Physican's Office

In the physician’s office, all local Medicare Administrative Contractors (MACs) cover Synvisc-One and SYNVISC and their associated procedures when administered “incident to” a physician’s care.

Synvisc-One^® and SYNVISC^® (hylan G-F 20) must be:

• Administered in the physician’s office by a physician or auxiliary personnel under the physician’s supervision
• Provided by and represent a cost to the physician. This means the physician must Buy and Bill the product

Coverage for Synvisc-One and SYNVISC depends on the specific billing and medical utilization guidelines that have been established by the MAC. These policies are known as Medicare local coverage determinations (LCDs). All MACs cover Synvisc-One and SYNVISC, along with associated procedures when appropriate, and each contractor has published written coverage policies.

Generally, Medicare considers Synvisc-One and SYNVISC to be medically necessary when the patient had documented knee pain due to OA, and has failed to respond to conventional therapies such as nonsteroidal anti-inflammatory drugs (NSAIDs) or other conservative therapies.

Comprehensive documentation of your patients’ medical charts is essential for billing third-party payers. Comprehensive documentation assists MACs in understanding the rationale for services billed and is critical in the event a claim is denied, due to requiring additional information or evidence of medical necessity. Documentation must always support the claims submitted for payment, and address elements such as:

• Patient history
• Other medical services
• Treatment rationale
• Previous treatment with Synvisc-One or SYNVISC

Hospital Outpatient

MACs and Fiscal Intermediaries (FIs) are responsible for setting policy for drugs and biologics administered in the hospital outpatient setting. Synvisc-One and SYNVISC used in the hospital outpatient setting are covered when medically appropriate, based on the coding and reimbursement mechanism described below.

• Medicare reimburses for hospital outpatient services under the Outpatient Prospective Payment System (OPPs), using Ambulatory Payment Classification (APC) payment rates
• A single hospital outpatient encounter may qualify for multiple APC payments, based on the type and number of services rendered
• Some drugs and supplies are bundled into the payment for the procedure APC, while others, such as Synvisc-One and SYNVISC, are reimbursed separately

Providers retain responsibility for determining reimbursement and insurance issues related to their patients. Genzyme cannot be responsible for failure of a provider to obtain reimbursement.