guidelines for intra-articular hyaluronan injections
06/1999, Correction: New reporting guidelines for intra-articular hyaluronan injections
08/2001, Repeat treatment cycles of intra-articular hyaluronan injections (e.g., Synvisc, Hyalgan)

References

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[Version 002 of G-25]
[Version 001 of G-25]

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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.

Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.