HIGHMARK MEDICARE ADVANTAGE MEDICAL POLICY - PENNSYLVANIA

 
 
Medical Policy:
G-25-018
Topic:
Hyaluronan Acid Therapies for Osteoarthritis of the Knee
Section:
Miscellaneous
Effective Date:
January 1, 2022
Issued Date:
February 8, 2022
Last Revision Date:
January 2022
 
 

Hyaluronic acid, also known as hyaluronan or hyaluronate, is a naturally occurring substance found in the synovial fluid surrounding joints. Osteoarthritic joints are found to have lower concentrations of hyaluronic acid. Intra-articular injection of hyaluronic acid, also known as viscosupplementation, has been proposed as a means of restoring the normal viscoelasticity of the synovial fluid in members with osteoarthritis of the knee.

Policy Position

To view specific LCD and NCD information, as well as other CMS sources, please refer to the LINKS section at the bottom of this policy page. 

 

When it is determined that the criteria contained in LCA A55036 and LCD L35427 for this indication has been met, then the preferred products required for members initiating new therapy is any of the following Euflexxa® (1% sodium hyaluronate), Durolane® (hyaluronic acid), Supartz FX™ (sodium hyaluronate), and GelSyn-3™ (hyaluronic acid).

A non-preferred product will be considered when the member has a documented therapy failure after an adequate therapeutic trial of all preferred products or the preferred products have not been tolerated or are contraindicated.

Adequate therapeutic trial is defined as six (6) months following the injection series at Food and Drug Administration (FDA) or compendia based therapeutic doses of preferred product.

New therapy is defined as no previous utilization within the last 365 calendar days.

20610

J7318

J7321

J7323

J7328

 

 



The following Non-Preferred hyaluronan preparations Gel One® (cross-linked hyaluronate), GenVisc 850® (sodium hyaluronate),  Hyalgan® (sodium hyaluronate), Hymovis® (high molecular weight viscoelastic hyaluronan), Monovisc® (lightly cross-linked high molecular weight hyaluronic acid),  Orthovisc® (high molecular weight hyaluronan), Synvisc® (hylan G-F 20), Synvisc-One® (hylan G-F 20), SynojoyntTM (1% sodium hyaluronate), TriluronTM (Sodium Hyaluronate), TriViscTM (sodium hyaluronte), Visco-3TM (hyaluronate sodium)or generic sodium hyaluronate 1% solution for injection may be considered medically necessary when BOTH of the following are met:

  • The member has met ALL the clinical criteria requirements as stated above for the preferred injections; and
  • The member must have had an adequate* therapeutic trial and experienced a documented drug therapy failure** with all applicable preferred intra-articular hyaluronan products.

*An adequate therapeutic trial is defined as six (6) months following a complete injection series of a preferred product at FDA or compendia based recommended therapeutic doses (unless the individual experiences an intolerable adverse effect due to drug therapy within that time period).  

**Drug therapy failure consists of not achieving the desired therapeutic goal, development of an intolerable adverse effect due to drug therapy, or development of a hypersensitivity reaction to the drug product. The length of therapy with the preferred product(s) and the reason(s) for drug therapy failure should be documented.

Non-Preferred Injections (Gel One® (cross-linked hyaluronate), GenVisc 850® (sodium hyaluronate),  Hyalgan® (sodium hyaluronate), Hymovis® (high molecular weight viscoelastic hyaluronan), Monovisc® (lightly cross-linked high molecular weight hyaluronic acid),  Orthovisc® (high molecular weight hyaluronan), Synvisc® (hylan G-F 20), Synvisc-One® (hylan G-F 20), SynojoyntTM (1% sodium hyaluronate), TriluronTM (Sodium Hyaluronate), TriViscTM (sodium hyaluronte), Visco-3TM (hyaluronate sodium)  or generic sodium hyaluronate 1% solution for injection) for any other indication are considered not medically necessary.

 

20610

J3490

J7320

J7321

J7322

J7324

J7325

J7326

J7327

J7329

J7331

J7332

 

 



    

20610

20611

77002

J7318

J7320

J7321

J7322

J7323

J7324

J7325

J7326

J7327

J7328

J7329

J7331

J7332

 

 

 

 

 

Not Medically Necessary Procedure Codes when reported at the same anatomic site with Procedure Codes J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, or J7332

27369

73580

76881

76882

76942

77012

77021


Covered Diagnosis Codes for Procedure Codes J7318, J7320, J7321, J7322, J7323, J7324, J7325, J7326, J7327, J7328, J7329, J7331, and J7332

M17.0

M17.11

M17.12

M17.2

M17.31

M17.32

M17.4

M17.5

 

 

 

 

 

 


Related Policies

Refer to Highmark Reimbursement Policy Bulletin RP-003 Drug Wastage and Convenience Kits for additional information. 

Refer to Medicare Advantage medical policy X-52 Non-Vascular Extremity Ultrasound for additional information.




The policy position applies to all Medicare Advantage lines of business



Links

CMS Links
Article Links
LCD Links
References
  • Novitas Solutions, Inc., LCD L35427. Revised 10/01/2019 (R11).
  • Novitas Solutions, Inc., LCA A55036. Revised 04/01/2021 (R7).
  • Centers for Medicare & Medicaid Services 42 CFR Parts 422 and 423.
  • Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses; May 23, 2019.




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 or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.

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, and subject to the applicable laws of your state.


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.

Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as: 
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as: 
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Civil Rights Coordinator. 

If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you. 

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: 

U.S. Department of Health and Human Services 
200 Independence Avenue, SW 
Room 509F, HHH Building 
Washington, D.C. 20201 
1-800-368-1019, 800-537-7697 (TDD) 

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. 

Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.