ARCHIVED Joint Surgery 2021-09-12 to 2022-09-10

CLINICAL APPROPRIATENESS GUIDELINES

Musculoskeletal Program

Appropriate Use Criteria: Joint Surgery

ARCHIVED SEPTEMBER 11, 2022 for commercial, Medicare, and Medicaid (except Indiana Medicaid)

This document has been archived because it has outdated information. It is for historical information only and should not be consulted for clinical use. Current versions of guidelines are available on the Carelon Medical Benefits Management website here.

EFFECTIVE SEPTEMBER 12, 2021

Proprietary

MSK02-0921.3

Approval and implementation dates for specific health plans may vary. Please consult the applicable health plan for more details.

Carelon disclaims any responsibility for the completeness or accuracy of the information contained herein.

CLINICAL APPROPRIATENESS GUIDELINES

Appropriate Use Criteria: Joint Surgery

Table of Contents

Description and Application of the Guidelines

General Clinical Guideline

Shoulder Arthroplasty (Total/Partial/Revision Shoulder Replacement)

Description and Scope

Shoulder Arthroscopy and Open Procedures

Description and Scope

Hip Arthroplasty (Total/Partial/Revision Hip Replacement)

Description and Scope

Description and Scope

Knee Arthroplasty (Total/Partial/Revision Knee Replacement)

Description and Scope

Knee Arthroscopy and Open Procedures

Description and Scope

Meniscal Allograft Transplantation of the Knee

Treatment of Osteochondral Defects

Description and Scope

Description and Application of the Guidelines

The Carelon Clinical Appropriateness Guidelines (hereinafter “the Carelon Clinical Appropriateness Guidelines” or the “Guidelines”) are designed to assist providers in making the most appropriate treatment decision for a specific clinical condition for an individual. As used by Carelon, the Guidelines establish objective and evidence-based criteria for medical necessity determinations where possible. In the process, multiple functions are accomplished:

To establish criteria for when services are medically necessary
To assist the practitioner as an educational tool
To encourage standardization of medical practice patterns
To curtail the performance of inappropriate and/or duplicate services
To advocate for patient safety concerns
To enhance the quality of health care
To promote the most efficient and cost-effective use of services

The Carelon guideline development process complies with applicable accreditation standards, including the requirement that the Guidelines be developed with involvement from appropriate providers with current clinical expertise relevant to the Guidelines under review and be based on the most up-to-date clinical principles and best practices. Relevant citations are included in the References section attached to each Guideline. Carelon reviews all of its Guidelines at least annually.

Carelon makes its Guidelines publicly available on its website twenty-four hours a day, seven days a week. Copies of the Carelon Clinical Appropriateness Guidelines are also available upon oral or written request. Although the Guidelines are publicly-available, Carelon considers the Guidelines to be important, proprietary information of Carelon, which cannot be sold, assigned, leased, licensed, reproduced or distributed without the written consent of Carelon.

Carelon applies objective and evidence-based criteria, and takes individual circumstances and the local delivery system into account when determining the medical appropriateness of health care services. The Carelon Guidelines are just guidelines for the provision of specialty health services. These criteria are designed to guide both providers and reviewers to the most appropriate services based on a patient’s unique circumstances. In all cases, clinical judgment consistent with the standards of good medical practice should be used when applying the Guidelines. Guideline determinations are made based on the information provided at the time of the request. It is expected that medical necessity decisions may change as new information is provided or based on unique aspects of the patient’s condition. The treating clinician has final authority and responsibility for treatment decisions regarding the care of the patient and for justifying and demonstrating the existence of medical necessity for the requested service. The Guidelines are not a substitute for the experience and judgment of a physician or other health care professionals. Any clinician seeking to apply or consult the Guidelines is expected to use independent medical judgment in the context of individual clinical circumstances to determine any patient’s care or treatment.

The Guidelines do not address coverage, benefit or other plan specific issues. Applicable federal and state coverage mandates take precedence over these clinical guidelines. If requested by a health plan, Carelon will review requests based on health plan medical policy/guidelines in lieu of the Carelon Guidelines.

The Guidelines may also be used by the health plan or by Carelon for purposes of provider education, or to review the medical necessity of services by any provider who has been notified of the need for medical necessity review, due to billing practices or claims that are not consistent with other providers in terms of frequency or some other manner.

General Clinical Guideline

Clinical Appropriateness Framework

Critical to any finding of clinical appropriateness under the guidelines for a specific diagnostic or therapeutic intervention are the following elements:

Prior to any intervention, it is essential that the clinician confirm the diagnosis or establish its pretest likelihood based on a complete evaluation of the patient. This includes a history and physical examination and, where applicable, a review of relevant laboratory studies, diagnostic testing, and response to prior therapeutic intervention.
The anticipated benefit of the recommended intervention should outweigh any potential harms that may result (net benefit).
Current literature and/or standards of medical practice should support that the recommended intervention offers the greatest net benefit among competing alternatives.
Based on the clinical evaluation, current literature, and standards of medical practice, there exists a reasonable likelihood that the intervention will change management and/or lead to an improved outcome for the patient.

If these elements are not established with respect to a given request, the determination of appropriateness will most likely require a peer-to-peer conversation to understand the individual and unique facts that would supersede the requirements set forth above. During the peer-to-peer conversation, factors such as patient acuity and setting of service may also be taken into account.

Simultaneous Ordering of Multiple Diagnostic or Therapeutic Interventions

Requests for multiple diagnostic or therapeutic interventions at the same time will often require a peer-to-peer conversation to understand the individual circumstances that support the medical necessity of performing all interventions simultaneously. This is based on the fact that appropriateness of additional intervention is often dependent on the outcome of the initial intervention.

Additionally, either of the following may apply:

Current literature and/or standards of medical practice support that one of the requested diagnostic or therapeutic interventions is more appropriate in the clinical situation presented; or
One of the diagnostic or therapeutic interventions requested is more likely to improve patient outcomes based on current literature and/or standards of medical practice.

Repeat Diagnostic Intervention

In general, repeated testing of the same anatomic location for the same indication should be limited to evaluation following an intervention, or when there is a change in clinical status such that additional testing is required to determine next steps in management. At times, it may be necessary to repeat a test using different techniques or protocols to clarify a finding or result of the original study.

