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: | April 26, 2004 |
Issued Date: | April 26, 2004 |
Date Last Reviewed: | 09/2001 |
Indications and Limitations of Coverage
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. Coverage for intra-articular hyaluronan injections is determined according to individual or group customer benefits. When a benefit, 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:
Description 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. |
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20610 | J7317 | J7320 |
Traditional (UCR/Fee Schedule) Guidelines
Comprehensive / Wraparound / PPO / Major Medical Guidelines
Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.
Managed Care (HMO/POS) Guidelines
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) |
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