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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case. You can findthis rule at 42 CFR 422.101.The rules say that the following guidelines identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice:-Medications given for a purpose other than the treatment of a particular condition, illness, or injury are not covered.-Medications administered for treatment of a disease and which exceed the frequency or duration of injections indicated by accepted standards of medical practice are not covered.-If a medication is determined not to be medically reasonable and necessary for diagnosis or treatment of an illness or injury according to these guidelines, the entire charge (i.e., for both the drug and its administration) is not considered medically necessary.You can find this rule at Local Coverage Article: Billing and Coding: Intraarticular Knee Injections of Hyaluronan (A56157) (eff. 11/1/19).Medicare rules also allow the plan to use step therapy. This is the process of beginning drug therapy for a medical condition with "preferred" (or more cost-effective) on-formulary drug alternative(s) and progressing to other drug therapies only as necessary. A plan must grant an exception to its step therapy rules if it determines that the requested drug is medically necessary, consistent with the prescriber's statement. The statement must show that the step therapy drugs: have been ineffective in treating the enrollee; or are likely to be ineffective or adversely affect the drug's effectiveness or patient compliance; or are likely to cause an adverse reaction or other harm to the enrollee. Medicare Advantage plans should ensure that new step therapy requirements do not disrupt ongoing Part B drug therapies for enrollees. Step therapy may only be applied to new prescriptions or administrations of Part B drugs for enrollees that are not actively receiving the affected medication. You can find this information at 42 CFR Section 423.578(b)(5)(ii).If you want to read these Medicare rules, you can go to this web site www.medicareappeal.com.The Plan contract says that the Plan covers items and services in accordance with Medicare rules. The contract says that the Plan has step therapy requirements for certain Medicare Part B covered drugs/biologicals. Enrollees may be required to try a preferred drug before the Plan will approve the requested medication. You can find this information on page 142 of the 2019 Evidence of Coverage (EOC).
as canes have been helpful in managing osteoarthritis.

Various polymers hyaluronic acid have been approved and marketed as implanted prosthetic devices.

    The FDA has approved Viscosupplementation as a device. Medicare is allowing this nonpharmacologic therapy. The contractor expects the use of those drugs and biologicals not listed here to be medically necessary and used according to their FDA indications.
    This treatment will only be covered for the treatment of pain in osteoarthritis of the knee. All other uses will be denied as investigational.
    All procedures are furnished by and administered by a physician and/or appropriately trained providers in the appropriate setting.
    Documentation in the patient's medical record must show the patient failed to respond adequately over a three month period to a past history of treatment with analgesics and conservative nonpharmacological therapy (exercise or physical therapy, weight loss if appropriate, use of assistive devices) and a radiological exam to support the diagnosis of osteoarthritis.
    The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee.

If subsequent courses of treatment are given, the medical records must support the effectiveness of the prior treatment and must clearly establish reduction of patient symptomatology and medication usage. This documentation must be submitted upon request. Claims submitted without requested supporting evidence in the medical record will be denied as being not medically necessary.

Repeat treatments are considered medically necessary for patients being treated for osteoarthritis of the knee, who meet both of the following criteria:

    Significant improvement in knee pain and known improvement in functional capacity resulted from the previous series of injections which has been documented in the record; and
    At least six (6) months have elapsed since the last injection in the series.

The Medicare program covers drugs that are furnished "incident to" a physician's service provided, that the drugs are not usually self-administered by the patients. Please refer to the WPS GHA Incident to Services.

The following guidelines identify three categories in which medications would not be reasonable and necessary according to accepted standards of medical practice:

    Medications given for a purpose other than the treatment of a particular condition, illness, or injury are not covered.
    Medications administered for treatment of a disease and which exceed the frequency or duration of injections indicated by accepted standards of medical practice are not covered.
    If a medication is determined not to be medically reasonable and necessary for diagnosis or treatment of an illness or injury according to these guidelines, the entire charge (i.e., for both the drug and its administration) is not considered medically necessary.