Hyaluronic Acid Intra-articular Products

Coverage is limited to FDA‑approved intra‑articular hyaluronic acid products for pain from osteoarthritis of the knee only (other joints/off‑label uses excluded). Initial approval requires radiographic confirmation of knee OA, ≥1 course of physical therapy, trials of at least two pharmacologic therapies (NSAID [oral/topical], acetaminophen, tramadol, or duloxetine — note multiple NSAIDs count as one), ≥2 intra‑articular corticosteroid injections, administration by or under the supervision of a rheumatologist/orthopedic surgeon/physiatrist, and adherence to product‑specific dosing (6‑month approval); reauthorization requires ≥6 months since the last HA injection and documented prior clinical response.

"Treatment of pain in osteoarthritis (OA) of the knee in individuals who have failed to respond adequately to conservative non-pharmacologic therapy and analgesics (e."