![]() Synovial fluid signs (clear fluid of normal viscosity and WBC less than 2000/mm 3) and.Rheumatoid factor less than 1:40 titer (agglutination method). ![]() Less than 30 minutes of morning stiffness.Erythrocyte sedimentation rate (ESR) less than 40 mm/hr.Crepitus (noisy, grating sound) on active motion.The diagnosis is supported by radiographic evidence of osteoarthritis of the knee (e.g., as joint space narrowing, subchondral sclerosis, osteophytes and sub-chondral cysts) or the member has at least 5 of the following signs and symptoms: For precertification of viscosupplementation products, call (866) 752-7021 (Commercial), or fax (888) 267-3277. For Statement of Medical Necessity (SMN) precertification forms, see Specialty Pharmacy Precertification.įor Medicare Part B plans, call (866) 503-0857, or fax (844) 268-7263.Īetna considers viscosupplementation (hyaluronates) medically necessary for the treatment of osteoarthritis (OA) in the knee when all of the following criteria are met: ![]() Precertification of viscosupplementation products are required of all Aetna participating providers and members in applicable plan designs.
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