Repeated testing for the same indication using the same or similar technology may be subject to additional review or require peer-to-peer conversation in the following scenarios:

Repeated diagnostic testing at the same facility due to technical issues
Repeated diagnostic testing requested at a different facility due to provider preference or quality concerns
Repeated diagnostic testing of the same anatomic area based on persistent symptoms with no clinical change, treatment, or intervention since the previous study
Repeated diagnostic testing of the same anatomic area by different providers for the same member over a short period of time

Repeat Therapeutic Intervention

In general, repeated therapeutic intervention in the same anatomic area is considered appropriate when the prior intervention proved effective or beneficial and the expected duration of relief has lapsed. A repeat intervention requested prior to the expected duration of relief is not appropriate unless it can be confirmed that the prior intervention was never administered.

Shoulder Arthroplasty (Total/Partial/Revision Shoulder Replacement)

Description and Scope

Shoulder arthroplasty includes several procedures to replace components of the shoulder joint, in part or in total, with the goal of improving function and reducing pain. Prosthetic replacement of the humeral head and the glenoid (total arthroplasty) is most commonly performed for joint damage due to osteoarthritis. Total shoulder arthroplasty requires an intact medial glenoid to support the glenoid prosthesis.

Reverse shoulder arthroplasty is similar in that both components of the joint are replaced but ball and socket portions of the joint are reversed, allowing the deltoid muscle to assume partial function of the rotator cuff. This procedure is typically utilized when there is concomitant rotator cuff disease.

When the medial glenoid is damaged by erosions such that a glenoid prosthesis cannot be adequately supported, then hemiarthroplasty is typically the procedure of choice. Here, only the humeral head is replaced with an artificial component. This procedure requires that the glenoid fossa be relatively free of disease.

This guideline addresses shoulder arthroplasty when performed as an elective, non-emergent procedure and not as part of the care of a congenital condition, acute or traumatic event such as fracture (excluding fracture of implant and periprosthetic fracture).

Clinical Indications

The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.

General Requirements

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

Clinical notes describing symptom duration and severity, specific functional limitations related to symptoms, and type and duration of all therapeutic measures provided. If conservative management is not appropriate, the reason must be clearly documented.

Conservative management¹ should include a combination of strategies to reduce inflammation, alleviate pain, and correct underlying dysfunction, including physical therapy AND at least one complementary conservative treatment strategy.

Physical therapy requirement includes ANY of the following:
- Physical therapy rendered by a qualified provider of physical therapy services
- Supervised home treatment program that includes ALL of the following:
  - Participation in a patient-specific or tailored program
  - Initial active instruction by MD/DO/PT with redemonstration of patient ability to perform exercises
  - Compliance (documented or by clinician attestation on follow-up evaluation)
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative treatment requirement includes ANY of the following:
- Prescription strength anti-inflammatory medications and analgesics²
- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants²
- Intra-articular corticosteroid injection(s)²
- Alternative therapies such as acupuncture, chiropractic manipulation, massage therapy, activity modification, and/or a trial period of rest (e.g., from the aggravating/contributing factors) where applicable

¹ Additional condition or procedure-specific requirements may apply and can be found in the respective sections of the guideline.

² In the absence of contraindications

Clinical reevaluation. In most cases, reevaluation should include a physical examination. Direct contact by other methods, such as telephone communication or electronic messaging, may substitute for in-person evaluation when circumstances preclude an office visit.

Failure of conservative management requires ALL of the following:

Patient has completed a full course of conservative management (as defined above) for the current episode of care
Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
More invasive forms of therapy are being considered

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

Reporting of symptom severity. Severity of pain and its associated impact on activities of daily living (ADLs) and instrumental ADLs (IADLs) are key factors in determining the need for intervention. For purposes of this guideline, significant pain and functional impairment refer to pain that is at least 3 out of 10 in intensity and is associated with inability to perform at least two (2) ADLs and/or IADLs.

Reports of imaging studies obtained within the past 12 months describing the degree of cartilage damage as determined by EITHER or BOTH of the following methods:

X-ray report that utilizes or can be correlated with the Kellgren-Lawrence grading system of osteoarthritis
MRI report from a radiologist that utilizes or can be correlated with the modified Outerbridge or similar classification system related to articular cartilage injury and osteoarthritis

See Appendix for a description of these grading systems.

The provider shall submit a detailed and specific imaging report that correlates with clinical findings of the requested procedure. In the absence of the detailed report, the provider will be required to submit a report from an independent radiologist. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.

Imaging reports should be thorough and describe the presence or absence of subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, avascular necrosis or bone on bone articulations. The degree of joint space narrowing should also be noted.

General Recommendations

Tobacco cessation. Adherence to a tobacco cessation program resulting in abstinence from tobacco for at least 6 weeks prior to surgery is recommended.

Diabetes. It is recommended that a patient with history of diabetes maintain a hemoglobin A1C of 8% or less prior to any joint replacement surgery.

Body mass index (BMI). It is recommended that any patient with a BMI equal to or greater than 40 attempt weight reduction prior to surgery.

Specific Requirements

ALL of the following conditions must be present, regardless of the indication for which the procedure is being performed:

Anticipated level of function should place limited demands on the shoulder joint
Deltoid muscle must be intact
Shoulder joint must be anatomically and structurally suited to receive selected implants (i.e., adequate bone stock to allow for firm fixation of implant)

Total Shoulder Arthroplasty or Hemiarthroplasty

Total shoulder arthroplasty or hemiarthroplasty may be considered medically necessary for EITHER of the following indications:

Malignancy involving the glenohumeral joint or surrounding soft tissue
Advanced joint disease of the shoulder due to osteoarthritis rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis when ALL of the following requirements are met:
- Limited range of motion or crepitus of the glenohumeral joint on physical examination
- Pain and loss of function of at least 6 months’ duration that interferes with daily activities
- Radiographic evidence of destructive degenerative joint disease as evidenced by 2 or more of the following:
  - Irregular joint surfaces
  - Glenoid sclerosis
  - Osteophyte changes
  - Flattened glenoid
  - Cystic changes in the humeral head
  - Joint space narrowing
- Failure of conservative management of at least 6 weeks’ duration

