INTRA-ARTICULAR HYALURONAN INJECTIONS

Transcription

1 INTRA-ARTICULAR HYALURONAN INJECTIONS Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Medical Coverage Guideline must be read in its entirety to determine coverage eligibility, if any. This Medical Coverage Guideline provides information related to coverage determinations only and does not imply that a service or treatment is clinically appropriate or inappropriate. The provider and the member are responsible for all decisions regarding the appropriateness of care. Providers should provide BCBSAZ complete medical rationale when requesting any exceptions to these guidelines. The section identified as Description defines or describes a service, procedure, medical device or drug and is in no way intended as a statement of medical necessity and/or coverage. The section identified as Criteria defines criteria to determine whether a service, procedure, medical device or drug is considered medically necessary or experimental or investigational. State or federal mandates, e.g., FEP program, may dictate that any drug, device or biological product approved by the U.S. Food and Drug Administration (FDA) may not be considered experimental or investigational and thus the drug, device or biological product may be assessed only on the basis of medical necessity. Medical Coverage Guidelines are subject to change as new information becomes available. For purposes of this Medical Coverage Guideline, the terms "experimental" and "investigational" are considered to be interchangeable. BLUE CROSS, BLUE SHIELD and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. All other trademarks and service marks contained in this guideline are the property of their respective owners, which are not affiliated with BCBSAZ. O docx Page 1 of 6

2 Description: Intra-articular injection of hyaluronan (HA) into osteoarthritic joints is thought to replace HA, restore the viscoelastic properties of the synovial fluid and improve pain and function. Intra-articular hyaluronan injections include, but are not limited to: Euflexxa (1% Sodium hyaluronate) Gel-One (Hyaluronan hydrogel) GELSYN-3 (Sodium Hyaluronate 0.84%) also known as Gel-Syn GenVisc 850 (Sodium hyaluronate) Hyalgan (Sodium hyaluronate) Hymovis High Molecular Weight Viscoelastic Hyaluronan Monovisc (Sodium hyaluronate) OrthoVisc (Hyaluronan, Sodium hyaluronate) Supartz FX (Sodium hyaluronate) formerly Supartz Synvisc (Hylan, Hylan GF 20) Synvisc-One (Hylan G-F 20) Definitions: Osteoarthritis: Degenerative joint disease that occurs when the cartilage in joint wears down and the bone surfaces rub against each other. Also referred to as degenerative arthritis or inflammatory osteoarthritis. Chondrolmalacia Patella: Softening and degeneration of the cartilage underneath the kneecap. May be considered a form of osteoarthritis. O docx Page 2 of 6

3 Criteria: Initial course of intra-articular hyaluronan injections for treatment of painful osteoarthritis of the knee is considered medically necessary with documentation of ALL of the following 1. Failure to respond to at least 3 months of conservative treatment (e.g., exercise, physical therapy, activity modification, knee bracing, analgesics, topical capsaicin cream, nonsteroidal antiinflammatories, unless otherwise clearly documented as contraindicated) 2. Failure to respond to aspiration and injection of intra-articular steroids 3. Pain which interferes with functional activities e.g., ambulation, prolonged standing) and the pain cannot be attributed to other forms of joint disease 4. Total knee replacement is not scheduled within 6 months of starting treatment 5. Course of treatment is ONE of the following: Weekly injections for 3-5 weeks with GenVisc 850, Hyalgan or Supartz FX Weekly injections for 3-4 weeks with OrthoVisc Weekly injections for 3 weeks with GELSYN-3 (Gel-Syn), Euflexxa or Synvisc Weekly injections for 2 weeks with Hymovis One injection of Synvisc-One, Gel-One or Monovisc Repeat course of intra-articular hyaluronan injections for recurrence or worsening of pain due to osteoarthritis of the knee is considered medically necessary with documentation of ALL of the following: 1. Positive response to the prior course of injections with documentation of ALL of the following: Significant pain relief achieved Improved range of motion (ROM) and function Improvement or maintenance of activities of daily living (ADLs) 2. Minimum of 6 months has elapsed since completion of the previous course of treatment 3. Course of treatment is ONE of the following: Weekly injections for 3-5 weeks with GenVisc 850, Hyalgan or Supartz FX Weekly injections for 3-4 weeks with OrthoVisc Weekly injections for 3 weeks with GELSYN-3 (Gel-Syn), Euflexxa or Synvisc Weekly injections for 2 weeks with Hymovis One injection of Synvisc-One, Gel-One or Monovisc O docx Page 3 of 6

4 Criteria: (cont.) If member was approved for intra-articular hyaluronan injections prior to 01/01/14, repeat course of intra-articular hyaluronan injections on the same knee is considered medically necessary with documentation of ALL of the following: 1. Recurrence or worsening of pain due to osteoarthritis of the knee 2. Positive response to the prior course of injections with documentation of ALL of the following: Significant pain relief achieved Improved range of motion (ROM) and function Improvement or maintenance of activities of daily living (ADLs) 3. Minimum of 6 months has elapsed since completion of the previous course of treatment 4. Course of treatment is ONE of the following: Weekly injections for 3-5 weeks with GenVisc 850, Hyalgan or Supartz FX Weekly injections for 3-4 weeks with OrthoVisc Weekly injections for 3 weeks with GELSYN-3 (Gel-Syn), Euflexxa or Synvisc Weekly injections for 2 weeks with Hymovis One injection of Synvisc-One, Gel-One or Monovisc Greater than 3 courses of treatment per knee will be reviewed by the medical director(s) and/or clinical advisor(s). Intra-articular hyaluronan injections for all other indications not previously listed or if above criteria not met are considered experimental or investigational based upon: 1. Lack of final approval from the Food and Drug Administration, and 2. Insufficient scientific evidence to permit conclusions concerning the effect on health outcomes, and 3. Insufficient evidence to support improvement of the net health outcome, and 4. Insufficient evidence to support improvement of the net health outcome as much as, or more than, established alternatives, and 5. Insufficient evidence to support improvement outside the investigational setting. These indications include, but are not limited to: Pain in partial or total artificial knees Any joint other than the knee O docx Page 4 of 6

