Advocacy for Continuing Hyaluronic Acid Knee Injection Coverage: BCBS IL Medicare Advantage 2026

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Introduction

Given the clinical value of hyaluronic acid (HA) knee injections, it is crucial to review the evidence supporting their continued coverage. This report gathers recent research on clinical efficacy, patient outcomes, cost-effectiveness, and policy status to argue that BCBS IL Medicare Advantage should maintain coverage of HA injections for knee OA in 2026 and beyond.

Eliminating coverage would deprive Medicare patients of an FDA-approved, low-risk therapy that can relieve pain, improve function, and postpone invasive surgery.

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Clinical Efficacy of Hyaluronic Acid Injections in Knee OA

Multiple randomized trials and meta-analyses confirm that intra-articular hyaluronic acid provides meaningful pain relief in knee osteoarthritis.

Key Research Findings

Study	Finding
BMJ 2022 Systematic Review	Viscosupplementation led to statistically significant reduction in knee pain vs placebo
2025 Network Meta-Analysis	At one-year follow-up, HA achieved better pain/functional outcomes than placebo and surpassed corticosteroid outcomes long-term
Multiple RCTs	Significant improvements in pain, stiffness, and function scores lasting up to 6 months

How HA Works

Intra-articular HA works by:

• Restoring viscoelasticity and joint lubrication
• Reducing friction and modulating inflammation
• Potentially protecting cartilage and reducing inflammatory cytokines
• Stimulating endogenous HA and proteoglycan synthesis

Safety Profile

HA injections are remarkably well tolerated:

• Most common side effects: transient local reactions (injection-site pain/swelling)
• Serious adverse events (septic joint): exceedingly rare (~few per 10,000 injections)
• 2022 comprehensive review: no increase in serious adverse events vs placebo
• Unlike chronic NSAIDs/opioids: no GI, renal, cardiovascular, or addiction risks

This allows HA injections to be repeated over time without cumulative toxicity—critical for elderly Medicare patients.

Medicare Coverage Criteria

Medicare’s coverage criteria allow additional courses every ≥6 months if prior injections yielded pain relief and functional gains. This recognizes that repeat injection cycles can be effective in responding patients.

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Comparative Effectiveness vs. Standard Treatments

When considering coverage policy, comparing viscosupplementation with alternative treatments is vital:

HA vs. Corticosteroid Injections

Factor	Corticosteroid	Hyaluronic Acid
Onset	Quick (days)	Gradual (weeks)
Duration	4-6 weeks	3-6 months
6-Month Outcomes	Waning	Superior pain/function scores
Cartilage Effects	Toxicity risk, accelerated degeneration	No cartilage damage
Repeat Use Safety	Risks increase	Safe for serial use

ECRI 2019 Conclusion: At 6 months post-injection, HA patients had significantly better pain and functional scores than corticosteroid patients.

HA vs. NSAIDs and Analgesics

Chronic NSAID therapy in older adults is limited by:

• Gastrointestinal bleeding
• Renal impairment
• Cardiovascular events

Many Medicare-age patients cannot tolerate NSAIDs or have contraindications. HA injections serve as local therapy reducing pain without systemic exposure.

• Patients on HA often reduce or stop NSAID intake
• Fewer systemic medications = fewer side effects and drug interactions
• Critical in polypharmacy-prone Medicare populations

HA vs. Physical Therapy

Rather than either/or, viscosupplementation is complementary to PT:

• By reducing pain, HA enables fuller participation in rehabilitation
• Treats joint internally without impeding mobility
• Extends therapeutic benefits of conservative management

HA vs. Total Knee Replacement

Factor	TKR Surgery	HA Injections
Cost	$30,000-$50,000+	$500-$1,500/series
Risks	Infection, blood clots, cardiac events	Minimal local reactions
Recovery	Significant rehabilitation	None required
Delay Benefit	N/A	1-3+ years before TKR needed

Real-world data show patients receiving HA experience significantly prolonged time before knee replacement. Every year of delay means:

• Preserved natural joint function
• Avoided surgical risk
• Reduced likelihood of revision surgery