Hemiarthroplasty

Hemiarthroplasty may be considered as an option for EITHER of the following indications:

Proximal humerus fracture not amenable to internal fixation
Advanced joint disease of the shoulder when criteria are met for total shoulder arthroplasty AND at least one of the following conditions is present:
- Osteonecrosis of the humeral head without glenoid involvement
- Advanced joint disease due to rotator cuff tear arthropathy
- Glenoid bone stock inadequate to support a glenoid prosthesis

Reverse Shoulder Arthroplasty

Reverse shoulder arthroplasty may be considered medically necessary for the following indications:

Reconstruction after a tumor resection
Glenohumeral osteoarthritis with irreparable rotator cuff tear
Failed hemiarthroplasty
Failed total shoulder arthroplasty with non-repairable rotator cuff
Shoulder fracture that is not repairable or cannot be reconstructed with other techniques
Advanced joint disease of the shoulder when criteria are met for total shoulder arthroplasty AND the following condition is present:
- Deficient rotator cuff and limited ability to actively flex the upper extremity to 90 degrees against gravity

Revision or Replacement of a Shoulder Prosthesis

Revision or replacement of a shoulder prosthesis may be considered medically necessary for ANY of the following conditions, when associated with pain and functional impairment:

Aseptic loosening of one or more prosthetic components confirmed by imaging
Fracture of one or more components of the prosthesis confirmed by imaging
Periprosthetic infection confirmed by gram stain and culture
Instability of the glenoid or humeral components
Migration of the humeral head

Contraindications

All arthroplasty procedures

Active infection of the joint
Active systemic bacteremia
Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the shoulder
Rapidly progressive neurologic disease
Intra-articular corticosteroid injection within the past 6 weeks in the joint being replaced

Exclusions

For total shoulder arthroplasty or hemiarthroplasty

Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to, the following:

Glenohumeral osteoarthritis with irreparable rotator cuff tear (see Reverse Arthroplasty indications)
Total shoulder arthroplasty or hemiarthroplasty under conditions which would result in excessive stress on the implant, including but not limited to Charcot joint and paralytic conditions of the shoulder

Selected References

1. American Academy of Orthopedic Surgeons, The treatment of glenohumeral joint osteoarthritis, (2009) Rosemont IL, 201 pgs.

2. Carter MJ, Mikuls TR, Nayak S, et al. Impact of total shoulder arthroplasty on generic and shoulder-specific health-related quality-of-life measures: a systematic literature review and meta-analysis. The Journal of bone and joint surgery American volume. 2012;94(17):e127.

3. Khan WS, Longo UG, Ahrens PM, et al. A systematic review of the reverse shoulder replacement in rotator cuff arthropathy, rotator cuff tears, and rheumatoid arthritis. Sports medicine and arthroscopy review. 2011;19(4):366-79.

4. Rasmussen JV. Outcome and risk of revision following shoulder replacement in patients with glenohumeral osteoarthritis. Acta orthopaedica Supplementum. 2014;85(355):1-23.

5. Singh JA, Sperling J, Buchbinder R, et al. Surgery for shoulder osteoarthritis. Cochrane Database Syst Rev. 2010(10):Cd008089.

Codes

CPT® (Current Procedural Terminology) is a registered trademark of the American Medical Association (AMA). CPT® five digit codes, nomenclature and other data are copyright by the American Medical Association. All Rights Reserved. AMA does not directly or indirectly practice medicine or dispense medical services. AMA assumes no liability for the data contained herein or not contained herein.

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

23470 Arthroplasty, glenohumeral joint; hemiarthroplasty

23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (e.g., total shoulder))

23473 Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component

23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component

Shoulder Arthroscopy and Open Procedures

Description and Scope

Arthroscopy is a surgical procedure in which a small fiberoptic camera is inserted into the joint through a small incision. In addition to allowing the surgeon to visualize the joint, arthroscopy may also be utilized for treatment of a variety of conditions involving the joint structures.

This guideline addresses shoulder arthroscopy and open procedures when performed as an elective, non-emergent procedure and not as part of the care of an acute fracture.

Clinical Indications

The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.

General Requirements

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

Imaging report. The provider shall submit a detailed and specific imaging report that correlates with clinical findings of the requested procedure. In the absence of the detailed report, the provider will be required to submit a report from an independent radiologist. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.

Conservative management. In the majority of cases, a period of conservative management is appropriate prior to intervention. Conservative management¹ should include a combination of strategies to reduce inflammation, alleviate pain, and correct underlying dysfunction, including physical therapy AND at least one complementary conservative treatment strategy.

Physical therapy requirement includes ANY of the following:
- Physical therapy rendered by a qualified provider of physical therapy services
- Supervised home treatment program that includes ALL of the following:
  - Participation in a patient-specific or tailored program
  - Initial active instruction by MD/DO/PT with redemonstration of patient ability to perform exercises
  - Compliance (documented or by clinician attestation on follow-up evaluation)
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative treatment requirement includes ANY of the following:
- Prescription strength anti-inflammatory medications and analgesics²
- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants²
- Intra-articular corticosteroid injection(s)²
- Alternative therapies such as acupuncture, chiropractic manipulation, massage therapy, activity modification, and/or a trial period of rest (e.g., from the aggravating/contributing factors) where applicable

¹ Additional condition or procedure-specific requirements may apply and can be found in the respective sections of the guideline.

² In the absence of contraindications

Failure of conservative management requires ALL of the following:

Patient has completed a full course of conservative management (as defined above) for the current episode of care
Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
More invasive forms of therapy are being considered

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

Shoulder Arthroscopy

Diagnostic arthroscopy

Diagnostic arthroscopy of the shoulder joint may be considered medically necessary for synovial biopsy or tissue harvest (chondrocyte) or when the involved joint demonstrates ALL of the following 4 requirements:

Presence of ONE of the following symptoms
- Significant pain and functional limitation
- Instability (e.g., giving way, catching, clicking, locking)
- Limited range of motion
Presence of ONE of the following physical exam findings
- Limited range of motion
- Joint swelling
- Inconclusive specific diagnostic exam maneuvers
- Local muscle weakness or atrophy
Inconclusive x-ray and/or advanced imaging studies
Failure of at least 6 weeks of conservative management

Exclusion: In-office diagnostic arthroscopy (e.g., mi-eye 2^®)

Rotator Cuff Repair

For primary rotator cuff repair, adherence to a tobacco cessation program resulting in abstinence from tobacco for at least 6 weeks prior to surgery is recommended.

