For dates of service beginning October 1, 2014, prior authorization is required for all hyaluronate preparations administered to members enrolled in Harvard Pilgrim’s HMO, POS, and PPO products. Harvard Pilgrim covers FDA-approved hyaluronate preparations that are medically necessary to treat pain associated with osteoarthritis of the knee in patients who have not gotten adequate relief from simple analgesics and conservative treatment. Coverage is limited to a maximum of 4 courses of treatment in 36 months.
Synvisc-One and Euflexxa are the preferred agents. Under our clinical medical policy for hyaluronic preparations, Harvard Pilgrim authorizes an initial course of treatment with Synvisc-One or Euflexxa when medical record documentation confirms all of the following:
- Prescribing physician is a rheumatologist, orthopedic specialist, physiatrist, or sports medicine specialist;
- Hyaluronate preparation is requested for member with Kellgren-Lawrence Scale (Grade 2 or greater) osteoarthritis of the knee (radiologic confirmation required);
- The member has obtained insufficient pain relief from conservative non-pharmacologic therapy and simple analgesics (e.g., acetaminophen, non-steroidal anti-inflammatory drugs, topical capsaicin);
- The member has had insufficient response after intra-articular corticosteroid injection (i.e., efficacy lasted less than 6-8 weeks).
Harvard Pilgrim will authorize an initial course of treatment with other FDA-approved hyaluronic agents — Gel-One, Hyalgan, Orthovisc, Supartz, Synvisc — only if the criteria listed above are met and medical records confirm that Synvisc-One and Euflexxa were previously ineffective or are contraindicated for the member. For further details, including coding information, please refer to our Hyaluronate Preparations for Osteoarthritis of the Knee Medical Review Criteria.
To request prior authorization, please fax a completed Hyaluronate Preparations for OA of Knee Prior Authorization Request form to 800-232-0816. You may also find it helpful to enter your request in HPHConnect to receive a tracking number and check the status of the request. To aid you in using HPHConnect for this purpose, a Pharmacy Service Transactions User Guide will be posed online prior to the October 1 effective date.