Appeal type: unknown
Decision: unknown

 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.  Medicare may cover the use of an FDA-approved drug or biological if it is safe and effective and otherwise reasonable and necessary for the patient. Food and Drug Administration (FDA) approved drugs used for indications other than what is indicated on the official label may be covered if the use is determined to be medically accepted, taking into consideration the major drug compendia, authoritative medical literature and/or accepted standards of medical practice. You can find this rule in the Centers for Medicare and Medicaid Services, Internet Only Manual, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Sections 50.4.1 and 50.4.2.  Hyaluronan Acid Therapies for Osteoarthritis of the Knee are covered when;      All documentation must be maintained in the patient's medical record and made available to the contractor upon request.     Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.     The medical record documentation must support the medical necessity of the services as stated in this policy.     The medical records must document that the patient has symptomatic osteoarthritis of the knee, the nature of the symptoms and the functional limitations using a standardized assessment tool.     Radiographic confirmation of osteoarthritis of the knee in the form of an x-ray report and/or notation in the record must accompany the clinical description.     The medical record must include documentation that supports that conservative therapy was attempted prior to viscosupplementation therapy. If conservative therapy and/or corticosteroid injections were contraindicated or failed, the reason(s) must be supported in the documentation submitted for review.     The medical record must indicate whether one or both knees are being treated and in the former instance, which knee is being treated.     If fluoroscopy or ultrasound is used for needle guidance with the intra-articular injection, documentation must support that the presentation of the patient's affected knee on the day of the procedure makes needle insertion problematic.     If intra-articular injections of other therapeutic agents, such as corticosteroids, are performed in the same knee during the course of viscosupplementation therapy, the reason(s) requiring the use of the additional therapeutic agent must be documented.     The frequency of injections and the dosage given must be clearly indicated.     The response to treatment must be noted. Medical records should describe the assessment tool utilized. Repeat courses of viscosupplementation in the absence of documentation of response to the previous course of treatment will be considered not reasonable and necessary and not subject to coverage.  you can find this information 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.