5 Resources: Literature reviewed 05/24/16. We do not include marketing materials, poster boards and nonpublished literature in our review. The BCBS Association Medical Policy Reference Manual (MPRM) policy is included in our guideline review. References cited in the MPRM policy are not duplicated on this guideline BCBS Association Medical Policy Reference Manual. Intra-articular Hyaluronan Injections for Osteoarthritis. Re-issue date 04/14/2016, issue date 07/10/ Altman, R, Moskowitz, R. Intraarticular Sodium Hyaluronate (Hyalgan) in the Treatment of Patients With Osteoarthritis of the Knee: A Randomized Clinical Trial. J Rheumatol ;25: American Academy of Orthopaedic Surgeons (AAOS). Treatment of Osteoarthritis of the Knee 05/18/2013; 2nd Edition. 4. BCBS Association. Special Report: Intra-Articular Hyaluronan Injections for the Treatment of Osteoarthritis of the Knee. 06/02/ BCBS Association Technology Assessment Program. Special Report: Intra-Articular Hyaluronan Injections for the Treatment of Osteoarthritis of the Knee. 02/ Bragantini, A, Cassini, M, et, al. Controlled Single-Blind Trial of Intra-Articularly Injected Hyaluronic Acid (Hyalgan) in Osteo-Arthritis of the Knee. Clinical Trials Journal ;24(No 4): California Technology Assessment Forum. Hyaluronic Acid for Treatment of Osteoarthritis of the Knee: Repeated Injections and Progression to Knee Replacement. 02/08/ Drug Facts and Comparisons. Hyaluronic Acid Derivatives (Hyalgan, Supartz, Synvisc, Orthovisc). 11/ External Consultant Review. Orthopedic. 03/28/ External Consultant Review. Orthopedic. 05/31/ External Consultant Review. Orthopedic Surgery. 10/ FDA. Gel-One. 03/22/ Ferring Pharmaceuticals. Euflexxa Package Insert. 10/ Genzyme. Synvisc Package Insert. 06/07/2004. O docx Page 5 of 6

6 Resources: (cont.) 15. Genzyme. Synvisc One (Hylan G-F 20) Package Insert. 03/19/ Genzyme, Clancy, A. Synvisc Repeat Treatment Letter, Synvisc Package Insert & Synvisc Patient Information. Letter 10/25/2006, Package Insert & Patient Information 11/15/ Genzyme, Clancy A. Synvisc Post Arthroscopic Use And Delay Progression to Surgery Letter, Attachments and Package Insert. Letter 10/26/2006, Package Insert 11/15/ Genzyme, R O. Synvisc Repeat Use Letter, Attachment and Package Insert. 05/11/ Lo GH, LaValley, M, et, al. Intra-Articular Hyaluronic Acid in Treatment of Knee Osteoarthritis: A Meta Analysis. JAMA. 12/17/2003;290(23): Lussier A, Cividino, A, et, al. Viscosupplementation With Hylan for the Treatment of Osteoarthritis: Findings From clinical Practice in Canada. J Rheumatol. 1996; Nephew S. Supartz Package Insert. 01/30/ Ortho Bioteck, Ali, S. OrthoVisc Repeat Use Letter, Attachments and Package Insert. 05/11/ Pritchard, C, Sripada, P, et, al. A Retrospective Comparison of the Efficacy and Tolerability of Sodium Hyaluronate and Hylan G-F 20 in the Treatment of Osteoarthritis of the Knee. Journal of Musculoskeletal Research. 2002;6(3 & 4): Raynauld, J, Goldsmith, C, et, al. Effectiveness and Safety of Repeat Courses of Hylan G-F 20 in Patients With Knee Osteoarthritis. OsteoArthritis and Cartilage. 2005;13: Sanofi Aventis, Lee, S. Hyalgan clinical studies letter. 07/07/ Sanofi-Aventis, Grunden, T. Hyalgan Repeat Use Letter and Package Insert. 05/11/ Scali, J. Intra-Articular Hyaluronic Acid in the Treatment of Osteoarthritis of the Knee: A Long Term Study. European Journal of Rheumatology and Inflammation. 1995; Smith & Nephew, Bostic, R. Supartz Informational Packet; Letter and Package Insert. 02/28/ Waddell, DD, Cefalu, C, et, al. An Open-Label Study of a Second Course of Hylan G-F 20 for the Treatment of Pain Associated With Knee Osteoarthritis. Curr Med Res Opin. 2003;19(6): Wang CT, Lin J, Chang CJ, Lin YT, Hou SM. Therapeutic effects of hyaluronic acid on osteoarthritis of the knee. A meta-analysis of randomized controlled trials. J Bone Joint Surg Am Mar 2004;86-A(3): O docx Page 6 of 6