Acute full thickness tear

ALL of the following are required:

Traumatic injury within the preceding 3 months with no preexisting shoulder pain
Shoulder pain ≥ 4 on the VAS scale exacerbated by movement
Weakness of rotator cuff muscle(s) (less than grade 4/5 on manual muscle testing)
Physical exam demonstrating a positive response to at least ONE of the following tests:
- Neer impingement test
- Drop arm test
- Painful arc test full/empty can test
- Weakness of external rotation
Advanced imaging confirms features of an acute full thickness tear

Chronic or degenerative full thickness tear

ALL of the following are required:

Gradual onset of shoulder pain, without a significant traumatic event
Pain ≥ 4 on the VAS scale which interferes with age-appropriate activities of daily living
Weakness of rotator cuff muscle(s) (less than grade 4/5 on manual muscle testing)
Physical exam demonstrating a positive response to at least ONE of the following tests:
- Drop arm test
- Painful arc test full/empty can test
- Weakness of external rotation
Recent advanced imaging confirms features of a degenerative full thickness tear
Failure of at least 6 weeks of conservative management

Partial thickness tear

ALL of the following are required:

Pain ≥ 4 on the VAS scale which interferes with age-appropriate activities of daily living
Weakness of rotator cuff muscle(s) (less than grade 4/5 on manual muscle testing)
Physical exam demonstrating a positive response to at least ONE of the following tests:
- Drop arm test
- Painful arc test full/empty can test
- Weakness of external rotation
Recent advanced imaging confirming a partial thickness tear
Symptoms present for at least 3 months
Failure of at least 6 weeks of conservative management

Revision Rotator Cuff Repair

For revision rotator cuff repair, adherence to a tobacco cessation program resulting in abstinence from tobacco for at least 6 weeks prior to surgery is required.

Revision Rotator Cuff Repair

ALL of the following are required:

Documentation of nicotine-free status for at least 6 weeks prior to surgery
Shoulder pain ≥ 4 on the VAS scale exacerbated by movement
Weakness of rotator cuff muscle(s) (less than grade 4/5 on manual muscle testing)
Recent advanced imaging confirming a full thickness tear
Failure of at least 12 weeks of conservative management

Contraindications

Revision rotator cuff repair is contraindicated when ANY of the following are present:

Presence rotator cuff arthropathy defined as combination of arthritis and lack of rotator cuff
Prior history of a revision surgery
Active infection of the joint
Active systemic bacteremia
Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the shoulder
Rapidly progressive neurological disease
Wheelchair bound and/or assistive device dependent

Labrum Repair

Labral tear including superior labral anterior-posterior (SLAP) tears

ALL of the following are required:

Shoulder pain ≥ 4 on the VAS scale which interferes with age-appropriate activities of daily living
Symptoms aggravated by heavy lifting, pushing, and overhead motion
Physical exam demonstrating a positive response to at least ONE of the following tests:
- O’Brien (active compression) test
- Anterior slide test
- Biceps load test (I and II)
- Pain provocation test
- Crank test
- Jobe relocation test
- Forced shoulder abduction and elbow flexion test
- Resisted supination external rotation test
MRI demonstrating a traumatic non-anatomic SLAP lesion consistent with subjective and objective findings
Failure of at least 12 weeks of conservative management

Other Arthroscopic and Open Procedures

Acromioclavicular arthritis

Partial claviculectomy (includes Mumford procedure) may be considered medically necessary when ALL of the following criteria are met:

Pain at the acromioclavicular (AC) joint aggravated by shoulder motion
Positive cross-arm adduction test
Tenderness over the acromioclavicular joint
Imaging findings (x-ray or MRI) consistent with acromioclavicular joint arthritis
- Moderate to severe degenerative joint disease of the acromioclavicular joint, distal clavicle edema, or osteolysis of the distal clavicle on MRI
- Moderate to severe acromioclavicular joint arthritis on x-ray
Failure of at least 12 weeks of conservative management

Adhesive capsulitis

Arthroscopic capsular release

ALL of the following are required:

History of trauma or post-operative contracture
Shoulder pain ≥ 4 on the VAS scale which interferes with age-appropriate activities of daily living
Reduced passive range of motion of the affected glenohumeral joint by at least 50% compared to unaffected shoulder
Failure of at least 12 weeks of conservative management

Manipulation under anesthesia (MUA)

ALL of the following are required:

History of trauma or post-operative contracture
Shoulder pain ≥ 4 on the VAS scale which interferes with age-appropriate activities of daily living
Reduced passive range of motion of the affected glenohumeral joint by at least 50% compared to unaffected shoulder
Failure of at least 12 weeks of conservative management

Chronic shoulder instability/laxity

Capsulorrhaphy (Bankart procedure) may be considered medically necessary when ALL of the following criteria are met:

History of a shoulder dislocation or recurrent subluxation
Positive apprehension/relocation test
Shoulder pain and/or instability which interferes with age-appropriate activities of daily living
MRI demonstrates at least ONE of the following:
- Bankart/labral lesion
- Hill-Sachs lesion
- Capsular tear
Failure of at least 12 weeks of conservative management (unless has multiple dislocations during management)*

*Early surgery may be considered for patients with large bone defects or patients under age 35.

Subacromial impingement syndrome

Subacromial decompression/acromioplasty is considered not medically necessary for all indications.

Synovectomy

Synovectomy refers to removal of the synovial lining of the joint when it has become symptomatic due to inflammation, irritation, or pathology. Synovectomy may be performed in a single joint compartment (limited) or multiple compartments (extensive).

