MEDICAL POLICY

POLICY
RELATED POLICIES
POLICY GUIDELINES
DESCRIPTION
SCOPE
BENEFIT APPLICATION
RATIONALE
REFERENCES
CODING
APPENDIX
HISTORY

Intra-articular Hyaluronan Injections for Osteoarthritis

Number 2.01.31

Effective Date This policy is effective July 1, 2014

Revision Date(s) 12/09/13; 11/11/13; 03/08/13

Replaces 5.01.506

To view the current policy, click here.

Policy

Intra-articular hyaluronan injections are considered not medically necessary to treat osteoarthritis of the knee.

Intra-articular hyaluronan injections are considered not medically necessary to treat osteoarthritis of any joint other than the knee.

Related Policies

1.01.27

Electrical Stimulation for the Treatment of Arthritis

2.01.21

Temporomandibular Joint Dysfunction (TMJ)

7.01.549

Knee Arthroscopy in Adults

Policy Guidelines

Coding

CPT

20610

Arthrocentesis, aspiration or injection; major joint or bursa

HCPCS

J7321

Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose

J7232

Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose

J7324

Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose

J7325

Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg

J7326

Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose

The initial office visit to initiate hyaluronan therapy may be billed using an evaluation and management CPT code; however, the use of both CPT code 20610 and an evaluation and management CPT code during subsequent visits for the sole purpose of hyaluronan injections is not routinely warranted.

Description

Intra-articular injection of hyaluronan (HA) into osteoarthritic joints is thought to replace HA, restore the viscoelastic properties of the synovial fluid, and improve pain and function. The majority of studies to date have assessed HA injections for knee osteoarthritis, and this is the U.S. Food and Drug Administration (FDA) -approved indication. Other joints, such as the hip and shoulder, are currently being investigated for intra-articular HA treatment of osteoarthritis (OA).

Background

Hyaluronan (HA) 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; crosslinked hyaluronans are referred to as hylans. In osteoarthritis (OA), the overall length of HA chains present in cartilage and the HA concentration in the synovial fluid are decreased. Intra-articular injection of HA (IAHA) has been proposed as a means of restoring the normal viscoelasticity of the synovial fluid in patients with OA. This treatment has been called viscosupplementation. Currently, no curative therapy is available for OA, and thus the overall goals of management are to reduce pain and prevent disability.

Regulatory Status

Six preparations of intra-articular (IA) hyaluronan have been approved by the FDA as an alternative to nonsteroidal anti-inflammatory drug therapy in the treatment of OA of the knee (Synvisc® and Synvisc-One®, Genzyme; Hyalgan®, Fidia; Supartz®, Smith and Nephew; OrthoVisc®, Anika; and Euflexxa®, previously named Nuflexxa, Savient). All products are manufactured from rooster combs except for Euflexxa and Orthovisc, which are produced from bacterial fermentation. Also, Synvisc undergoes additional chemical crosslinking to create hylans with increased molecular weight (6,000 kDa) compared to Hyalgan (500-730 kDa) and Supartz (620-1,170 kDa). The differing molecular weights of the products lead to different half-lives; the half-life of Hyalgan or Supartz is estimated at 24 hours, while the half-life of Synvisc may range up to several days.

Intra-articular hyaluronic acid is “indicated for the treatment of pain in osteoarthritis of the knee in patients who have failed to respond adequately to conservative nonpharmacologic therapy, and to simple analgesics, e.g., acetaminophen.” The product inserts further indicate that Synvisc® and Euflexxa® should be injected intra-articularly into the knee joint once per week for a total of 3 injections over a 2- to 3-week period. In contrast, 5 weekly injections are recommended for the Hyalgan® and Supartz® products, and 34 weekly injections are recommended for OrthoVisc®. In February 2009, the FDA approved the use of single-dose hylan G-F 20 (Synvisc-One™) for the treatment of OA of the knee. In 2011, The FDA approved the use of the single-dose cross-linked hyaluronate Gel-One® (also known as Gel-200) for the treatment of OA of the knee.