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Real-World Outcomes in Medicare-Aged Populations

Large population studies provide evidence of meaningful long-term benefits:

Delayed Need for Total Knee Replacement

Improved Functional Status and Quality of Life

• Single HA injection significantly reduced pain intensity at 1 and 3 months
• Improved physical function and quality of life vs matched controls
• Patients report walking farther, relying less on assistive devices
• Maintained mobility and independence longer

Medication Sparing Effects

Patients on HA therapy may consume fewer pain medications:

• Reductions in NSAID and opioid prescription fills
• Fewer GI bleeds and opioid-related adverse events
• Important in polypharmacy-prone Medicare populations

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Cost-Effectiveness Considerations

Cost per Quality-Adjusted Life Year (QALY)

Treatment	QALYs	Cost	$/QALY
HA Injections	0.58	~$5,300	$5,332
PRP Injections	Similar	Higher	~$8,600
Typical threshold	—	—	$50,000

HA injections are well below cost-effectiveness thresholds, meaning they’re considered a high-value intervention.

Costs Relative to Surgery

Treatment Path	Cost Range
Single TKR surgery	$25,000-$30,000+
Multiple HA courses over years	Fraction of surgical costs
Avoided surgery	$30,000+ saved per patient

Even multiple yearly injection cycles amount to a fraction of surgical costs. If HA postpones TKR by even one year, it can be considered cost-saving.

Pharmacy and Complication Cost Offsets

• Reduced chronic NSAID/opioid use prevents costly adverse events
• Fewer ulcers, GI bleeds, fractures from opioids
• Keeping patients active may avoid costs related to immobility

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CMS Policy and Current Coverage Status

CMS has not issued any national non-coverage for hyaluronic acid injections.

Coverage is governed by Local Coverage Determinations (LCDs) from Medicare Administrative Contractors. Multiple MAC jurisdictions actively cover intra-articular HA for knee OA:

Palmetto GBA LCD (L39260)

Covers HA as “reasonable and necessary” when patient meets ALL:

• Radiographic evidence of knee OA
• Pain causing functional limitations
• Failure of ≥3 months conservative therapy
• Failure or contraindication to corticosteroid injection

Permits repeat series every 6+ months if prior injections improved pain/function.

WPS LCD (L39529) - Covers Illinois

• Provides coverage under similar medical necessity criteria
• Updated in 2025 with no changes in coverage intent
• Indicates Medicare Part B recognizes and reimburses HA for Illinois beneficiaries

Key Policy Points

• No National Coverage Determination to exclude HA
• Each MAC reviewed literature and decided to cover with appropriate safeguards
• CMS rules generally require Medicare Advantage to provide at least original Medicare coverage
• Since original Medicare covers HA via MACs, MA plans risk non-compliance if categorically denying

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Coverage by Other Major Medicare Advantage Payers

A decision to drop coverage would make BCBS IL an outlier among major payers:

UnitedHealthcare (Largest MA Insurer)

• Lists HA as “proven and medically necessary” for knee OA
• Requires documented OA, tried conservative measures, pain interfering with function
• Employs prior authorization but coverage is provided
• No intent to remove coverage as of 2025

Aetna

• Clinical Policy Bulletin #0179 states HA is medically necessary when:
  • Radiographic evidence of OA
  • Moderate to severe knee pain affecting function
  • Failed conservative therapy and steroid injections
• Comprehensive list of covered brands and dosing schedules
• For MA members, defers to Medicare coverage criteria

Humana

• Covers HA with prior authorization
• Processes requests consistent with Medicare guidelines
• No indication of eliminating coverage

Other BCBS Affiliate MA Plans

BCBS Louisiana Blue Advantage (MA) Policy MNG-015 (Dec 2024):

• Explicitly covers HA for knee OA
• Allows repeat injections after 6 months if conditions met
• Demonstrates BCBS family maintains coverage

If BCBS IL diverges, it would go against the trend seen in peer plans.