Partial/Complete synovectomy may be considered medically necessary for symptomatic (pain, swelling, limited function) synovitis caused by ANY of the following:

Synovial plica (partial synovectomy)
Inflammatory arthritides (e.g., rheumatoid arthritis, psoriatic arthritis)
Crystalline arthropathy (e.g., gout, pseudogout)
Felty’s syndrome
Pigmented villonodular synovitis (PVNS)
Synovial hemangioma
Synovial chondromatosis/osteochondromatosis
Post-traumatic synovitis
Hemophilic synovitis or arthropathy
Infection (bacterial or fungal septic arthritis)
Subacromial bursitis

Exclusion: Synovectomy performed solely for visualization or approach

Debridement

Debridement of discrete structures of the shoulder (e.g., humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies]) may be considered medically necessary when ALL of the following criteria are met:

Shoulder pain unresponsive to 6 weeks of conservative management
Surgical pathology is confirmed by imaging
Limited debridement involves no more than 2 discrete structures
Extensive debridement involves 3 or more discrete structures

Tendinopathy of the long head of the biceps

Biceps tenodesis or tenotomy may be considered medically necessary for shoulder pain when ALL of the following criteria are met:

Pain in the front of the shoulder and/or clicking, popping or catching sensation when using the arm and shoulder
Clinical exam is consistent with long head of biceps pathology (at least 2 of the following: anterior shoulder pain, weakness, tenderness over the biceps groove, pain in the anterior shoulder during resisted supination of the forearm [Yergason test], positive Speed test)
MRI findings consistent with biceps tendinopathy or Carelon criteria met for SLAP tear
Failure of at least 12 weeks of conservative management OR at least 6 weeks when Carelon criteria for rotator cuff tear are met

Exclusions

Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to, the following:

For treatment of all rotator cuff repairs

Treatment of asymptomatic, full thickness rotator cuff tear
Active infection of the joint
Active systemic bacteremia
Active skin infection (exception recurrent cutaneous staph infections) or open wound within the planned surgical site of the shoulder
Rapidly progressive neurological disease
Deltoid or rotator cuff paralysis
Use of xenografts or biologic scaffold for augmentation or bridging reconstruction
Use of platelet rich plasma or other biologics
Concomitant subacromial decompression/acromioplasty

In-office diagnostic arthroscopy (e.g., mi-eye 2^®)

Synovectomy performed solely for visualization or approach

Selected References

1. American Academy of Orthopaedic Surgeons. Management of rotator cuff injuries clinical practice guideline. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2019. 79 pgs.

2. American Academy of Orthopaedic Surgeons, Optimizing the management of rotator cuff problems guideline and evidence report, (2010) Rosemont IL, 325 pgs.

3. American Academy of Orthopedic Surgeons, The treatment of glenohumeral joint osteoarthritis, (2009) Rosemont IL, 201 pgs.

4. Cancienne JM, Brockmeier SF, Gulotta LV, et al. Ambulatory Total Shoulder Arthroplasty: A Comprehensive Analysis of Current Trends, Complications, Readmissions, and Costs. The Journal of bone and joint surgery American volume. 2017;99(8):629-37.

5. Gebremariam L, Hay EM, Koes BW, et al. Effectiveness of surgical and postsurgical interventions for the subacromial impingement syndrome: a systematic review. Arch Phys Med Rehabil. 2011;92(11):1900-13.

6. Health Information and Quality Authority, Health Technology Assessment of Scheduled Procedures – Shoulder Arthroscopy, (2014) Dublin, 46 pgs.

7. Huisstede BM, Koes BW, Gebremariam L, et al. Current evidence for effectiveness of interventions to treat rotator cuff tears. Manual therapy. 2011;16(3):217-30.

8. Itoi E. Rotator cuff tear: physical examination and conservative treatment. Journal of orthopaedic science : official journal of the Japanese Orthopaedic Association. 2013;18(2):197-204.

9. Karjalainen TV, Jain NB, Page CM, et al. Subacromial decompression surgery for rotator cuff disease. Cochrane Database Syst Rev. 2019;1:CD005619.

10. Lahdeoja T, Karjalainen T, Jokihaara J, et al. Subacromial decompression surgery for adults with shoulder pain: a systematic review with meta-analysis. 2019

11. Li Y, Zhao L, Zhu L, et al. Internal fixation versus nonoperative treatment for displaced 3-part or 4-part proximal humeral fractures in elderly patients: a meta-analysis of randomized controlled trials. PLoS ONE. 2013;8(9):e75464.

12. Mao F, Zhang DH, Peng XC, et al. Comparison of Surgical versus Non-Surgical Treatment of Displaced 3- and 4-Part Fractures of the Proximal Humerus: A Meta-Analysis. Journal of investigative surgery : the official journal of the Academy of Surgical Research. 2015;28(4):215-24.

13. Saltychev M, Virolainen P, Laimi K. Conservative treatment or surgery for shoulder impingement: updated meta-analysis. Disabil Rehabil. 2019:1-2.

14. Song L, Miao L, Zhang P, et al. Does concomitant acromioplasty facilitate arthroscopic repair of full-thickness rotator cuff tears? A meta-analysis with trial sequential analysis of randomized controlled trials. Springerplus. 2016;5(1):685.

15. Sun Z, Fu W, Tang X, et al. Systematic review and Meta-analysis on acromioplasty in arthroscopic repair of full-thickness rotator cuff tears. Acta Orthop Belg. 2018;84(1):54-61.

16. University of New South Wales HK, Clinical practice guidelines for the management of rotator cuff syndrome in the workplace, (2013) Port Macquarie Australia, 80.

17. Vandvik PO, Lahdeoja T, Ardern C, et al. Subacromial decompression surgery for adults with shoulder pain: a clinical practice guideline. Bmj. 2019;364:l294.

18. Washington State Department of Labor and Industries, Shoulder Conditions Diagnosis and Treatment Guideline, (2013) Olympia WA, 28 pgs.