In 2000, the FDA approved removal of a precautionary statement from the package inserts for Hyalgan and Synvisc that stated that the safety and efficacy of repeat courses have not been established.

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

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

The coverage for hyaluronan injections is typically based on coverage benefits for injectable drugs, in addition to the office visit.

Rationale

This policy was created in 1998 and updated regularly with searches of the MEDLINE database. The most recent literature search was performed through July 31, 2013. Following is a summary of key literature to date.

Knee

Systematic Reviews

This policy was originally based on a 1998 TEC Assessment on intra-articular hyaluronan (IAHA) for osteoarthritis (OA), (1) and in 2004, TEC published a Special Report on IAHA for OA of the knee. (2) Overall, the 2004 review found that the evidence was still consistent with that presented in the 1998 TEC Assessment, showing a statistically significant effect in almost all studies, although the magnitude and clinical significance of the effect may be small. Similar results were obtained in Cochrane reviews in 2005 and 2006. (3, 4) In 2007, the TEC Evidence-based Practice Center published a technology assessment for the Agency for Healthcare Research and Quality (AHRQ) on the treatment of primary and secondary OA of the knee. (5) The report concluded that results from 42 trials (n=5,843) generally showed positive effects of viscosupplementation on pain and function scores compared to placebo for patients with primary OA of the knee. However, the evidence on viscosupplementation was accompanied by considerable uncertainty due to variable trial quality, potential publication bias, and unclear clinical significance of the changes reported. Trials of hylan G-F 20 (Synvisc, 6,000 kDa), the highest molecular weight cross-linked product, generally reported better results than other trials. Similar concerns were noted in a 2012 meta-analysis of 89 trials (12,667 patients) on viscosupplementation for OA of the knee. (6)

In 2013, the American Academy of Orthopaedic Surgeons (AAOS) conducted a systematic review of treatments for osteoarthritis (OA) of the knee. (7) Included was a meta-analysis of 3 high-strength and 11 moderate-strength studies of IAHA for OA of the knee. Pain outcomes were significantly lower in the treatment group compared to placebo, but the difference was found to be not clinically important, since the lower bound of the confidence interval was higher than the minimal clinically important difference. This indicated a low likelihood that an appreciable number of patients achieved clinically important benefits. Similar results were obtained for functional outcomes. This meta-analysis found evidence that high molecular-weight preparations were more effective than those with low weights, indicating a possible clinically important difference for the higher molecular-weight preparations.

Section Summary

There are a large number of RCTs completed on treatment of OA of the knee with hyaluronan (HA) and numerous systematic reviews of these trials. The majority of systematic reviews concluded that there is a modest beneficial effect of treatment, but that the clinical significance of the magnitude of difference is uncertain. A 2013 meta-analysis by the AAOS that included 14 moderate- to high-strength studies concluded that the improvements in health outcomes with IAHA were statistically but not clinically significant.

Joints Except the Knee

Colen et al. conducted a 2012 systematic review of prospective trials of IAHA for joints other than the knee. (8) In addition to non-randomized prospective studies, the search identified 5 randomized controlled trials (RCTs) for the hip, 1 for the shoulder, 4 for the ankle, 5 for the carpometacarpal-1 joint, 1 for the lumbar facet joint, and 1 for the first metatarsophalangeal joint. Examination of the literature for each joint found evidence for a positive effect of IAHA when compared to baseline, with limited evidence that IAHA is superior to placebo, and no evidence that IAHA is better than corticosteroids or other conservative therapies. Following is a summary of systematic reviews and primary evidence by joint.

Ankle

Migliore and colleagues conducted a review of 7 studies on IAHA for ankle OA, identified from the period of 2006-2009, that included 3 small RCTs with a total of 75 patients, and 4 case series. (9) For 2 of the RCTs, IAHA was compared to saline injection, and the results showed benefit on some outcome measures but not others. The third RCT compared IAHA to exercise therapy and reported no differences in outcomes. The authors were unable to do a meta-analysis due to the limited number of studies and study heterogeneity.

