Clinical Policy Title: Intra-articular hyaluronic acid injection for osteoarthritis Clinical Policy Number: CCP.1100 Effective Date: October 1, 2014 Initial Review Date: April 16, 2014 Most Recent Review Date: August 7, 2018 Next Review Date: August 2019 Related policies: Policy contains: Hyaluronic acid. Viscosupplementation. Osteoarthritis of the knee. Chondromalacia. CCP.1127 CCP.1144 CCP.1217 CCP.1155 CCP.1101 Aquatic therapy Major joint replacement (hip and knee) Prolotherapy Acupuncture Hierarchy of chronic pain management ABOUT THIS POLICY: Select Health of South Carolina has developed clinical policies to assist with making coverage determinations. Select Health of South Carolina s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peerreviewed professional literature. These clinical policies, along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of medically necessary, and the specific facts of the particular situation are considered by Select Health of South Carolina when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. Select Health of South Carolina s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. Select Health of South Carolina s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, Select Health of South Carolina will update its clinical policies as necessary. Select Health of South Carolina s clinical policies are not guarantees of payment. Coverage policy Select Health of South Carolina considers the use of intra-articular injection with hyaluronic acid to be clinically proven and, therefore, medically necessary when all of the following criteria are met (Altman, 2018; Ran, 2018; Zhang, 2018; Stitik, 2017; Schmajuk, 2014): Documented symptomatic mild to moderate knee osteoarthritis. Patient reports pain interfering with functional activities, such as ambulation or prolonged standing. One of the following criteria: Conservative therapy (oral analgesics and anti-inflammatories) over the past four months has not resulted in functional improvement after at least three months. Patient cannot tolerate other treatments (e.g., non-steroidal anti-inflammatory drugs) because of adverse effects. Other therapy is contraindicated because of other medical problems. 1
Steroid injection therapy was administered within the prior two months and aspiration for effusion was unsuccessful, per affected knee. Steroid injection therapy is contraindicated or not tolerated. The pain cannot be attributed to other forms of joint disease. A single course of treatment is given as described in the package insert of each product. Specific prior authorization criteria in Appendix A are met. Limitations: All other uses of intra-articular injection with hyaluronic acid are not medically necessary, including, but not limited to (Leite, 2018; Moldez, 2018; Vannabouathong, 2018; American Academy of Orthopaedic Surgeons, 2017; Kroon, 2016; Lee, 2015; Krogh, 2013): Lateral epidcondyltis ( tennis elbow ), as the condition is frequently self-limiting. Any tendinitis diagnosis. Chondromalacia. Osteoarthritis of any joint other than the knee. Coverage of specific pharmaceuticals and/or treatments is subject to prior authorization by plan criteria. Prior authorization criteria for the pharmaceuticals listed in this policy is set forth in Appendix A. Alternative covered services: Simple analgesics. Nonsteroidal anti-inflammatory drugs. Corticosteroid injections. Background Osteoarthritis is a chronic and progressive disease resulting from failure of joint cartilage repair after breakdown or wear, accompanied by changes in synovial fluid, pain, and joint movement limitations (OrthoInfo, 2017). Osteoarthritis is the most common type of arthritis, particularly in the elderly, and is associated with high rates of disability. The most commonly affected joints include cervical and lumbosacral spine, hip, knee, and first metatarsal-phalangeal (base of thumb). Osteoarthritis is diagnosed by structural abnormalities (loss of joint space) on imaging studies and associated symptoms (activity-related joint pain and disability) (OrthoInfo, 2017). Pharmacologic treatment includes acetaminophen, nonsteroidal anti-inflammatory drugs, and COX-2 inhibitors. Other options include intra-articular injections with corticosteroids or hyaluronic acid. Optimal therapy tends to the idiosyncratic and is achieved by trial and error for each patient. When medical therapy fails and 2
