Medicare AdvantagePrior AuthMedium impact
Viscosupplements - Single Injection (Revised)
Humana·Orthopedics, Rheumatology, Sports Medicine +1 more·Medicare Advantage
Effective date
Jan 28, 2026
We identified it
Jun 25, 2026
Summary
Humana Medicare Advantage updated its Viscosupplements - Single Injection prior authorization policy effective January 28, 2026. The policy requires prior authorization for Gel-One and Hymovis ONE intra-articular injections for knee osteoarthritis. Billing teams must verify members meet all three approval criteria: documented symptomatic knee OA, prior treatment/failure with specific agents (Durolane, Monovisc, or Synvisc-One), and 6-month interval for re-treatment. Step therapy requirements do not apply for Medicare Part B continuation requests within 365 days.
Action Required
By January 28, 2026: Billing team must update prior authorization workflows to reflect the revised policy. (1) Ensure all Gel-One and Hymovis ONE injection requests require prior authorization submission before claim processing. (2) Implement three-part eligibility verification in billing system: confirm documented symptomatic knee osteoarthritis limited to knee, verify prior treatment/contraindication/intolerance with Durolane/Monovisc/Synvisc-One, and confirm 6-month interval since last treatment if re-treatment requested. (3) For Medicare Part B requests: flag continuation of prior therapy within past 365 days as exempt from step therapy requirement. (4) Update prior auth request forms and provider communication templates with these specific criteria. (5) Train billing staff to identify and document allergy contraindications (avian origin for Synvisc-One and Gel-One; bacterial origin for Hymovis-ONE and Durolane; Monovisc origin not specified in policy). Failure to obtain proper prior authorization will result in claim denials.