In 2012, DeGroot et al. reported on an RCT of 64 patients with ankle OA that compared a single IAHA to a single intra-articular (IA) saline injection. (10) At 6 weeks and 12 weeks, there were no significant differences in improvement between treatment groups on the American Orthopaedic Foot & Ankle Society clinical rating score, the Ankle Osteoarthritis Scale score, and the patient-reported visual analog pain scale (VAS).

Foot

There is a very limited amount of evidence on IAHA injections in the foot. Munteanu and colleagues reported on an RCT of a single IAHA injection in 151 patients with first metatarsophalangeal joint OA. (11) At 1, 3, and 6 months’ follow-up, there were no significant differences between the IAHA and placebo groups on the Foot Health Status Questionnaire.

Hand

Two small RCTs that enrolled a total of 100 patients evaluated HA injections compared to steroid injections for arthritis of the thumb. (12, 13) Fuchs et al. (13) reported that steroid injections were superior at 2-3 weeks post-treatment but that IAHA was superior at 6 months’ follow-up. Stahl et al. (12) reported essentially equivalent outcomes between steroid injections and IAHA, although IAHA was superior to steroids for some aspects of fine motor function. The results of these trials are not sufficient to determine the efficacy of IAHA for thumb arthritis and are not sufficient for determining comparative efficacy to steroids.

Hip

A 2008 systematic review of 2 RCTs and 9 cohort studies concluded that viscosupplementation therapy with HA appears to be “a safe and effective method in the treatment of hip OA resistant to conventional treatment modalities.” (14) In their 2012 systematic review, Colen et al. identified 3 RCTs that compared IAHA with placebo, 1 that compared IAHA with IA anesthetic, and 1 that compared hyaluronans of different molecular weights. (8) These three trials showed a statistical effect favoring IAHA treatment. However, the effect size was small compared to saline injections, and there were not significant differences between IAHA and other conservative treatments such as steroid injections.

The largest RCT randomized 101 patients to receive either HA injections or saline. (15) There was a small reduction in pain with walking in patients treated with HA injections over the 3-month evaluation period. An industry-sponsored RCT compared a single 2.5 mL IAHA (Adant, 900 kDa, unavailable in the U.S.) to saline injection for treatment of hip OA in 85 patients. (16) at 3 months, there were no significant differences between groups in any outcome measure. The number of patients who experienced mild to moderate treatment-related adverse events (injection-site pain, pain flare, hematoma, pruritus) did not differ between groups. Atchia and colleagues reported on a randomized, controlled trial (RCT) of 77 patients with hip OA who were potential candidates for total hip replacement. (17) In this study, patients were randomized to receive standard care or an injection of saline, hyaluronan or methylprednisolone and followed for 8 weeks. Significant improvement was only seen in the steroid group in the numerical rating scale for worst pain, and the Western Ontario and McMaster Osteoarthritis Index for pain and function. No improvements were reported in the IAHA group.

In an industry-sponsored, single-center, randomized, double-blind, active-controlled trial, published in 2009,forty-two patients with OA of the hip were randomly assigned to receive 2 monthly injections of high-molecular weight IAHA (Hyalubrix® - unavailable in the U.S.) or IA mepivacaine, a local anesthetic. (18) At 3 and 6 months, there was a significant decrease in the Lequesne algofunctional index (LFI) in the IAHA group compared to the mepivacaine group (5.15 vs. 6.53 at 3 months; 3.94 vs. 6.41 at 6 months, both respectively). The only reported adverse event was injection-site pain occurring in 1 patient in each group.

Shoulder

A 2010 meta-analysis of 19 blinded RCTs examined the use of viscosupplementation for chronic painful shoulder in a total of 2,120 patients. (19) A variety of shoulder disorders were included, e.g., adhesive capsulitis, rotator cuff tear, shoulder impingement syndrome, and frozen shoulder. Sample size ranged from 20 to 660 patients, mean trial duration was 3.5 weeks, and mean Jadad score was 3.5 ± 1.5. Ten trials (1,435 patients) reported pain outcomes. The combined effect size (standardized mean difference) for categorical and continuous pain ratings favored IAHA (0.39). There was no heterogeneity and no evidence of publication bias. Because the studies included in the meta-analysis were of short duration and included a variety of shoulder diseases, they do not provide conclusive evidence of the effectiveness of IAHA in OA of the shoulder.