patients find unacceptable reduction in quality of life, knee or hip total arthroplasty (arthroscopic debridement and lavage) may be considered. Viscosupplementation using intra-articular hyaluronic acid: Hyaluronic acid is a viscoelastic substance occurring naturally in synovial fluid and extracellular matrices of many tissues, including cartilage and skin. It plays a role in joint lubrication, protection, and cartilage maintenance. Commercially available preparations, administered as intra-articular injections, are used to relieve pain, improve synovial fluid quantity or quality, and modify disease progression in osteoarthritis and other joint diseases (OrthoInfo, 2015). Searches: Select Health of South Carolina searched PubMed and the databases of: UK National Health Services Centre for Reviews and Dissemination. Agency for Healthcare Research and Quality Guideline Clearinghouse and evidence-based practice centers. The Centers for Medicare & Medicaid Services. We conducted searches on July 18, 2018. Searched terms were: hyaluronic acid, injection therapies, and osteoarthritis. We included: Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes sometimes referred to as efficiency studies which also rank near the top of evidence hierarchies. Findings The evidence supporting the efficacy and safety of hyaluronic acid intra-articular injection for improving pain and function in osteoarthritis and other musculoskeletal conditions has recently improved. Prior to 2010, most reviewers cited insufficient evidence; since then, reviewers generally agree on hyaluronic acid s effectiveness. However, experts continue to cite small study sizes and the need for larger randomized controlled trials to support selection criteria and cost-utility. This information, along with the safety profiles and relative costs of included treatments, will be helpful for individualized patient care decisions. 3
Select Health of South Carolina identified one systematic review from the Blue Cross Blue Shield Technology Evaluation Center for the Agency for Healthcare Research and Quality (Samson 2014); one analysis of Medicare utilization data (Schmajuk 2014); and one clinical practice guideline from the American Academy of Orthopedic Surgeons (2013). Results of the two systematic reviews reflect some continued uncertainty regarding the effectiveness of intra-articular hyaluronic acid for treatment of knee osteoarthritis. Indirect comparisons suggest some improvement in pain and function relative to other available treatments, but comparisons to placebo have yielded conflicting results. An analysis of Medicare utilization data found frequent use of intraarticular hyaluronic acid among Medicare beneficiaries despite its higher cost, uncertain effectiveness, lack of optimal patient selection criteria, and variations in recommendations from evidence-based guidelines (Schmajuk, 2014). Therefore, it is reasonable to offer intra-articular hyaluronic acid for individuals who have failed to respond adequately to conservative nonpharmacologic therapy, simple analgesics, and anti-inflammatories. Policy updates A randomized controlled trial (Askari 2016) inclusive of 140 patients with knee osteoarthritis randomized subjects to receive intra-articular injection of either hyaluronic acid or corticosteroid. The mean age of the patients in the corticosteroid group was 57 ± 1.9 years and in the hyaluronic acid group was 58.5 ± 8.3 years. Pain and stiffness did not improve in either of the groups at any time points after the intervention (P > 0.05). However, a different pain scale suggested that symptoms improved after three months in both corticosteroid and hyaluronic acid groups, and daily activity improved in both groups (P < 0.05). The most important difference between the two intervention groups was the duration of effectiveness. Hyaluronic acid could be administered intra-articularly every three months for knee joint osteoarthritis, while corticosteroids needed to be injected every two months to maintain symptom control. Strand (2016) evaluated an injectable viscoelastic hydrogel composed of a cross-linked hyaluronate (Gel- 200) in a 13-week trial and demonstrated statistically significant improvements in patients treated with a single injection of Gel-200 compared with a saline control. Improvements in pain score were evident as early as 3 weeks following injection with