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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 find this rule at 42 Code of Federal Regulations (CFR) Section 422.101. 
 
The rules say that hyaluronic acid, also known as hyaluronan or hyaluronate, is a naturally occurring substance 
found in the synovial fluid surrounding joints. Osteoarthritic joints are found to have lower concentrations of 
hyaluronic acid.1 Intra-articular injection of hyaluronic acid, also known as viscosupplementation, has been 
proposed as a means of restoring the normal viscoelasticity of the synovial fluid in individuals with 
osteoarthritis. Viscosupplementation is most commonly used to treat symptoms of osteoarthritis of the knee. 
Osteoarthritis (OA) results from articular cartilage failure due to the complex interplay of genetic, metabolic, 
biochemical and biomechanical factors with a secondary component of inflammation. In most patients the 
initiating mechanism is damage to the articular cartilage either as a single large injury or a series of repeated 
smaller injuries. The primary symptom of osteoarthritis of the knee is pain, however, because cartilage is 
aneural, significant radiographic findings are often noted in asymptomatic individuals imaged for other reasons.  
 
Viscosupplementation therapy for the knee via intra-articular injections of hyaluronic preparations will be 
considered medically reasonable and necessary when ALL of the following conditions are met: 
 
    The patient is symptomatic. Such symptoms may include pain which interferes with the activities of daily 
living such as ambulation and prolonged standing, or pain interrupting sleep, crepitus, and/or knee stiffness. 
    The clinical diagnosis is supported by radiologic evidence of osteoarthritis of the knee such as joint space 
narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts. 
    If appropriate, other diagnoses have been excluded by appropriate evaluation and management services, 
laboratory and imaging studies (i.e., the pain and functional disability is not considered likely to be due to a 
diagnosis other than osteoarthritis of the knee). 
    The patient has failed at least three months of conservative therapy. Conservative therapy is defined as: 
        Nonpharmacologic therapy (such as but not limited to home exercise program, education, weight loss, 
physical therapy if indicated); and 
        If not contraindicated, simple analgesics and (e.g., acetaminophen) or NSAIDS per hyaluronan product 
prescribing information. 
    The patient has failed to respond to aspiration of the knee when effusion is present and intra-articular 
corticosteroid injection therapy when inflammation is a significant component of the patients symptoms and 
intra-articular corticosteroids are not contraindicated. 
 
A repeat series* of hyaluronan knee injection(s) for patients who have responded to a prior series is considered 
to be reasonable and necessary under the following circumstances: 
     Symptoms have recurred 
    And, 
    At least six months have elapsed since the prior series of injections 
    And, 
    There was significant improvement in pain and functional capacity achieved with the prior series of 
injections using a standardized assessment tool 
    Or, 
    There is significant reduction in the doses of NSAID medications taken or reduction in the number of intra-
articular steroid injections to the knees during the six-month period following the injection(s). 
 
*Note: A series is defined as a set of injections for each joint and each treatment (initial or repeat). You can 
find these rules in the Local Coverage Determination (LCD) Hyaluronan Acid Therapies for Osteoarthritis of 
the Knee L35427. 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com. 
 
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.