The largest trial is an industry-sponsored RCT of 660 patients with persistent shoulder pain due to glenohumeral joint OA, rotator cuff tear, and/or adhesive capsulitis compared 3 weekly injections versus 5 weekly injections of sodium hyaluronate (Hyalgan) versus 5 weekly injections of saline. (20) Approximately 60% of patients had OA, although the majority of those with OA also had rotator cuff disorders or capsulitis. Sixty-nine percent (n=456) of the patients had a follow-up visit at 26 weeks. There was no significant difference among groups in the primary outcome measure, shoulder pain with movement at 13 weeks. Analysis of predefined, stratified subgroups revealed no significant differences in reported pain at 13 weeks but a statistically significant decrease of 7.5 and 7.8 mm (on a 100-mm VAS scale) in reported pain in both treatment groups at 26 weeks compared to placebo among patients with OA. In those without OA, there was no significant improvement with either regimen. Of note, this appears to be an as-treated analysis of the OA subgroup data, and the difference may not be clinically important.

In 2013, Kwon et al. reported a multicenter randomized double-blind placebo-controlled trial of IAHA in 300 patients with glenohumeral OA. (21) Intent-to-treat analysis found similar improvement in VAS for pain (19.88 mm for IAHA and 16.29 mm for placebo) and in the Outcome Measures in Rheumatoid Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) high responder rate (40.8% for IAHA and 34.9% for sham). In a subset of patients, there was a statistically significant difference in VAS of 4.0 mm on a 100 -mm scale and 8.37% on the OMERACT-OARSI. However, the clinical significance of these differences is uncertain.

Other

Data from small pilot studies, and case series have been reported using hyaluronan for arthritis of the spine and for lateral condylitis of the elbow (tennis elbow).

Section Summary

The evidence on the efficacy of IAHA for joints other than the knee is less robust. While some studies show benefit, others do not, and systematic reviews have not concluded that there is a clinically significant benefit.

Ongoing Clinical Trials

A search of online site ClinicalTrials.gov in July 2013 identified a number of open trials with IAHA. These include Phase III and Phase IV trials evaluating IAHA for OA of the knee (NCT01372475, NCT01543737, NCT01557868, NCT01335321 and a pivotal multicenter trial of Hylan G-F 20 for OA of the hip (NCT01618708).

Clinical Input Received through Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received from 3 physician specialty societies and 5 academic medical centers (6 reviewers) while this policy was under review in 2011. Most reviewers agreed that IAHA of the knee was medically necessary. In addition, those providing input supported an interval of 6 months for repeat injections. In response to a question about total number of treatment courses, there was no consensus.

Summary

Intra-articular injection of hyaluronan into osteoarthritic joints is thought to replace hyaluronan, restore the viscoelastic properties of the synovial fluid, and improve pain and function. The largest amount of evidence is on treatment of osteoarthritis (OA) of the knee. Individual trials show inconsistent results in pain and functional outcomes for intra-articular injection of hyaluronan (IAHA) compared to placebo or active control. Meta-analyses of RCTs shows improvements in pain and function that are statistically but not clinically significant, and recent guidelines from the American Academy of Orthopaedic Surgeons give a strong recommendation against the use of IAHA.

IAHA continues to be investigated for off-label uses in other joints. Current evidence on these off-label uses is limited, consisting of small RCTs and case series. Some RCTs on IAHA injections for OA of the ankle, foot, hand and shoulder have shown treatment benefits; however, these studies are not consistent in reporting improvements that are significantly greater than placebo and/or control treatments. RCTs on IAHA injections for OA of the hip have also been inconsistent, with some RCTs reporting improvements in outcomes with IAHA hip injections and others reporting no improvement. Currently, given the limited and inconsistent available data, and the low likelihood that IAHA for joints other than the knee are more effective than IAHA for the knee, these uses are also considered not medically necessary.