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Clinical Guidelines and Professional Recommendations

American Academy of Orthopaedic Surgeons (AAOS)

Year	Position
2013	Strong recommendation against
2021	Changed to “not recommended for routine use”

The shift from “strongly against” to “not for routine use” indicates AAOS recognized newer evidence. Allows HA in certain patients based on clinical judgment.

American College of Rheumatology (ACR) / Arthritis Foundation (2019)

• Conditional recommendation against routine use
• “Conditional” = close balance of pros/cons, decision varies by patient
• Specifically notes: “consistent with use of HA in occasional patients who have contraindications to preferred therapies”
• Leaves room for clinical discretion

Osteoarthritis Research Society International (OARSI)

• Acknowledged HA provides pain relief beyond 12 weeks
• Favorable safety profile vs repeated steroids
• “Findings support use of viscosupplementation” in appropriate patients

European Guidelines (ESCEO, EUROVISCO)

• Include viscosupplementation as recommended second-line therapy
• Particularly for patients with risk factors limiting NSAID/steroid use

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Conclusion and Recommendations

Hyaluronic acid knee injections represent an important therapy in the continuum of osteoarthritis care for Medicare patients. The evidence demonstrates that continuing coverage is well-justified:

Clinical Benefit

HA provides significant pain relief and functional improvement with minimal risk, helping patients stay active and delay invasive interventions.

Patient Outcomes

Real-world data show viscosupplementation delays progression to knee replacement by 1-3+ years, with better mobility and reduced medication reliance.

Cost-Effectiveness

Covering HA is financially sound—low cost per treatment, potential savings from deferred surgeries, and reduced complications from alternative medications.

Policy Alignment

Medicare’s current policy supports viscosupplementation. Major competing MA plans cover it. Removing coverage would deviate from federal standards and competitor offerings.

Guideline Consistency

No guideline prohibits HA use. Coverage with prior authorization aligns with expert recommendations for targeted, judicious use.

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Sources

1. Altman R. et al. (2015). Hyaluronic Acid Injections Are Associated with Delay of Total Knee Replacement Surgery in Patients with Knee OA: Large U.S. Claims Database Study. PLoS One. 10(12):e0145776.

2. Park JG. et al. (2024). Association between IA hyaluronic acid injections and delaying total knee arthroplasty: analysis of 36,983 patients. BMC Musculoskelet Disord. 25:706.

3. Samuelson EM. et al. (2020). Cost-Effectiveness of PRP vs Hyaluronic Acid for Knee Osteoarthritis. Arthroscopy. 36(12):3072-78.

4. CMS Local Coverage Determination L39260 (Palmetto GBA). Hyaluronic Acid Injections for Knee Osteoarthritis. Effective 8/21/2022.

5. CMS Local Coverage Determination L39529 (WPS). Intraarticular Knee Injections of Hyaluronan. Effective 6/11/2023 (rev. 5/1/2025).

6. UnitedHealthcare Medical Policy (2025). Sodium Hyaluronate Injections – Medicare & Commercial.

7. Aetna Clinical Policy Bulletin #0179 (2023). Viscosupplementation (Hyaluronates).

8. American Academy of Orthopaedic Surgeons (AAOS). Clinical Practice Guideline on Management of Knee Osteoarthritis, 3rd Ed. (2021).

9. American College of Rheumatology/Arthritis Foundation. 2019 OA Treatment Guideline.

10. Osteoarthritis Research Society International (OARSI) Steering Committee. Treatment Guidelines (2019).

11. BCBS Illinois Provider Notice (Sept 2025). “Member Benefit Coverage for Viscosupplementation for OA will End Jan. 1, 2026.”

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Related Resources

• RCT Evidence: HA Injections Improve Quality of Life - Clinical trial data
• Don’t Make Seniors Choose Between Pain and Poverty - Op-ed on the human impact
• BCBS Illinois Ends Viscosupplementation Coverage: Full Analysis - Complete breakdown
• Medicare Coverage for Knee Injections - Understanding your options
• Hyaluronic Acid Injections: Complete Guide - What the research shows
• HA vs. Cortisone: Which Is Right for You? - Comparing treatments