Depending on the procedure codes entered for authorizations, the following documentation may be required. In very few circumstances, additional information that is not listed may be requested.

For every authorization, regardless of service, please include an office visit note with TWO (2) patient identifiers.

We encourage all users to print this checklist and utilize it when submitting viscosupplementation requests. 

Documentation Details
Advanced imaging
  • Findings of osteoarthritis on x-ray/ MRI
  • Dated imaging report

Attempted and failed non-operative/ non-drug therapy

(6 weeks)


  • Weight loss education
  • Assisted device (walker/ cane/ brace)
  • Home exercise program
Physical therapy & duration
Medication or steroid injection Have attempted medications OR steroid injections OR document contraindication
If the patient has had a previous visco injection:
Outcome of prior treatments

Include the percent (%) of relief from previous injections + the date of last injection*

*at least 6 months should have passed since last treatment


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