Practice Guidelines and Position Statements

The American Academy of Orthopaedic Surgeons’ (AAOS) 2013 guideline on treatment of osteoarthritis of the knee states that they cannot recommend using hyaluronic acid for patients with symptomatic knee OA. (7) This is a strong recommendation, meaning that the quality of the supporting evidence is high. This recommendation was based on a meta-analysis of 3 high-strength and 11 moderate-strength studies that showed that the overall effect was less than 0.5 minimally important different units, indicating a low likelihood that an appreciable number of patients achieved clinically important benefits. The AAOS states that practitioners should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. This replaces a 2008 guideline in which a recommendation could not be made for IAHA due to inconclusive evidence.

The 2009 AAOS Clinical Practice Guideline on glenohumeral joint osteoarthritis (22) includes a weak grade C recommendation that “the use of injectable viscosupplementation is an option when treating patients with glenohumeral [shoulder] osteoarthritis.” Grade C recommendations are based on poor-quality evidence. In this instance, the recommendation is based on a single case series of 30 patients with OA of the glenohumeral joint who received 3 weekly IA injections of Synvisc. (23) At 1, 3, and 6 months, clinically significant improvements were seen in pain, function, and quality-of life-measures.

In 1995, the American College of Rheumatology (ACR) published guidelines for the treatment of osteoarthritis (OA) of the knee, which recommended acetaminophen as first-line therapy, followed by low-dose ibuprofen, and then full-dose nonsteroidal anti-inflammatory drugs (NSAIDs), when necessary. In 2000, the ACR published updated guidelines on the management of hip and knee OA. (24) These guidelines recommend nonpharmacologic approaches and drug therapy for management of hip and knee OA. Intra-articular hyaluronan (IAHA) or glucocorticoids are considered alternative approaches to oral agents for knee OA, based on studies demonstrating effectiveness in reducing knee pain. However, the guidelines noted the absence of studies demonstrating the efficacy of IAHA or glucocorticoids for hip OA. Updated guidelines from 2012 addressed OA of the hand, hip, and knee. (25) A conditional recommendation was given for IAHA to treat OA of the knee. The ACR recommends not using IAHA for OA of the hand. For OA of the hip, the ACR explicitly makes no recommendation regarding treatment with IAHA.

The Osteoarthritis Research Society International (OARSI) guidelines, (26) developed by consensus after review of existing guidelines and systematic reviews, recommend:

Injections of IA [intra-articular] hyaluronate may be useful in patients with knee or hip OA [osteoarthritis]. They are characterized by delayed onset, but prolonged duration, of symptomatic benefit when compared to IA injections of corticosteroids.

The recommendation is made with a strength of 64% (CI: 43–85%).

The 2009 Bannuru et al. meta-analysis, (27) noted above, was cited in a 2010 evidence update by OARSI. (28) In an accompanying editorial, OARSI authors note that IAHA “has a time-dependent trajectory of therapeutic effect. Thus, the time point at which its outcome is assessed will influence its apparent effectiveness.” (29)

2008 Guidelines published by the National Institute for Health and Clinical Excellence (NICE) do not recommend IAHA injections for the treatment of OA because “the cost-effectiveness estimate is outside the realms of affordability” to the National Health Service. (30) However, guideline developers state, “Overall, the evidence suggests that hyaluronans and hylan derivatives seem to be superior to placebo in terms of efficacy and quality of life outcomes in patients with OA in the knee at different post-injection periods but especially at the 5- to 13-week post-injection period.” Toxicity of IAHA was noted to be small.

