Anthem Blue Cross Viscosupplementation Coverage
Yes, Anthem Blue Cross covers viscosupplementation for knee osteoarthritis with prior authorization. You must have documented failure of conservative treatments before Anthem will approve coverage.
Quick Facts
| Coverage Aspect | Details |
|---|---|
| Covered? | Yes (knee OA) |
| Prior Authorization | Required |
| Conservative TX First | Yes |
| Your Cost | Plan-specific coinsurance |
Anthem’s Requirements
Anthem’s medical policy requires:
- Knee osteoarthritis diagnosis confirmed by X-ray or MRI
- Failed conservative treatment documented in medical records:
- Physical therapy or exercise
- NSAIDs or acetaminophen
- Activity modification
- Prior authorization obtained before the procedure
- FDA-approved viscosupplement used by an in-network provider
Covered Benefit
Anthem covers viscosupplementation when clinical criteria are met. Make sure your doctor documents all prior treatments before requesting authorization.
Covered Products
| Brand | Injections | Schedule |
|---|---|---|
| Synvisc-One | 1 | Single injection |
| Euflexxa | 3 | Weekly x 3 weeks |
| Hyalgan | 3-5 | Weekly series |
| Orthovisc | 3-4 | Weekly series |
| Gel-One | 1 | Single injection |
| Monovisc | 1 | Single injection |
Anthem may have preferred brands that offer better cost-sharing. Check with your provider.
What You Will Pay
| Plan Type | Typical Cost |
|---|---|
| PPO in-network | 20% coinsurance after deductible |
| HMO | Specialist copay + procedure share |
| Medicare Advantage | 20% coinsurance typical |
| Out-of-network | 40-50% coinsurance |
Authorization Process
- See your orthopedist for evaluation and imaging
- Complete conservative treatment and document results
- Your doctor submits prior auth with medical records
- Anthem reviews (typically 5-15 business days)
- If approved, schedule with an in-network provider
- If denied, request peer-to-peer review
Get Approval First
Never have the injection before receiving written prior authorization approval. Retroactive authorizations are difficult to obtain and you may be stuck with the full bill.
Frequently Asked Questions
How often does Anthem cover viscosupplementation?
Anthem typically approves one treatment series per knee every 6 months. Repeat treatments require new prior authorization.
Is viscosupplementation the same as HA injections?
Yes. Viscosupplementation is the medical term for hyaluronic acid (HA) injections into the joint. They are the same procedure.
Does Anthem cover this for Medicare Advantage members?
Yes. Anthem Medicare Advantage plans follow Medicare’s coverage guidelines, which include viscosupplementation for knee OA.