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: | January 1, 2003 |
Issued Date: | January 6, 2003 |
Date Last Reviewed: | 09/2001 |
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 J7317), or Supartz (code J7317). 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), J7317 (Hyalgan), or J7317 (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:
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 provider 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.
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:
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20610 | J7317 | J7320 |
Traditional (UCR/Fee Schedule) Guidelines
Comprehensive/Wraparound/PPO Guidelines
Under the Western Region PreferredBlue PPO product, effective June 1, 2002, Highmark will reimburse KHPW network physicians for their office visits and administration (20610) fees only. The preparations, e.g., Hyalgan, Synvisc, Supartz, will be billed to Highmark by selected pharmacy vendors. |
Managed Care (HMO/POS) Guidelines
Under the Western Region HMO and POS products, including DirectBlue and CommunityBlue Direct, effective June 1, 2002, Highmark will reimburse KHPW network physicians for their office visits and administration (20610) fees only. The preparations, e.g., Hyalgan, Synvisc, Supartz, will be billed to Highmark by selected pharmacy vendors. |
PRN References |
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