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

23000 Removal of subdeltoid calcareous deposit

23020 Capsular contracture release (eg, Sever type procedure)

23105 Arthrotomy; glenohumeral joint, with synovectomy, with or without biopsy

23107 Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of loose or foreign body

23120 Claviculectomy; partial

23130 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament release

23410 Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; acute

23412 Repair of ruptured musculotendinous cuff (e.g., rotator cuff) open; chronic

23415 Coracoacromial ligament release, with or without acromioplasty

23420 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes acromioplasty)

23430 Tenodesis of long tendon of biceps

23440 Resection or transplantation of long tendon of biceps

23450 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson-type operation

23455 Capsulorrhaphy, anterior; with labral repair (e.g., Bankart procedure)

23460 Capsulorrhaphy, anterior, any type; with bone block

23462 Capsulorrhaphy, anterior, any type; with coracoid process transfer

23465 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block

23466 Capsulorrhaphy, glenohumeral joint, any type multidirectional instability

23700 Manipulation under anesthesia, shoulder joint, including application of fixation apparatus (dislocation excluded)

29805 Arthroscopy, shoulder, diagnostic, with or without synovial biopsy (separate procedure)

29806 Arthroscopy, shoulder, surgical; capsulorrhaphy

29807 Arthroscopy, shoulder, surgical; repair of SLAP lesion

29819 Arthroscopy, shoulder, surgical; with removal of loose body or foreign body

29820 Arthroscopy, shoulder, surgical; synovectomy, partial

29821 Arthroscopy, shoulder, surgical; synovectomy, complete

29822 Arthroscopy, shoulder, surgical; debridement, limited, 1 or 2 discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])

29823 Arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])

29824 Arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface

29825 Arthroscopy, shoulder, surgical; with lysis and resection of adhesions, with or without manipulation

29826 Arthroscopy, shoulder, surgical; decompression of subacromial space with partial acromioplasty, with coracoacromial ligament (i.e., arch) release, when performed (list separately in addition to code for primary procedure)

29827 Arthroscopy, shoulder, surgical; with rotator cuff repair

29828 Arthroscopy, shoulder, surgical; biceps tenodesis

Hip Arthroplasty (Total/Partial/Revision Hip Replacement)

Description and Scope

Total hip arthroplasty (THA), also referred to as total hip replacement (THR), involves removal of the femoral head and acetabulum and placement of a prosthesis anchored to the bone. Numerous implants composed of various biomaterials have been approved by the U.S. Food and Drug Administration (FDA) for use in hip arthroplasty. The goal of the procedure is long-term pain relief and restoration of function.

Degenerative joint disease, or osteoarthritis, is the most common condition leading to the need for total hip arthroplasty. Other conditions that may also cause significant hip joint damage include neoplasm, femoral fracture, avascular necrosis (osteonecrosis), inflammatory arthritis (e.g., rheumatoid arthritis) and developmental hip dysplasia.

This guideline addresses hip arthroplasty when performed as an elective, non-emergent procedure and not as part of the care of an acute fracture (excluding fracture of implant and periprosthetic fracture).

Clinical Indications

The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.

General Requirements

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

Physical therapy requirement includes ANY of the following:
- Physical therapy rendered by a qualified provider of physical therapy services
- Supervised home treatment program that includes ALL of the following:
  - Participation in a patient-specific or tailored program
  - Initial active instruction by MD/DO/PT with redemonstration of patient ability to perform exercises
  - Compliance (documented or by clinician attestation on follow-up evaluation)
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative treatment requirement includes ANY of the following:
- Prescription strength anti-inflammatory medications and analgesics²
- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants²
- Intra-articular corticosteroid injection(s)²
- Alternative therapies such as acupuncture, chiropractic manipulation, massage therapy, activity modification, and/or a trial period of rest (e.g., from the aggravating/contributing factors) where applicable

¹ Additional condition or procedure-specific requirements may apply and can be found in the respective sections of the guideline.

² In the absence of contraindications

Failure of conservative management requires ALL of the following:

Patient has completed a full course of conservative management (as defined above) for the current episode of care
Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
More invasive forms of therapy are being considered

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

Reports of imaging studies obtained within the past 12 months describing the degree of cartilage damage as determined by EITHER or BOTH of the following methods:

X-ray report that utilizes or can be correlated with the Kellgren-Lawrence grading system of osteoarthritis
MRI report from a radiologist that utilizes or can be correlated with the modified Outerbridge or similar classification system related to articular cartilage injury and osteoarthritis

See Appendix for a description of these grading systems.

General Recommendations

Tobacco cessation. Adherence to a tobacco cessation program resulting in abstinence from tobacco for at least 6 weeks prior to surgery is recommended.

Diabetes. It is recommended that a patient with history of diabetes maintain a hemoglobin A1C of 8% or less prior to any joint replacement surgery.

Body mass index (BMI). It is recommended that any patient with a BMI equal to or greater than 40 attempt weight reduction prior to surgery.

Primary Total Hip Arthroplasty

Primary total hip arthroplasty may be considered medically necessary for ANY of the following indications:

Primary and secondary tumors of the proximal femur
Hip fracture or complications including malunion, nonunion or failed prior fixation
Failed previous hip fracture fixation
Avascular necrosis (osteonecrosis) with unresponsive severe pain
Revision of hip arthrodesis
Joint damage or destruction due to osteoarthritis, inflammatory disease or other chronic condition when ALL of the following requirements have been met:
- Imaging evidence of significant joint destruction and cartilage loss, defined as Tönnis grade 3, modified Outerbridge grade III – IV, or Kellgren-Lawrence grade 3 – 4
- Limited range of motion, antalgic gait and disabling pain of at least 3 months’ duration
- Pain with passive internal or external rotation
- Failure of at least 3 months of non-surgical conservative management (unless radiographs show Kellgren-Lawence grade 4)
- Functional limitation secondary to hip pathology which interferes with the ability to carry out age-appropriate daily activities

Revision Total Hip Arthroplasty

Revision total hip arthroplasty may be considered medically necessary when at least ONE of the following conditions is present:

Aseptic loosening
Substantial osteolysis of the weight bearing surface
Progressive soft tissue or bone reaction including symptomatic synovitis
Component instability, failure, or recall
Displaced periprosthetic fracture or irreducible dislocation
Previous removal of prosthesis due to infection or catastrophic failure
Recurrent disabling pain or significant functional disability that persists despite at least 3 months of conservative management in conjunction with ANY of the following:
- Antalgic or Trendelenburg gait
- Abnormal findings confirmed by plain radiography or imaging studies such as implant malposition or impingement
- Leg length inequality
- Audible noise

Resection Arthroplasty of the Hip

Resection arthroplasty of the hip, femoral head ostectomy, or Girdlestone resection arthroplasty may be considered medically necessary when at least ONE of the following conditions is present:

Painful stiff hip after infection (tuberculosis of the hip or otherwise)
Peri-prosthetic infection
Aseptic loosening of the hip
Recurrent dislocation of the hip
Failed internal fixation of a femoral neck fracture
Unsalvageable failed hip replacement

Contraindications

Total hip arthroplasty is contraindicated when ANY of the following are present:

Presence of a skin infection at the surgical site
Presence of a systemic infection
Rapidly progressive neurological disease
Neuropathic joint
Intra-articular corticosteroid injection within the past 6 weeks in the joint being replaced

Exclusions

Indications for total hip arthroplasty other than those addressed in this guideline are considered not medically necessary.

