State and School Employees' Health Insurance Plan - Intra-articular Hyaluronan Injections for Osteoarthritis

POLICY NUMBER

S.2.01.422

Durolane (hyaluronic acid)

Euflexxa (1% sodium hyaluronate)

Gel-One (cross-linked hyaluronate)

Gelsyn-3 (sodium hyaluronate)

GenVisc 850 (sodium hyaluronate)

Hyalgan (sodium hyaluronate)

Hymovis (high molecular weight hyaluronan)

Monovisc (high molecular weight hyaluronan)

Orthovisc (high molecular weight hyaluronan)

Supartz FX (sodium hyaluronate)

Synojoynt (sodium hyaluronate)

Synvisc (Hylan G-F 20)

Synvisc One (Hylan G-F 20)

Triluron (sodium hyaluronate)

TriVisc (sodium hyaluronate)

Visco-3 (sodium hyaluronate)

DESCRIPTION

Intra-articular injection of hyaluronan has been proposed as a means of restoring the normal viscoelasticity of the synovial fluid in patients with osteoarthritis and reducing pain and improving function. This treatment may also be called viscosupplementation. Hyaluronan is a naturally occurring macromolecule that is a major component of synovial fluid and is thought to contribute to its viscoelastic properties. Chemical crosslinking of hyaluronan increases its molecular weight; cross-linked hyaluronans are referred to as hylans. In osteoarthritis, the overall length of hyaluronan chains present in cartilage and the hyaluronan concentration in the synovial fluid are decreased.

Most studies to date have assessed hyaluronan injections for knee osteoarthritis, the U.S. Food and Drug Administration-approved indication. Other joints (eg, hip, shoulder) are being investigated for intra-articular hyaluronan treatment of osteoarthritis.

Knee Osteoarthritis

Knee osteoarthritis is common, costly, and a cause of substantial disability. Among U.S. adults, the most common causes of disability are arthritis and rheumatic disorders.

Treatment

Currently, no curative therapy is available for osteoarthritis, and thus the overall goals of management are to reduce pain, disability, and the need for surgery.

The FDA has not approved intra-articular hyaluronan for joints other than the knee.

POLICY

Durolane and Euflexxa may be considered medically necessary for treatment of painful osteoarthritis of the knee in individuals who have insufficient pain relief from conservative nonpharmacologic therapy and simple analgesics.

Repeated courses of Durolane and Euflexxa injections may be considered medically necessary under the following conditions:

• Significant pain relief achieved with the prior course of injections; and

• At least six (6) months have passed since the prior course in the affected knee

The use of intra-articular hyaluronan injections into joints other than the knee is considered investigational.

The following medications are not covered on the State Health Plan Medical Drug Formulary:

• Gel-One

• Gelsyn-3

• GenVisc 850

• Hyalgan

• Hymovis

• Monovisc

• Orthovisc

• Supartz FX

• Synojoynt

• Synvisc

• Synvisc One

• Triluron

• TriVisc

• Visco-3

Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

Medical Policy Manual coverage guidelines should not be used in lieu of the Participant's specific benefit plan language outlined in the Mississippi's State and School Employees’ Life and Health Insurance Plan.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Participant’s illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A. consistent with the symptoms or diagnosis and treatment of the Participant’s condition, illness, or injury; and

B. appropriate with regard to standards of good medical practice; and

C. not solely for the convenience of the Participant, his or her Provider; and

D. the most appropriate supply or level of care which can safely be provided to the Participant. When applied to the care of an Inpatient, it further means that services for the Participant’s medical symptoms or conditions require that the services cannot be safely provided to the Participant as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

07/01/2023: New policy added.

10/31/2023: Policy reviewed; no changes.

05/06/2024: Policy description updated regarding products. Policy statements unchanged.

11/01/2024: Added list of products to the top of the policy. Policy description revised to remove products. Revised policy statement to specify that Durolane and Euflexxa may be considered medically necessary for treatment of painful osteoarthritis of the knee in individuals who have insufficient pain relief from conservative nonpharmacologic therapy and simple analgesics. Added statement that the following medications are not covered: Gel-One, Gelsyn-3, GenVisc 850, Hyalgan, Hymovis, Monovisc, Orthovisc, Supartz FX, Synojoynt, Synvisc, Synvisc One, Triluron, TriVisc, and Visco-3. Sources updated. Code Reference section updated to move the following HCPCS codes from the Covered Codes table to the Not Covered/Non-Formulary Codes table: J7320, J7321, J7322, J7324, J7325, J7326, J7327, J7328, J7329, J7331, and J7332. Effective 01/01/2025.

12/02/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Sources updated.

SOURCE(S)

1. Blue Cross Blue Shield Association policy # 2.01.31

2. Durolane prescribing information. Bioventus LLC. Last accessed September 2025.

3. Euflexxa prescribing information. Ferring Pharmaceuticals Inc. July 2016. Last accessed September 2025.

4. Gel-One product information. Zimmer Biomet. Last accessed September 2025.

5. Gelsyn-3 prescribing information. Bioventus LLC. Last accessed September 2025.

6. GenVisc 850 prescribing information. Avanos Medical, Inc. Last accessed September 2025.

7. Hyalgan prescribing information. Fidia Pharma USA INC. August 2017. Last accessed September 2025.

8. Hymovis prescribing information. Fidia Pharma USA Inc. October 2015. Last accessed September 2025.

9. Monovisc prescribing information. Anika Therapeutics, Inc. Last accessed September 2025.

10. Orthovisc prescribing information. Anika Therapeutics, Inc. Last accessed September 2025.

11. Supartz FX prescribing information. Bioventus LLC. March 2016. Last accessed September 2025.

12. Synojoint prescribing information. Arthrex Inc. Last accessed September 2025.

13. Synvisc prescribing information. Genzyme Corporation. Last accessed September 2025.

14. Synvisc-One prescribing information. Genzyme Corporation. Last accessed September 2025.

15. Triluron prescribing information. Fidia Pharma USA Inc. July 2019. Last accessed September 2025.

16. Trivisc prescribing information. Avanos Medical, Inc. Last accessed September 2025.

17. Visco-3 prescribing information. Zimmer Biomet. Last accessed September 2025.

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

Not Covered/Non-Formulary

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.