Medicare typically covers and reimburses SYNVISC® in both the physician's office and hospital outpatient settings when the patient has documented knee pain due to OA, and has failed to respond to conventional therapies. Medicare does not require prior authorization.

Physician's Office

Hospital Outpatient

SYNVISC is covered according to specific local coverage determinations (LCDs) that have been established by the regional Medicare carrier, and when administered "incident to" a physician's care. This means SYNVISC must:

• Be provided by and represent a cost to the physician
• Be administered in the physician's office by a physician or someone under the physician's supervision.

For billing instructions in the office setting:

• Download the Sample CMS-1500 Claim Form (PDF)
• Download the Blank CMS-1500 Claim Form (PDF)
• Download more Forms & Sample Letters

Medicare coverage is subject to the same general criteria in the hospital outpatient setting, modified as follows:

• Services are reimbursed under the Medicare hospital outpatient prospective payment system (OPPS), using ambulatory payment classifications (APCs) that map procedures to fixed payment amounts.
• A single hospital outpatient visit may qualify for multiple APC payments.
• Under the Medicare OPPS, the hospital outpatient department acquires and bills for SYNVISC and its related administration services.
• Medicare reimburses hospitals for SYNVISC and related administration services using unique APC payment amounts.
• In addition, physicians bill for their professional services and receive separate reimbursement for the administration on a separate Blank CMS-1500 Claim Form (PDF).

For billing instructions in the hospital outpatient setting:

• Download the Sample CMS-1450 or UB92 Hospital Claim Form (PDF)
• Download the Blank CMS-1450 or UB92 Claim Form (PDF)
• Download more Forms & Sample Letters

Medicare Advantage (MA) Plans

Medicare offers managed care insurance as an alternative to traditional Medicare Part B coverage. These MA plans:

• Are administered by commercial insurers and serve one or more entire regions
• Provide the scope of benefits offered under Part B, as well as supplemental benefits, including coverage of Medicare premiums, deductibles and prescription drug coverage
• Have a network of contracted providers offering benefits at a uniform premium and level of cost-sharing to all Medicare beneficiaries residing in the MA plan service area

It's important to confirm your patient's specific MA plan benefits to understand Medicare coverage and reimbursement requirements for SYNVISC.

Questions about SYNVISC Medicare coverage?

SYNVISC Connection^SM is staffed with a team of reimbursement specialists who can help you understand Medicare coverage and payment requirements for SYNVISC.

Call 1-800-982-8292, M-F, 9am-8pm (EST).

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.