Selected References

1. American Academy of Orthopaedic Surgeons, Management of Osteoarthritis of the hip – evidence-based clinical practice guideline, (2017) Rosemont IL, 850.

2. Arbab D, Konig DP. Atraumatic Femoral Head Necrosis in Adults. Dtsch Arztebl Int. 2016;113(3):31-8.

3. Department of Veterans Affairs DoDN-SMoHaKOWG, VA/DoD clinical practice guideline for the non-surgical management of hip and knee osteoarthritis., (2014) Washington DC, 126.

4. Goyal N, Chen AF, Padgett SE, et al. Otto Aufranc Award: A Multicenter, Randomized Study of Outpatient versus Inpatient Total Hip Arthroplasty. Clinical orthopaedics and related research. 2017;475(2):364-72.

5. Hagel A, Siekmann H, Delank KS. Periprosthetic femoral fracture – an interdisciplinary challenge. Dtsch Arztebl Int. 2014;111(39):658-64.

6. Kort NP, Bemelmans YF, van der Kuy PH, et al. Patient selection criteria for outpatient joint arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2016.

7. National Institute for Health and Care Excellence, Hip fracture: management, (2011)

8. Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Seminars in arthritis and rheumatism. 2014;43(6):701-12.

9. Nelson SJ, Webb ML, Lukasiewicz AM, et al. Is Outpatient Total Hip Arthroplasty Safe? The Journal of arthroplasty. 2017;32(5):1439-42.

10. Oliver D, Griffiths R, Roche J, et al. Hip fracture. BMJ clinical evidence. 2010;2010.

11. Scottish Intercollegiate Guidelines Network, Management of hip fracture in older people: A national clinical guideline, (2009)

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

27120 Acetabuloplasty; (eg, Whitman, Colonna, Haygroves, or cup type)

27122 Acetabuloplasty; resection, femoral head (eg, Girdlestone procedure)

27125 Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty)

27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft

27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft

27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft

27137 Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft

27138 Revision of total hip arthroplasty; femoral component only, with or without allograft

Hip Arthroscopy

Description and Scope

Hip arthroscopy is most often utilized in diagnosing and treating conditions of the joint space which impede normal function and result in pain and disability. A more recent application of this procedure is treatment of femoroacetabular impingement syndrome (FAIS), a condition of the hip in which the acetabular rim of the pelvis articulates abnormally with the femoral head. Over time, contact may result in damage to joint cartilage, potentially leading to degenerative joint disease.

Surgical treatment of FAIS may involve an open approach, arthroscopic surgery, or a combination of the two. Components of FAIS surgery include the following:

Capsular plication
Capsular repair
Labral reconstruction
Iliotibial band windowing
Trochanteric bursectomy
Abductor muscle repair
Iliopsoas tenotomy
Acetabuloplasty
Femoroplasty

This guideline addresses hip arthroscopy when performed as an elective, non-emergent procedure and not as part of the care of an acute fracture.

Clinical Indications

General Requirements

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

Physical therapy requirement includes ANY of the following:
- Physical therapy rendered by a qualified provider of physical therapy services
- Supervised home treatment program that includes ALL of the following:
  - Participation in a patient-specific or tailored program
  - Initial active instruction by MD/DO/PT with redemonstration of patient ability to perform exercises
  - Compliance (documented or by clinician attestation on follow-up evaluation)
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative treatment requirement includes ANY of the following:
- Prescription strength anti-inflammatory medications and analgesics²
- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants²
- Intra-articular corticosteroid injection(s)²
- Alternative therapies such as acupuncture, chiropractic manipulation, massage therapy, activity modification, and/or a trial period of rest (e.g., from the aggravating/contributing factors) where applicable

¹ Additional condition or procedure-specific requirements may apply and can be found in the respective sections of the guideline.

² In the absence of contraindications

Failure of conservative management requires ALL of the following:

Patient has completed a full course of conservative management (as defined above) for the current episode of care
Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
More invasive forms of therapy are being considered

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

Hip Arthroscopy

Diagnostic arthroscopy

Diagnostic arthroscopy of the hip joint may be considered medically necessary for synovial biopsy or tissue harvest (chondrocyte) or when the involved joint demonstrates ALL of the following 4 requirements:

Presence of ONE of the following symptoms
- Significant pain and functional limitation
- Instability (e.g., giving way, catching, clicking, locking)
- Limited range of motion
Presence of ONE of the following physical exam findings
- Limited range of motion
- Joint swelling
- Inconclusive specific diagnostic exam maneuvers
- Local muscle weakness or atrophy
Inconclusive x-ray and/or advanced imaging studies
Failure of at least 6 weeks of conservative management

Exclusion: In-office diagnostic arthroscopy (e.g., mi-eye 2^®)

Synovectomy/biopsy/removal of loose or foreign body

Any combination of these procedures may be considered medically necessary when EITHER of the following requirements are met:

Radiographic evidence of acute, post-traumatic, intra-articular foreign body or displaced fracture fragment
Hip pain associated with grinding, catching, locking or popping, and ALL of the following:
- Failure of least 3 months of conservative management
- Exam findings confirming pain with limited range of motion
- Imaging (x-ray, CT or MRI) which shows synovial proliferation, calcifications, nodularity, inflammation, pannus, or loose body

Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS)

ALL of the following are required:

