September 5, 2013

HHA-13-10
DC-13-10
ASC-13-11
MS-13-13

BC-13-13
SA-13-10
HP-13-10

To:

All Blue Cross and Blue Shield of Kansas Contracting Providers

From:

Connie Winkley – Education/Communication Coordinator
Institutional Provider Relations
Blue Cross and Blue Shield of Kansas, Inc.
An Independent Licensee of the Blue Cross and Blue Shield Association

Subject:

Intra-articular Hyaluronan Injections for Osteoarthritis

The Intra-articular Hyaluronan Injections for Osteoarthritis prior authorization and quantity limits medical policy will be effective for all BCBSKS members on October 1, 2013. Injections will be medically necessary for treatment of painful osteoarthritis of the knee in patients who have insufficient pain relief from conservative non-pharmacologic therapy and simple analgesics.

Repeated courses of intra-articular hyaluronan injections of the knee may be considered medically necessary if significant pain relief was achieved with the prior course of injections and at least six months have passed since completion of the prior course. Injections in joints other than the knee are considered experimental/investigational.

The preferred agents will be Euflexxa, Synvisc and Synvisc-One. Use of a non-preferred product will only be allowed if the member meets the criteria above and has evidence of use of the preferred product in pharmacy claims or medical history, or the member has a contraindication or documented intolerance to the preferred agent. The complete medical policy for Intra-articular Hyaluronan Injections for Osteoarthritis policy can be accessed by clicking on the link and is published on the BCBSKS Website.

If you have questions on this newsletter, please contact your Institutional Provider Representative.  Denny Hartman can be reached at 1-316-269-1602, Cindy Garrison at 1-785-291-8862 and Janne Adams-Denton at 1-785-291-8813.

 

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