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Sodium Hyaluronate – Commercial Medical Benefit Drug …

Sodium Hyaluronate Page 1 of 18 UnitedHealthcare Commercial Medical Benefit Drug policy Effective 10/01/2020 Proprietary Information of UnitedHealthcare. Copyright 2020 United HealthCare services , Inc. UnitedHealthcare Commercial Medica l Benefit Drug policy Sodium Hyaluronate policy Number: 2020D0081C Effective Date: October 1, 2020 Instructions for Use Table of Contents Page Coverage Rationale .. 1 Documentation Requirements .. 3 Applicable Codes .. 4 Background .. 6 Clinical Evidence .. 6 Food and Drug Administration .. 13 Centers for Medicare and Medicaid services .. 14 References .. 14 policy History/Revision Information .. 17 Instructions for Use .. 18 Coverage Rationale Medical Necessity Plans Coverage for Durolane, Euflexxa, and Gelsyn-3 is contingent on criteria in the Diagnosis-Specific Criteria section.

UnitedHealthcare Commercial Medical Benefit Drug Policy Effective 11/01/2021 ... (e.g., ambulation, prolonged standing); and The pain is attributed to degenerative joint disease/primary osteoarthritis of the knee; and ... Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may

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  Policy, Services, Sodium, Prolonged, Sodium hyaluronate, Hyaluronate

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