Quick Answer
Yes, Medicare Part B covers Synvisc-One injections for knee osteoarthritis when medical necessity criteria are met. As a single-injection treatment, Synvisc-One is one of the most convenient viscosupplementation options available. Most patients pay 20% coinsurance after meeting their Part B deductible.
Medicare Part B Coverage for Synvisc-One
Synvisc-One is a hylan G-F 20 viscosupplement made by Sanofi. It is one of the most prescribed single-injection hyaluronic acid products in the United States. Medicare covers Synvisc-One under Part B (the medical benefit), not under Part D (the pharmacy benefit), because it is administered in a physician’s office or outpatient setting.
Key coverage facts:
- Covered under Part B as a physician-administered injectable
- No prior authorization required under Original Medicare
- Subject to Local Coverage Determinations (LCDs) from your regional Medicare Administrative Contractor (MAC)
- Must meet medical necessity criteria documented in your medical records
Coverage Requirements
Medical Necessity Criteria
For Medicare to pay for Synvisc-One, your medical records must show:
- Diagnosis of knee osteoarthritis with ICD-10 code M17.x
- Failure of conservative treatment for at least 3 months, including physical therapy, oral anti-inflammatory medications (NSAIDs), or activity modification
- Documentation in your medical chart that these treatments did not provide adequate relief
- X-ray evidence confirming osteoarthritis (most MACs require imaging within the past 12 months)
Billing Codes
| Code | Description | 2026 Estimated Allowable |
|---|---|---|
| J7325 | Synvisc-One (hylan G-F 20), per dose | $750 - $900 |
| 20610 | Arthrocentesis, large joint (knee) | $85 - $110 |
| 77002 | Fluoroscopic guidance (if used) | $75 - $95 |
Your provider bills Medicare using J-code J7325 for the Synvisc-One product itself, plus a procedure code for the injection.
Frequency Limits
- Medicare typically covers one Synvisc-One injection per knee every 6 months
- Some MACs allow repeat treatment after 6 months if the initial course provided meaningful relief
- Your provider should document the clinical response to justify repeat treatment
- Bilateral knee treatment (both knees at once) is generally covered when both knees have documented OA
Your Out-of-Pocket Costs
| Item | Amount |
|---|---|
| Part B deductible (2026) | $257/year |
| Coinsurance | 20% of Medicare-approved amount |
| Typical total patient cost | $150 - $200 per injection |
| With Medigap | May cover the 20% coinsurance |
Example Cost Calculation
If Medicare approves $850 for a Synvisc-One injection:
- Medicare pays: $680 (80%)
- You pay: $170 (20%)
- If you have a Medigap plan: your supplement may cover some or all of that $170
Medicare Advantage Plans
If you have a Medicare Advantage (Part C) plan instead of Original Medicare:
- Coverage generally follows Original Medicare guidelines, but your plan may have additional rules
- Prior authorization may be required — check with your plan before scheduling
- Copays vary by plan and may differ from the standard 20% coinsurance
- Network restrictions may apply — your provider may need to be in-network
- Contact your plan’s member services to verify coverage before your appointment
What If Medicare Denies Coverage?
If your claim is denied, you have the right to appeal:
- Request the denial reason in writing from your Medicare Administrative Contractor
- Gather supporting documentation including X-rays, treatment history, and your provider’s letter of medical necessity
- File a redetermination (Level 1 appeal) within 120 days
- Include clinical evidence showing why Synvisc-One is medically appropriate for your condition
Many initial denials are overturned on appeal when proper documentation is submitted.
Synvisc-One Product Details
| Feature | Detail |
|---|---|
| Manufacturer | Sanofi |
| Active ingredient | Hylan G-F 20 (high molecular weight hyaluronan) |
| Injection schedule | 1 injection per treatment course |
| FDA-approved for | Knee osteoarthritis |
| Molecular weight | 6 million daltons (highest available) |
| Volume per injection | 6 mL |
| Derived from | Avian (chicken comb) source |
Synvisc-One’s single-injection format means only one office visit per treatment course, which can be more convenient than multi-injection brands that require weekly visits over 3 to 5 weeks.
Frequently Asked Questions
How often will Medicare pay for Synvisc-One?
Medicare generally covers one Synvisc-One injection per knee every 6 months. Your provider must document that the treatment is medically necessary each time and that prior courses provided clinical benefit.
Do I need prior authorization for Synvisc-One under Medicare?
No. Original Medicare (Parts A and B) does not require prior authorization for Synvisc-One. However, if you have a Medicare Advantage plan, your plan may require prior authorization. Always check with your plan before scheduling.
Is Synvisc-One covered under Medicare Advantage?
Medicare Advantage plans must cover everything Original Medicare covers, so Synvisc-One should be covered. However, your plan may have different cost-sharing, network requirements, or prior authorization rules. Call your plan’s member services number for specifics.
What is the difference between Medicare Part B and Part D for injections?
Part B covers medications administered by a healthcare provider in a clinical setting (like Synvisc-One injections in your doctor’s office). Part D covers medications you pick up at a pharmacy and take at home. Since Synvisc-One is given by injection in a medical office, it falls under Part B.
Does Synvisc-One contain animal products?
Yes. Synvisc-One is derived from chicken combs (avian source). If you have a known allergy to birds, feathers, or egg products, tell your doctor. Non-avian alternatives like Euflexxa are available.