Hyaluronic Acid Intra-articular Products

Coverage is limited to FDA‑approved intra‑articular hyaluronic acid products for pain from osteoarthritis of the knee (non‑knee joints or non‑FDA indications are excluded). Approval requires radiologic confirmation of knee OA, documented failure of conservative care with at least TWO of these modalities (one course of PT; OR at least TWO specified pharmacologic agents — note two or more NSAIDs count as one pharmacologic therapy; OR at least two intra‑articular corticosteroid injections), administration by or under a rheumatologist/orthopedic surgeon/physiatrist, adherence to product‑specific dosing limits, and for reauthorization a ≥6‑month interval since prior injection plus documented prior response; authorizations are granted for 6 months.

"Indicated for the treatment of pain in osteoarthritis of the knee in individuals who have failed to respond adequately to conservative non-pharmacologic therapy and analgesics (eg, non-steroidal an..."