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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 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 NSAIDS. 
    The patient has failed to respond to aspiration of the knee and intra-articular corticosteroid injection therapy 
when inflammation is a significant component of the patients symptoms and intra-articular corticosteroids are 
not contraindicated. 
 
Limitations 
 
    1. Drugs and biologicals approved for marketing by the FDA are considered safe and effective when used for 
indications specified on the labeling. The labeling lists the safe and effective, i.e., medically reasonable and 
necessary dosage and frequency. Therefore, doses and frequencies that exceed the accepted standard of 
recommended dosage and/or frequency, as described in the package insert, are considered not reasonable and 
necessary and therefore, not subject to coverage. 
    2. Intra-articular injections of other therapeutic agents, such as corticosteroids, should not be performed in 
the same knee during the course of viscosupplementation therapy. 
    3. If the first course of treatment produces relief, subsequent courses of treatment may be reasonable if 
symptoms return. Subsequent courses of treatment will be allowed six (6) months after the last injection of a 
previous course of treatment. 
    4. Viscosupplementation of joints other than the knee(s) will be considered not reasonable and necessary and 
will not be subject to coverage.  
    5. Imaging procedures performed routinely for the purpose of visualization of the knee to provide guidance 
for needle placement will not be covered. Fluoroscopy may be medically necessary and allowed if documentation supports that the presentation of the patients affected knee on the day of the procedure makes 
needle insertion problematic. No other imaging modality for the purpose of needle guidance and placement will 
be covered. 
    6. Arthrography to provide needle guidance for knee injections will not be covered. 
    7. Coverage of viscosupplementation therapy of the knee assumes that knee arthroplasty is not being 
considered as a current treatment option. 
    8. The course of treatment should consist of the use of one agent. One agent should be used for the entire 
course of treatment. Therefore, initiating a course of treatment with one agent, then switching before 
completion to a different agent is considered not medically reasonable and necessary. Example: Treatment is 
initiated with Synvisc. After the application of two doses, the provider switches to Synvisc-one. The Synvisc-
one would not be considered medically reasonable and necessary. 
    9. It is not expected that routine imaging for the purpose of needle guidance would be required. Therefore, 
routine use of fluoroscopy may result in a pre- payment medical review of records. Documentation should 
provide justification when imaging is performed for the purpose of needle guidance. The use of hand held 
ultrasound devices are not separately reimbursed. 
    Viscosupplementation will not be covered: 
        When the diagnosis is anything other than osteoarthritis 
        For intra-articular injection in joints other than the knee 
        As the initial treatment of osteoarthritis of the knee 
        When failure of/or contraindication to conservative therapy and/or corticosteroid injections are not 
documented in the medical record 
        When the dose and treatment regimen exceeds those approved under the FDA label 
        When a repeat series of injections is initiated prior to six months after completion of the previous course 
of treatment 
        When a repeat series of injections is administered when there was no symptomatic/functional 
improvement evidenced from the previous series of injections 
        For topical application of hyaluronate preparations 
 
As published in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Section 
13.5.4, an item or service may be covered by a contractor LCD if it is reasonable and necessary under the 
Social Security Act Section 1862 (a)(1)(A). Contractors shall determine and describe the circumstances under 
which the item or service is considered reasonable and necessary. You can find this information in Medicare's 
Local Coverage Determination (LCD): Viscosupplementation Therapy for Knee (L33767). 
 
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.