J2150, Injection, mannitol, 25% in 50 ml
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Documentation the member is not scheduled to undergo total knee replacement within 6 months of starting treatment.
- Radiographic evidence of osteoarthritis of the knee (e.g., joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts) OR documentation that member has at least 5 of the specified signs/symptoms (bony enlargement; bony tenderness; crepitus on active motion; ESR < 40 mm/hr; < 30 minutes morning stiffness; no palpable warmth of synovium; age > 50; rheumatoid factor < 1:40 titer (agglutination method); synovial fluid clear with normal viscosity and WBC < 2000/mm3).
- Documentation that knee pain interferes with functional activities (e.g., ambulation, prolonged standing).
- Documentation of inadequate response or adverse effects with non-pharmacologic treatment options (e.g., physical therapy, regular exercise, insoles, knee bracing, weight reduction).
Key Coverage Criteria
- Bony enlargement
- Over 50 years of age
- Rheumatoid factor less than 1:40 titer (agglutination method)
- Synovial fluid signs (clear fluid of normal viscosity and WBC less than 2000/mm3)
- The member has knee pain which interferes with functional activities (e.g., ambulation, prolonged standing)
- The member has experienced an inadequate response or adverse effects with non-pharmacologic treatment options (e.g., physical therapy, regular exercise, insoles, knee bracing, weight reduction)
1 Active Policy
AETNA-CPB-0179, Viscosupplementation
Related Codes
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