more than 40 percent improvement from baseline. Adverse events were not significantly different between the intervention group and saline controls. No unanticipated treatment-related serious adverse events were reported. A systematic review of 72 randomized controlled trials assessed the use of corticosteroid, hyaluronic acid, and platelet rich plasma in the non-operative management of osteoarthritis and femoroacetabular impingement (Chandrasekaran, 2016). The authors affirmed the efficacy of diagnostic intra-articular hip injections, finding them sensitive and specific for differentiating between intra-articular, extra-articular, and spinal causes of hip symptoms. With regard to therapy, corticosteroids were more effective than 4
hyaluronic acid and platelet rich plasma in alleviating pain from hip osteoarthritis. A higher dose of corticosteroids produced a longer benefit. A systematic review evaluated the effectiveness of a course of three or five weekly intra-articular injections of Hyalgan (Fidia PharmaUSA Inc., Florham Park, New Jersey) to treat knee osteoarthritis pain in 2,168 study participants (Stitik, 2017). The pooled estimates for relief from baseline pain were similar between the two treatment courses: -31.4 (standard error [SE] 5.46; 95% confidence interval [CI] -45.5 to -17.4) with a 3-week course of Hyalgan and -32.2 (SE 5.25; 95% CI -45.6 to -18.7) with a 5-week course of Hyalgan (P =.916). The pooled estimate for relief from baseline pain with a 3-week course of other hyaluronic acid products was -29.4 (SE 4.98; 95% CI -42.2 to -16.6), also indicating pain relief with a 3-week course of Hyalgan is similar to that with a 3-week course of other hyaluronic acid products (P =.696). In 2018, we added one evidence based guideline for management of hip osteoarthritis (American Academy of Orthopaedic Surgeons, 2017) and six systematic reviews and meta-analyses of the effectiveness of intra-articular hyaluronic acid treatment for osteoarthritis of various joints: knee (Altman, 2018; Ran, 2018; Zhang, 2018); ankle (Vannabouathong, 2018); hip (Leite, 2018); glenohumeral (Lee, 2015); temporomandibular joint (Moldez, 2018); and hand (Kroon, 2016). The new evidence confirms a role for intra-articular hyaluronic acid injections in managing osteoarthritis of the knee in persons who do not respond to or cannot tolerate conservative treatment, but not for managing osteoarthritis of other joints. No policy changes are warranted. Policy ID changed from CP# 00.02.08 to CCP.1100. Summary of clinical evidence: Citation Altman (2018) Efficacy and safety of repeated courses of hyaluronic acid injections for knee osteoarthritis Leite (2018) Viscosupplementation for hip Content, Methods, Recommendations Systematic review of seven randomized controlled trials and 10 cohort studies comparing the efficacy and safety of repeated courses of hyaluronic acid injection in terms of knee pain reduction after each treatment course and/or last reported followup visit, treatment-related adverse events, and serious adverse events. Overall quality: low with high risk of bias, significant between-study heterogeneity in methods, and inconsistent reporting of adverse events and reasons for treatment discontinuation. Repeated courses of hyaluronic acid injections were effective and safe for managing pain associated with knee osteoarthritis, and continued use further maintained or improve pain reduction while introducing no increased safety risk. Most commonly reported adverse events were joint swelling and arthralgia; no serious adverse events were reported. Systematic review and meta-analysis of eight randomized controlled trials (n = 807) 5
Citation osteoarthritis: a systematic review and meta-analysis of the efficacy on pain and disability, and the occurrence of adverse events. Moldez (2018) Effectiveness of intraarticular injections of sodium hyaluronate or corticosteroids for intracapsular temporomandibular disorders Ran (2018) Comparison of intra-articular hyaluronic acid and methylprednisolone for pain management in knee osteoarthritis Vannabouathong (2018) Content, Methods, Recommendations comparing hyaluronic acid to: placebo (four studies); platelet-rich plasma (three); methylprednisolone (three); and mepivacaine (one). Overall quality: variable. Hyaluronic acid is not superior to placebo for reducing pain at 3 months (standardized mean difference [SMD] = -.06; 95% CI -.38 to.25; P =.69) or in adverse events (risk ratio [RR] = 1.21; 95% CI 0.79 to 1.86; P =.38). Hyaluronic acid is not superior to platelet rich plasma for reducing pain at one, six, and 12 months. Hyaluronic acid is not different from methylprednisolone for reducing pain at one month (SMD =.02; 95% CI -.18 to.22; P =.85), Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society International Responders Index at one month (RR =.44; 95% CI 0.10 to 1.95; P =.28), or adverse events (RR = 1.21; 95% CI.79 to 1.87; P =.38). Viscosupplementation for hip osteoarthritis is not recommended. Systematic review and meta-analysis of seven randomized controlled trials comparing the effectiveness of intra-articular injections of sodium hyaluronate or corticosteroids to each other or placebo. Overall quality: low with unclear or high risk of bias. Sodium hyaluronate versus corticosteroids: no significant difference in short- or longterm pain improvement. Sodium hyaluronate versus placebo: significantly higher number of responders to sodium hyaluronate than placebo (one study) Sodium hyaluronate versus corticosteroids: no significant difference (one study). Inconclusive evidence. The minimum effective dose and long-term side effects of both injections needs to be determined. A meta-analysis of five randomized controlled trials (n= 1,004) comparing the efficacy and safety of intra-articular methylprednisolone and hyaluronic acid. There were no significant between group differences in terms of Western Ontario and McMaster Universities Osteoarthritis Index pain score, physical function, or stiffness at four weeks, 12 weeks, and 26 weeks There were no increased risks of adverse events in either group, nor significant between-group differences in long-term follow-up of adverse effects. Intra-articular injections in the treatment of symptoms from ankle arthritis Systematic review and meta-analysis of 27 observational studies and randomized controlled studies of the effectiveness of corticosteroids, hyaluronic acid, platelet-rich plasma, and mesenchymal stem cells, including three randomized placebo-controlled trials of hyaluronic acid injections. Overall quality: low with high risk of bias, imprecision. Hyaluronic acid versus saline (three studies, n = 109 patients): hyaluronic acid significantly improved Ankle Osteoarthritis Scale scores at 6 months (MD = 12.47 points; 95% CI 1.18 to 23.77, P =.03). 6
Citation Zhang (2018) Intra-articular platelet-rich plasma versus hyaluronic acid in the treatment of knee osteoarthritis American Academy of Orthopedic Surgeons (2017) Management of osteoarthritis of the hip Kroon (2016) Intra-articular therapies in the treatment of hand osteoarthritis (Only data for hyaluronic acid reported) Lee (2015) Effectiveness of hyaluronic acid administration in treating adhesive capsulitis of the shoulder Content, Methods, Recommendations Relative effectiveness of hyaluronic acid and other injectables is inconclusive. A systematic review of three prospective trials and 10 randomized controlled trials comparing the effectiveness of platelet-rich plasma (n = 788) and hyaluronic acid injections (n = 736); 91% had confirmed early stage osteoarthritis of the knee. Overall quality: low with significant risk of bias and heterogeneous methods. Platelet-rich plasma injections reduced pain more effectively than hyaluronic acid injections in osteoarthritis of the knee at six months (mean difference [MD]=-14.18; 95% CI -26.12 to -2.23; P =.02; I 2 = 95%) and 12 months (MD=-15.25; 95% CI -22.17 to -8.32; P <.01; I 2 = 81 %), based on the Western Ontario and McMaster Universities Osteoarthritis Index pain score.using a visual analog scale, there was no significant difference between interventions in pain at 3 months (MD=-0.98; 95% CI -2.55 to 0.59; P =.22; I 2 = 90%) and 6 months (MD=-0.82; 95% CI -1.80 to 0.16; P =.1; I 2 = 83%). More high-quality data from randomized studies are needed. Strong recommendation against using intraarticular hyaluronic acid for patients with symptomatic osteoarthritis of the hip. Based on strong evidence from two high-quality studies that it does not perform better than placebo for function, stiffness, and pain in patients. Systematic review of controlled trials comparing the efficacy or safety of any intraarticular therapy in carpometacarpal and interphalangeal osteoarthritis with placebo or