Intra-articular hyaluronan injections should be reported under code 20610 (arthrocentesis, major joint) to represent the aspiration/injection procedure.  The specific preparation used should be reported using code Q4083 for Supartz® and Hyalgan®, Q4084 for Synvisc®, Q4085 for Euflexxa®, and Q4086 for Orthovisc®.

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 the following criteria have been met:

1. The patient has symptomatic osteoarthritis of the knee (715.16, 715.26, 715.36, 715.96);
2. The medical record contains documentation that the patient has failed to respond to conservative therapy methods (analgesics, NSAIDs or intra-articular corticosteroid injections), or is unable to tolerate conservative therapy methods, 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. Supartz, Hyalgan, Synvisc, Euflexxa and Orthovisc are FDA-approved for this indication.

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.

NOTE:

Intra-articular hyaluronan injections, (e.g., Supartz, Hyalgan, Synvisc, Euflexxa and Orthovisc), 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 Supartz, Hyalgan, Synvisc, Euflexxa and Orthovisc:

• Supartz - one injection per week for five weeks.
• Hyalgan - one injection per week for three or five weeks.
• Synvisc - one injection per week for three weeks.
• Euflexxa - one injection per week for three weeks.
• Orthovisc - one injection per week for three to four weeks.

• At least six 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.

Description

Osteoarthritis is the most common form of arthritis. Pathologically, in the knee, osteoarthritis 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 Supartz, Hyalgan, Synvisc, Euflexxa and Orthovisc.

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 (Supartz, Hyalgan, Synvisc, Euflexxa or Orthovisc) is injected.

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.

This medical policy may not apply to FEP.  Medical policy is not an authorization, certification, explanation of benefits or a contract.  Benefits are determined by the Federal Employee Program.