References

  1. Ghofrani HA, D'Armini AM, Grimminger F et al. Riociguat for the treatment of chronic thromboembolic pulmonary hypertension. N Engl J Med 2013; 369(4):319-29.
  2. FDA Draft Briefing Document for the Cardiovascular and Renal Drugs Advisory Committee (CRDAC). FDA; 2013. http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs/CardiovascularandRenalDrugsAdvisoryCommittee/UCM363541.pdf. Accessed August 2013.
  3. Bellamy N, Campbell J, Robinson V et al. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2005; (2):CD005321.
  4. Bellamy N, Campbell J, Robinson V et al. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006; (2):CD005321.
  5. Samson DJ, Grant MD, Ratko TA et al. Treatment of primary and secondary osteoarthritis of the knee. AHRQ Publication No. 07-E012. September 2007. Available online at: http://www.ncbi.nlm.nih.gov/books/NBK38385/. Last accessed January, 2013.
  6. Rutjes AW, Juni P, da Costa BR et al. Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis. Ann Intern Med 2012; 157(3):180-91.
  7. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee. 2013. Available online at: http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Last accessed July, 2013.
  8. Colen S, Haverkamp D, Mulier M et al. Hyaluronic acid for the treatment of osteoarthritis in all joints except the knee: what is the current evidence? BioDrugs 2012; 26(2):101-12.
  9. Migliore A, Giovannangeli F, Bizzi E et al. Viscosupplementation in the management of ankle osteoarthritis: a review. Arch Orthop Trauma Surg 2011; 131(1):139-47.
  10. Degroot H, Uzunishvili S, Weir R et al. Intra-articular injection of hyaluronic Acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am 2012; 94(1):2-8.
  11. Munteanu SE, Zammit GV, Menz HB et al. Effectiveness of intra-articular hyaluronan (Synvisc, hylan G-F 20) for the treatment of first metatarsophalangeal joint osteoarthritis: a randomised placebo-controlled trial. Ann Rheum Dis 2011; 70(10):1838-41.
  12. Stahl S, Karsh-Zafrir I, Ratzon N et al. Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints. J Clin Rheumatol 2005; 11(6):299-302.
  13. Fuchs S, Monikes R, Wohlmeiner A et al. Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis. Osteoarthritis Cartilage 2006; 14(1):82-8.
  14. Abate M, Pelotti P, De Amicis D et al. Viscosupplementation with hyaluronic acid in hip osteoarthritis (a review). Ups J Med Sci 2008; 113(3):261-77.
  15. Qvistgaard E, Christensen R, Torp-Pedersen S et al. Intra-articular treatment of hip osteoarthritis: a randomized trial of hyaluronic acid, corticosteroid, and isotonic saline. Osteoarthritis Cartilage 2006; 14(2):163-70.
  16. Richette P, Ravaud P, Conrozier T et al. Effect of hyaluronic acid in symptomatic hip osteoarthritis: a multicenter, randomized, placebo-controlled trial. Arthritis Rheum 2009; 60(3):824-30.
  17. Atchia I, Kane D, Reed MR et al. Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis. Ann Rheum Dis 2011; 70(1):110-6.
  18. Migliore A, Massafra U, Bizzi E et al. Comparative, double-blind, controlled study of intra-articular hyaluronic acid (Hyalubrix) injections versus local anesthetic in osteoarthritis of the hip. Arthritis Res Ther 2009; 11(6):R183.
  19. Saito S, Furuya T, Kotake S. Therapeutic effects of hyaluronate injections in patients with chronic painful shoulder: a meta-analysis of randomized controlled trials. Arthritis Care Res (Hoboken) 2010; 62(7):1009-18.
  20. Blaine T, Moskowitz R, Udell J et al. Treatment of persistent shoulder pain with sodium hyaluronate: a randomized, controlled trial. A multicenter study. J Bone Joint Surg Am 2008; 90(5):970-9.
  21. Kwon YW, Eisenberg G, Zuckerman JD. Sodium hyaluronate for the treatment of chronic shoulder pain associated with glenohumeral osteoarthritis: a multicenter, randomized, double-blind, placebo-controlled trial. J Shoulder Elbow Surg 2013; 22(5):584-94.
  22. American Academy of Orthopaedic Surgeons. The treatment of glenohumeral joint osteoarthritis: guideline and evidence report. 2009. Available online at: http://www.aaos.org/research/guidelines/gloguideline.pdf. Last accessed July, 2013.
  23. Silverstein E, Leger R, Shea KP. The use of intra-articular hylan G-F 20 in the treatment of symptomatic osteoarthritis of the shoulder: a preliminary study. Am J Sports Med 2007; 35(6):979-85.
  24. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the Medical Management of Osteoarthrits of the Hip and Knee. 2000. Available online at: http://www.rheumatology.org/Practice/Clinical/Guidelines/Practice_Guidelines/. Last accessed July, 2013.
  25. 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 Res (Hoboken) 2012; 64(4):465-74.
  26. Zhang W, Moskowitz RW, Nuki G et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16(2):137-62.
  27. Bannuru RR, Natov NS, Obadan IE et al. Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Arthritis Rheum 2009; 61(12):1704-11.
  28. Zhang W, Nuki G, Moskowitz RW et al. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010; 18(4):476-99.
  29. McAlindon TE, Bannuru RR. OARSI recommendations for the management of hip and knee osteoarthritis: the semantics of differences and changes. Osteoarthritis Cartilage 2010; 18(4):473-5.
  30. Galie N, Olschewski H, Oudiz RJ et al. Ambrisentan for the treatment of pulmonary arterial hypertension: results of the ambrisentan in pulmonary arterial hypertension, randomized, double-blind, placebo-controlled, multicenter, efficacy (ARIES) study 1 and 2. Circulation 2008; 117(23):3010-9.

