Wiki Medical necessity of Viscosupplementation

[NEOSM507]

There are a number of carriers that will not cover Viscosupplementation for the treatment of osteoarthritis in the knee, as they deem it ineffective. Specific carrier verbage reads:

"..... many analyses have not shown a clinical benefit beyond the effect seen with placebo, and evidence from recent large, double-blinded, and high-quality trials suggests the clinical benefit of hyaluronan is of minimal benefit over intra-articular placebo (Bannuru, 2015).

The question raised is are providers still allowed to bill the injection (20610, 20611) for OA to the carrier, and charge the patient for the drug? Or because we are injecting a substance that is not covered by the plan, would the administration of that substance also fall under not medically necessary?

Here is the actual policy from the carrier for your reference. https://www.empireblue.com/medicalpolicies/guidelines/gl_pw_c160709.htm

Thank you for your help.

 

[Melissa Harris CPC]

I have been looking into this as well as many insurances are starting to not cover visco supplementation. Any guidance is much appreciated

 

[daedolos]

There is a pain management component for 20610 so if you are reworking old claims, you might bill 20610 for pain management then settle the viscosupplementation portion with the patient. As far as getting authorizations for viscosupplementation, I agree it's getting more difficult. However, as a conservative modality, you'd think insurance would allow it in lieu of surgery which should be a last resort.

Peace
@_*

 

[Wbeshears]

For plans that no longer cover it, I try to get approval through specialty pharmacies that the patient may have, like CVS CareMark or Express Scripts. I usually have no problem getting approval that way. Some plans don't find the ultrasound component necessary and don't pay for that.