20605
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.66
Facility
$32.06
Non-Facility
$57.12
Documentation Required
- Medical notes documenting all of the following (Preferred Products: Durolane, Euflexxa, and Gelsyn-3) for HCPCS codes J7318, J7323, J7328: - Current prescription - Name and tax ID number of the servicing provider/facility to facilitate claim processing - Member diagnosis of OA of the knee - Conservative treatment tried for at least 3 months including response - Signs and symptoms - Current functional limitations - Complete report(s) of diagnostic imaging (X-ray, CT, or MRI reports) - Previous sodium hyaluronate treatment provided including the brand name of the drug, course of treatment, and response - Dose, frequency, interval since previous sodium hyaluronate treatment - Physician treatment plan
- Medical notes documenting all of the following (Non-Preferred Products) for HCPCS codes J3490, J7320, J7321, J7322, J7324, J7325, J7326, J7327, J7329, J7331, J7332: - Current prescription - Name and tax ID number of the servicing provider/facility to facilitate claim processing - Member diagnosis of OA of the knee - Conservative treatment of at least 3 months, including response - Signs and symptoms - Current functional limitations - Complete report(s) of diagnostic imaging (X-ray, CT, or MRI reports) - One of the following: - Both of the following: - History of a trial of adequate dose and duration of Durolane, Gelsyn-3, and Euflexxa with minimal response; and - Attestation that the clinical response would be expected to be superior than experienced with Durolane, Gelsyn-3, and Euflexxa - Both of the following: - History of intolerance, contraindication, or adverse event to Durolane, Gelsyn-3, and Euflexxa; and - Physician attests that, in their clinical opinion, the same intolerance, contraindication, or adverse event would not be expected to occur with the requested non-preferred product - Physician treatment plan
Key Coverage Criteria
- Intra-articular injections of sodium hyaluronate are proven and medically necessary when all of the following are met: - Diagnosis of knee osteoarthritis; and - The member has not responded adequately to conservative therapy which may include physical therapy or pharmacotherapy [e.g., non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and/or topical capsaicin cream] or injection of intra-articular steroids and such therapy has not resulted in functional improvement after at least 3 m [...]
- Repeated courses of intra-articular hyaluronan injections may be considered when all of the following are met: - Diagnosis of knee osteoarthritis; and - Documentation of positive clinical response to therapy (e.g., significant pain relief was achieved with the prior course of injections); and - Pain has recurred; and - At least 6 months have passed since the prior course of treatment for the respective joint; and - Dosing is in accordance with the US FDA approved labeling as shown in the table b [...]
- Coverage for Durolane, Euflexxa, and Gelsyn-3 is contingent on criteria in the Diagnosis-Specific Criteria section. Prior authorization is not required.
- Treatment of Temporomandibular Joint (TMJ) disorders
- The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Arthrocentesis
- The following non-surgical services are proven and medically necessary for treating disorders of the temporomandibular joint (TMJ): Intra-articular injections of corticosteroids
8 Active Policies
UHC-POL-sodium-hyaluronate — Sodium Hyaluronate
UHC-POL-temporomandibular-joint-disorders — Treatment of Temporomandibular Joint Disorders
UMR-POL-UMR-sodium-hyaluronate — Sodium Hyaluronate
UMR-POL-UMR-temporomandibular-joint-disorders — Treatment of Temporomandibular Joint Disorders
SUREST-POL-SUREST-sodium-hyaluronate
Related Codes
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