Hyaluronic acid derivatives
No prior authorization required for:
- Emergency room
- Skilled nursing facility
Injectable auth/billing notes:
Medications billed with miscellaneous codes will be reviewed. Explanatory notes must accompany the claim.
Priority Health Medicare applies CMS local coverage determination criteria when available for Part B drugs.
- Treatment of osteoarthritis of the knee
- ALL formulations are NOT COVERED for fully funded or self-funded group plans or Medicaid as of January 1, 2017
- Covered for Medicare without prior authorization
Hymovis, Hyalgan or Supartz: J7320, J7322, J7322
Orthovisc: J7324; length of authorization, 3-5 injections
Synvisc or Synvisc One: J7325; length of authorization, 1-5 injections
Gel-Syn: J7328 (0.1mg)
GelVisc: Q9980 (1mg)