Viscosupplementation therapy for knee Documentation Requirements

The medical records must document that the patient has symptomatic osteoarthritis of the knee, the nature of the symptoms and the functional limitations. Radiographic confirmation in the form of an x-ray report and/or notation in the record must accompany the clinical description. The frequency of injections and the dosage given must be clearly indicated. The response to treatment must also be noted. Repeat courses of viscosupplementation in the absence of documentation of response to the previous course of treatment will be considered not reasonable and necessary and not subject to coverage. The record should also indicate whether one or both knees are being treated and in the former instance, which knee is being treated.

The medical record must include documentation that supports that conservative therapy was attempted prior to viscosupplementation therapy. If conservative therapy and/or corticosteroid injections were contraindicated or failed, the reason(s) must be supported in the documentation submitted for review.

Utilization Guidelines

It is expected that these services would be performed as indicated by current medical literature and/or standards of practice. When services are performed in excess of established parameters, they may be subject to review for medical necessity.

Additional dosage(s) may be reviewed for medical necessity when the patient receives more than the recommended number of injections. In addition, a single course of treatment of either of these medications should be given no more than once every six months.

Medication: Supartz
Weekly Dosage/Injections per week: 25 mg/1
Total Dosage: 125 mg
Duration of Treatment: 5 weeks/single course of treatment per knee

Medication: Synvisc/Hyalan G F
Weekly Dosage/Injections per week: 16 mg/1
Total Dosage: 48 mg
Duration of Treatment: 3 weeks/single course of treatment per knee

Medication: Hyalgan
Weekly Dosage/Injections per week: 20 mg/1
Total Dosage: 100 mg
Duration of Treatment: 5 weeks/single course of treatment per knee

Medication: Orthovisc
Weekly Dosage/Injections per week: 30 mg/1
Total Dosage: 90-120 mg
Duration of Treatment: 3-4 weeks/single course of treatment per knee

Medication: Euflexxa
Weekly Dosage/Injections per week: 20 mg/1
Total Dosage: 60 mg
Duration of Treatment: 3 weeks/single course of treatment per knee

Medication: *Synvisc-one/Hyalan
Weekly Dosage/Injections per week: N/A
Total Dosage: 48 mg
Duration of Treatment: One time/single course of treatment

Medication: *Gel-One®
Weekly Dosage/Injections per week: N/A
Total Dosage: 30 mg
Duration of Treatment: One time/single course of treatment

Medication: Monovisc TM
Weekly Dosage/Injections per week: N/A
Total Dosage: 88 mg
Duration of Treatment: One time/single injection (the effectiveness of Monovisc™ has not been established for more than one course of treatment)

Arthrography to provide guidance for injections will not be covered. Therefore, the billing of CPT code 73580 (Radiologic examination, knee, arthrography, radiological supervision and interpretation) and 27370 (Injection of contrast for knee arthrography) or similar services will not be covered when billed with HCPCs codes J7321, J7323, J7324, J7325, J7326 or J7327. The course of treatment should consist of the use of one agent. The use of one agent should be used for the entire course of treatment. Therefore, initiating a course of treatment with one agent, then switching before completion to a different agent is considered not medically reasonable and necessary. Example: Treatment is initiated with Synvisc. After the application of two doses, the provider switches to Synvisc-one. The Synvisc-one would not be considered medically reasonable and necessary.

It is not expected that routine imaging for the purpose of needle guidance would be required. Therefore, routine use of fluoroscopy may result in a pre- payment medical review of records. Documentation should provide justification when imaging is performed for the purpose of needle guidance. The use of hand held ultrasound devices are not separately reimbursed.


* Synvisc-one/Hyalan and Gel-One® are administered as a single intra-articluar injection per course of treatment.