Submitting Viscosupplementation Requests

If you would like additional resources regarding viscosupplementation, check out out "How to submit Viscosupplementation" webinar slides and recording!

Clinical Background

Viscosupplementation is a procedure in which a gel-like fluid (hyaluronic acid) is injected into the knee joint. It is used for the temporary relief of symptoms associated with arthritic conditions. It will not reverse the arthritic condition in the knee joint or cure arthritis. 

Hyaluronate injections are not a first-line treatment for arthritis of the knee joint*. Other preferred first-line treatment options include activity modification, weight loss, physical therapy, anti-inflammatory medications, corticosteroid injections.

*Viscosupplementation is not FDA-approved for any indications other than osteoarthritis of the knee. Requests for viscosupplementation at another body site will pend for review and will likely be denied upon final review unless withdrawn.*

Preferred Drugs

For service dates beginning January 1, 2022, Humana has added Durolane, Supartz FX and Synvisc-1 as preferred drugs for Medicare members. There are no additions to the preferred drug list for commercial members.

Commercial
Monovisc (J7327)
  • 1 unit per knee or 2 units for both knees
Orthovisc (J7324)
  • 3 or 4 units per knee or 6 or 8 units for both knees

 

Medicare
Monovisc (J7327)
  • 1 unit per knee or 2 units for both knees
Orthovisc (J7324)
  • 3 or 4 units per knee or 6 or 8 units for both knees

Durolane (J7318)

  • 1 unit per knee

Supartz FX (J7321)

  • 5 units per knee

Synvisc-1 (J7325)

  • 1 unit per knee

Evidence-Based Suggestions: 

If the number of units you enter in the service request exceeds our recommended threshold, the portal will present you with a message asking to update your request with the appropriate number for auto-approval.

You have 3 options when presented with this message:

  1. Press “More information” to open a separate tab with additional information regarding this suggestion.
  2. Press “Accept” to change your request to the suggested number. If you accept these changes the new number will be reflected in the request.
  3. Ignore this message and continue submitting your request as is. This may result in the request pending for review. 

How to submit

Steroid injections do NOT need authorization

Cohere will approve only one series of viscosupplementation requests at a time, this is inclusive of bilateral injections.

There are two possible scenarios of submission for this service:

  1. If you are submitting a preferred drug: both the INJECTION and DRUG should be submitted to Cohere. This includes the injection code (20610, 20611) and the preferred drug J-code (see table above).
  2. If you are submitting a request for a non-preferred drug, you must submit two authorizations:
    • Injection (20610, 20611) to Cohere
    • Non-preferred drug to Humana

What will auto-approve?

A single request in one submission. This includes both the procedure code for the injection (20610, 20611) AND the J-code for the preferred drug.

What does this mean for a bilateral injection?

  • To do this, enter “2” in the quantity field and indicate the injection is for both the LEFT and RIGHT in the clinical assessment questions*.

*Please note, if “2” is entered as the quantity and only left or right is selected in the questions, then the authorization will pend.

What to include with your request?

Initial requests Subsequent requests
  • X-ray results
  • Non-pharmacologic conservative care (like physical therapy, home exercises, weight loss)
  • Any medications or injections that have been tried
  • Non-pharmacologic conservative care (like physical therapy, home exercises, weight loss)
  • Any medications or injections that have been tried
  • X-ray results
  • Date of last viscosupplementation: Request must not exceed more than 2 treatments within a 12-month span, 6 months apart, per body site.
  • Must demonstrate improvement of symptoms from the first injection.

 

Have more questions?
Submit a request