other treatments. Overall quality: low with unclear or high risk of bias. Hyaluronic acid appears not more efficacious than placebo for treating pain with carpometacarpal osteoarthritis (three studies, n = 96). Hyaluronic acid appears comparable to corticosteroid for improving pain in carpometacarpal osteoarthritis (six studies, n = 405). Intra-articular injections appear relatively safe with no important adverse events reported in any trial. Low dosages of hyaluronic acid were used (range 5 15 mg per injection). More rigorous studies are unlikely to substantially change this conclusion. Systematic review of four randomized controlled trials (273 participants, 278 shoulders): intra-articular hyaluronic acid versus conventional therapies (two trials); intra-articular hyaluronic acid as an adjuct to conventional therapies (two trials). Overall quality: low with high risk of bias, heterogeneity among trials, small sample sizes. Pain and shoulder function/disability outcomes in the HA injection group were not superior to those achieved in the conventional therapy groups. No significant differences in pain or shoulder function/disability outcomes were noted between the groups with and without adjunctive HA administration. 7
Citation American Academy of Orthopedic Surgeons (2013) Treatment of osteoarthritis of the knee Krogh (2013) Comparative effectiveness of injection therapies in lateral epicondylitis Hochberg (2012) for the American College of Rheumatology (2018 update in progress) Recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Content, Methods, Recommendations Strong recommendation against using intra-articular hyaluronic acid for patients with symptomatic knee osteoarthritis. Based on 14 studies (3 high-strength studies and 11 moderate-strength studies) indicating a low likelihood that intra-articular hyaluronic acid provides minimum clinically important improvement to patients. Systematic review and network meta-analysis of 17 randomized controlled trials (n = 1,381 subjects) of eight treatments, including one study of hyaluronic acid. Overall quality: low with unclear or high risk of bias. Hyaluronic acid was more efficacious than placebo (SMD -5.58; 95% CI -6.35 to - 4.82). Additional research is needed. Knee osteoarthritis conditionally recommended for patients who had an inadequate response to initial therapy. Hand osteoarthritis conditionally not recommended. Hip osteoarthritis no recommendation. References Professional society guidelines/other: American Academy of Orthopedic Surgeons. Available at: https://www.aaos.org/cpg/. Accessed July 19, 2018: Management of Osteoarthritis of the Hip. 2017. Treatment of Osteoarthritis of the Knee (2nd edition). 2013. Hochberg MC, Altman RD, April KT, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis care & research. 2012; 64(4): 465 474. Available at: https://www.rheumatology.org/practice- Quality/Clinical-Support/Clinical-Practice-Guidelines/Osteoarthritis. Accessed July 19, 2018. Peer-reviewed references: Altman R, Hackel J, Niazi F, Shaw P, Nicholls M. Efficacy and safety of repeated courses of hyaluronic acid injections for knee osteoarthritis: A systematic review. Semin Arthritis Rheum. 2018 Jan 31. DOI: 8
10.1016/j.semarthrit.2018.01.009. [Epub ahead of print]. Askari A, Gholami T, NaghiZadeh MM, et al. Hyaluronic acid compared with corticosteroid injections for the treatment of osteoarthritis of the knee: a randomized control trail. Springerplus. 2016; 5: 442. DOI: 10.1186/s40064-016-2020-0. Chandrasekaran S, Lodhia P, Suarez-Ahedo C, et al. Symposium: evidence for the use of intra-articular cortisone or hyaluronic acid injection in the hip. J Hip Preserv Surg. 2016; 3(1): 5 15. DOI: 10.1093/jhps/hnv020. Krogh TP, Bartels EM, Ellingsen T, et al. Comparative effectiveness of injection therapies in lateral epicondylitis: a systematic review and network meta-analysis of randomized controlled trials. The American journal of sports medicine. 2013; 41(6): 1435 1446. DOI: 10.1177/0363546512458237. Kroon FP, Rubio R, Schoones JW, Kloppenburg M. Intra-articular therapies in the treatment of hand osteoarthritis: a systematic literature review. Drugs Aging. 