Coding

Codes

Number

Description

CPT

20610

Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa)

ICD-9 Procedure

81.92

Injection of therapeutic substance into joint or ligament

ICD-9 Diagnosis

715.0 – 715.9

Osteoarthrosis code range. A fifth digit of “6” in the ICD-9 code indicates osteoarthrosis of the knee

ICD-10-CM
(effective 10/01/14)

M17.0 – M17.9

Osteoarthritis of knee, code range

ICD-10-PCS
(effective 10/01/14)

3E0U3GC

Administration, introduction, joints, percutaneous, other therapeutic substance, other substance

HCPCS

J7321

Hyaluronan or derivative, Hyalgan or Supartz, for intra-articular injection, per dose

 

J7323

Hyaluronan or derivative, Euflexxa, for intra-articular injection, per dose

 

J7324

Hyaluronan or derivative, Orthovisc, for intra-articular injection, per dose

 

J7325

Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg

 

J7326

Hyaluronan or derivative, Gel-One, for intra-articular injection, per dose

Type of Service

Medicine

 

Place of Service

Physician’s Office

 

Appendix

N/A

History

Date

Reason

05/08/12

New policy, add to Medicine section. This policy replaces 5.01.506. Added the table listing FDA approved hyaluranon products and recommended course(s) of treatment per MPC request. The 3rd sentence of the 4th paragraph regarding The product inserts further indicates…was moved from the description to the policy guidelines section for ease of policy administration. Policy approved with 90-day hold for provider notification. The policy effective date is November 7, 2012.

08/03/12

Correct Error on Related Policy number. Changed from 7.01.118 to 7.01.117.

08/27/12

Update Coding Section – ICD-10 codes are now effective 10/01/2014.

11/7/12

Policy effective after hold for provider notification. 5.01.506 is deleted.

03/08/13

Policy updated. Rationale and references revised. “in the knee when the above criteria are not met, and” was added to the investigational statement.

07/16/13

Update Related Policies. Add 7.01.549, and remove 7.01.188 as it was archived.

11/11/13

Replace Policy. Policy updated with literature review through July 31, 2013; reference 7 added; policy changed to not medically necessary based on new guidelines from the American Academy of Orthopaedic Surgeons. Policy change aligns with UM initiative and recent change in coverage from BCBSA. Policy held for provider notification; the effective date is April 1, 2014.

12/09/13

Minor update: When this policy was approved last month a sentence was left out. A second policy statement is now included: “Intra-articular hyaluronan injections are considered not medically necessary to treat osteoarthritis of any joint other than the knee.”

01/23/14

Policy implementation delayed; the effective date of the policy is moved to June 1, 2014.

03/03/14

Policy implementation delayed; the effective date of the policy is moved to July 1, 2014.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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