In several U.S. states, Blue Cross/Blue Shield and other insurers have dropped or are considering dropping coverage of hyaluronic acid injection—or viscosupplementation—for patients with knee osteoarthritis. The decision appears to be based on guidelines published by the American Academy of Orthopaedic Surgeons in 2013, which at that time specified that research had not found hyaluronic acid injection “effective at significantly reducing pain or improving function.”1
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However, Charles Degenhardt III, MD, a rheumatologist based in Savannah, Ga., says the guidelines were never intended to serve as the basis for coverage determination.
David Jevsevar, MD, MBA, chair of the AAOS Council on Research and Quality, told Medscape in 2013: “Even though we say in the guidelines that we don’t want the guidelines used for coverage-based determinations, our fear is that payers will do that.”6
Why Is the ACR Stepping In?
Those same guidelines acknowledge that some patients do report pain relief following injection of the naturally occuring joint lubricant. The ACR’s Committee on Rheumatologic Care (CORC) is taking steps to protect patient access to the treatment.
“As common as osteoarthritis is, we have so few options for treatment, and we feel we need to keep all available options open and have it be an individual decision made in conjunction with our patients,” says Dr. Degenhardt, who is also a CORC member.
The treatment may also help delay a patient’s need for surgery, “which we perceive as a benefit,” Dr. Degenhardt adds.
A Critical Alternative
Viscosupplementation is among the options recommended in the ACR’s 2012 osteoarthritis guidelines.2 In 2015, a meta-analysis published in Annals of Internal Medicine examined 137 randomized, controlled trials of patients with primary knee osteoarthritis, comparing treatment options for pain. It found hyaluronic acid injection to be the most efficacious when weighed against other treatments, including acetaminophen, intra-articular corticosteroids, naproxen, celecoxib and and other pharmacologics.3
Further, although viscosupplementation is not a frontline option for most osteoarthritis patients, it remains a critical alternative for some, especially those unable to tolerate other treatments, Dr. Degenhardt explains. For example, steroid injections in patients with type 2 diabetes can cause spikes in blood sugar that may lead to hospitalization. Patients with chronic kidney disease can’t tolerate non-steroidal anti-inflammatory drugs (NSAIDs). Others are not candidates for surgical repair or want to try non-pharmacologic options first, like strengthening and weight loss, due to their complex medical conditions.
“Viscosupplementation is not at all meant to replace other options,” says Dr. Degenhardt, noting that it is a safe treatment. But “every patient is different, every patient decision is different, and what we’re trying to do is advocate for the options that are out there.”