2016; 33(2): 119 133. DOI: 10.1007/s40266-015-0330-5. Lee LC, Lieu FK, Lee HL, Tung TH. Effectiveness of hyaluronic acid administration in treating adhesive capsulitis of the shoulder: a systematic review of randomized controlled trials. Biomed Res Int. 2015; 2015: 314120. DOI: 10.1155/2015/314120. Leite VF, Daud Amadera JE, Buehler AM. Viscosupplementation for hip osteoarthritis: a systematic review and meta-analysis of the efficacy on pain and disability, and the occurrence of adverse events. Arch Phys Med Rehabil. 2018; 99(3): 574 583.e571. DOI: 10.1016/j.apmr.2017.07.010. Moldez MA, Camones VR, Ramos GE, Padilla M, Enciso R. Effectiveness of intra-articular injections of sodium hyaluronate or corticosteroids for intracapsular temporomandibular disorders: a systematic review and meta-analysis. J Oral Facial Pain Headache. 2018; 32(1): 53 66. DOI: 10.11607/ofph.1783. OrthoInfo Diseases and Conditions. Osteoarthritis. Last reviewed August, 2017. American Academy of Orthopaedic Surgeons website. https://orthoinfo.aaos.org/en/diseases--conditions/osteoarthritis/. Accessed July 19, 2018. OrthoInfo Treatment. Viscosupplementation treatment for knee arthritis. American Academy of Orthopaedic Surgeons website. https://orthoinfo.aaos.org/en/treatment/viscosupplementationtreatment-for-knee-arthritis/. Accessed July 19, 2018. Ran J, Yang X, Ren Z, Wang J, Dong H. Comparison of intra-articular hyaluronic acid and methylprednisolone for pain management in knee osteoarthritis: a meta-analysis of randomized controlled trials. Int J Surg. 2018 Mar 21; 53: 103 110. DOI: 10.1016/j.ijsu.2018.02.065. 9
Schmajuk G, Bozic KJ, Yazdany J. Using Medicare data to understand low-value health care: the case of intra-articular hyaluronic acid injections. JAMA Intern Med. 2014; 174(10): 1702 1704. DOI: 10.1001/jamainternmed.2014.3926. Stitik TP, Issac SM, Modi S, Nasir S, Kulinets I. Effectiveness of 3 weekly injections compared with 5 weekly injections of intra-articular sodium hyaluronate on pain relief of knee osteoarthritis or 3 weekly injections of other hyaluronan products: a systematic review and meta-analysis. Arch Phys Med Rehabil. 2017; 98(5): 1042 1050. DOI: 10.1016/j.apmr.2017.01.021. Strand V, Lim S, Takamura J. Evidence for safety of retreatment with a single intra-articular injection of Gel-200 for treatment of osteoarthritis of the knee from the double-blind pivotal and open-label retreatment clinical trials. BMC Musculoskeletal Disorders. 2016; 17: 240. DOI: 10.1186/s12891-016- 1101-0. Vannabouathong C, Del Fabbro G, Sales B, et al. Intra-articular Injections in the Treatment of Symptoms from Ankle Arthritis: A Systematic Review. Foot Ankle Int. 2018: 1071100718779375. DOI: 10.1177/1071100718779375. Zhang HF, Wang CG, Li H, Huang YT, Li ZJ. Intra-articular platelet-rich plasma versus hyaluronic acid in the treatment of knee osteoarthritis: a meta-analysis. Drug Des Devel Ther. 2018 Mar 5; 12: 445 453. DOI: 10.2147/DDDT.S156724. Centers for Medicare & Medicaid Services National Coverage Determinations: No National Coverage Determinations identified as of the writing of this policy. Local Coverage Determinations: No Local Coverage Determinations identified as of the writing of this policy. Commonly submitted codes Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code Description Comments 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance 20611 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance 10
ICD-10 Code Description Comments M17.0 Bilateral primary osteoarthritis of knee M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M17.2 Bilateral post-traumatic osteoarthritis of knee M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee M17.31 Unilateral post-traumatic osteoarthritis, right knee M17.32 Unilateral post-traumatic osteoarthritis, left knee M17.4 Other bilateral secondary osteoarthritis of knee M17.5 Other unilateral secondary osteoarthritis of knee M17.9 Osteoarthritis of knee, unspecified HCPCS Level II Code J7321 J7323 J7324 J7325 J7326 Description Hyaluronan or derivative:(hylgan or Supartz) for intra-articular injection. Hyaluronan or derivative: (Euflexxa)for intra-articular injection. Hyaluronan or derivative: (Orthovisc) for intra-articular injection. Hyaluronan or derivative: (ynvisc or SynviscOne) for intra-articular injection. Hyaluronan or derivative: (Gel-One) for intra-articular injection. Comments Appendix Pharmacy prior authorization criteria (published April 30, 2018) 11
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Source: https://keystonefirstpa.com/pdf/pharmacy/prior-auth-criteria.pdf. Accessed July 19, 2018. 13