Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive

by  Find-A-Code
January 9th, 2018

According to Palmetto GBA, Medicare will cover the cost of the injection and the injected hyaluronate polymer for patients who meet the following clinical criteria:

The frequency of injections is:

An initial series of three to five weekly injections per knee. Note: Synvisc-One® and Gel-One® are administered through a single intra-articular injection.

A repeat series of injections for patients who have responded to the first series may be given individual consideration by Medicare for coverage under the following circumstances:

Drug Wastage

Medicare provides payment for the discarded drug/biological remaining in a single-use drug product after administering what is reasonable and necessary for the patient's condition. If the physician has made good faith efforts to minimize the unused portion of the drug/biological in how patients are scheduled and how he ordered, accepted, stored, and used the drug, and made good faith efforts to minimize the unused portion of the drug in how it is supplied, the program will cover the amount of drug discarded along with the amount administered.

Note: The JW modifier is not used on claims for drugs or biologicals provided under the Competitive Acquisition Program (CAP).

References:

Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive. (2018, January 9). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/coverage-and-or-medical-necessity-for-the-use-of-hyaluronan-or-derivitive-32793.html

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