Moderate to severe hip pain (primarily in the groin) worsened by flexion activities (e.g., squatting or prolonged sitting) that interferes with activities of daily living, which is not explained by another diagnosis.
Positive impingement sign on clinical examination, defined as pain elicited with 90 degrees of flexion and internal rotation and adduction of the femur, or extension and external rotation)
Imaging studies (radiographs, MRI or 3D computed tomography) suggesting a diagnosis of FAIS, including cam impingement and/or pincer impingement as evidenced by ONE or more of the following:
- Pistol-grip deformity
- Femoral head-neck offset with an alpha angle greater than 50 degrees
- Positive posterior wall sign
- Acetabular retroversion (over coverage with crossover sign)
- Coxa profunda or protrusion
- Damage of the acetabular rim
Failure of conservative management for a duration of at least 3 months*, including avoidance of hip stretching or any activity that elicits or aggravates symptoms

* Less than the full duration of conservative management is permitted in the presence of an alpha angle greater than 65 degrees (a measure of asphericity of the femoral head).

High probability of a causal association between the femoroacetabular impingement morphology and damage, e.g., a pistol-grip deformity with a tear of the acetabular labrum and articular cartilage damage in the anterosuperior quadrant

Labral tear

ALL of the following are required:

Moderate to severe hip pain (primarily in the groin) worsened by flexion activities (e.g., squatting or prolonged sitting) that interferes with activities of daily living, which is not explained by another diagnosis
Positive impingement sign on clinical examination, defined as pain elicited with 90 degrees of flexion and internal rotation and adduction of the femur, or extension and external rotation
MRI suggests a labral tear
Failure of conservative management for a duration of at least 3 months, including avoidance of hip stretching or any activity that elicits or aggravates symptoms
No evidence of advanced osteoarthritis, defined as Tönnis grade 2 or greater, or joint space of less than 2 mm
No evidence of severe (Outerbridge grade IV) chondral damage

Exclusions

Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to, the following:

For treatment of FAIS

Shaving or debridement of articular cartilage (chondroplasty), and/or abrasion arthroplasty when not performed in conjunction with FAIS repair
The use of capsular plication as the sole treatment of FAIS
Capsular plication, capsular repair, labral reconstruction, iliotibial band windowing, trochanteric bursectomy, abductor muscle repair, and/or iliopsoas tenotomy, when performed at the time of any FAIS surgery, would be considered a component of and incidental to the FAIS procedure
Evidence of advanced osteoarthritis, defined as Tönnis grade ≥ 2, or joint space narrowing ≤ 2 mm along the lateral/medial sourcil (roof or weight-bearing area of acetabulum)
Evidence of severe (Outerbridge grade IV) chondral damage
Positive broken Shenton line
Inclination Tönnis angle greater than 13-15 degrees

In-office diagnostic arthroscopy (e.g., mi-eye 2^®)

Selected References

1. Bedi A, Kelly BT. Femoroacetabular impingement. The Journal of bone and joint surgery American volume. 2013;95(1):82-92.

2. DeSa D, Phillips M, Philippon MJ, et al. Ligamentum teres injuries of the hip: a systematic review examining surgical indications, treatment options, and outcomes. Arthroscopy. 2014;30(12):1634-41.

3. Kroger EW, Griesser MJ, Kolovich GP, et al. Efficacy of surgery for internal snapping hip. International journal of sports medicine. 2013;34(10):851-5.

4. Lustenberger DP, Ng VY, Best TM, et al. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin J Sport Med. 2011;21(5):447-53.

5. Nelson SJ, Webb ML, Lukasiewicz AM, et al. Is Outpatient Total Hip Arthroplasty Safe? The Journal of arthroplasty. 2017;32(5):1439-42.

6. Oliver D, Griffiths R, Roche J, et al. Hip fracture. BMJ clinical evidence. 2010;2010.

7. Saadat E, Martin SD, Thornhill TS, et al. Factors Associated With the Failure of Surgical Treatment for Femoroacetabular Impingement: Review of the Literature. Am J Sports Med. 2014;42(6):1487-95.

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

29860 Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure)

29861 Arthroscopy, hip, surgical; with removal of loose body or foreign body

29862 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum

29863 Arthroscopy, hip, surgical; with synovectomy

29914 Arthroscopy, hip, surgical; with femoroplasty (i.e., treatment of cam lesion)

29915 Arthroscopy, hip, surgical; with acetabuloplasty (i.e., treatment of pincer lesion)

29916 Arthroscopy, hip, surgical; with labral repair [when repair of the labral tear is associated with FAIS]

Knee Arthroplasty (Total/Partial/Revision Knee Replacement)

Description and Scope

Total knee arthroplasty (TKA), also referred to as total knee replacement (TKR), involves removal of diseased articular surfaces of the knee, followed by resurfacing with metal and polyethylene prosthetic components. Numerous implants composed of various biomaterials have been approved by the U.S. Food and Drug Administration (FDA) for use in TKA procedures. The goal of the procedure is long-term pain relief and restoration of function.

This guideline addresses TKA, revision TKA, and unicompartmental knee arthroplasty (UKA) performed as elective, non-emergent procedures and not as part of the care of a congenital condition, acute or traumatic event such as fracture (excluding periprosthetic fracture).

Clinical Indications

The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.

General Requirements

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

Physical therapy requirement includes ANY of the following:
- Physical therapy rendered by a qualified provider of physical therapy services
- Supervised home treatment program that includes ALL of the following:
  - Participation in a patient-specific or tailored program
  - Initial active instruction by MD/DO/PT with redemonstration of patient ability to perform exercises
  - Compliance (documented or by clinician attestation on follow-up evaluation)
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative treatment requirement includes ANY of the following:
- Prescription strength anti-inflammatory medications and analgesics²
- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants²
- Intra-articular corticosteroid injection(s)²
- Alternative therapies such as acupuncture, chiropractic manipulation, massage therapy, activity modification, and/or a trial period of rest (e.g., from the aggravating/contributing factors) where applicable

¹ Additional condition or procedure-specific requirements may apply and can be found in the respective sections of the guideline.

² In the absence of contraindications

Failure of conservative management requires ALL of the following:

Patient has completed a full course of conservative management (as defined above) for the current episode of care
Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
More invasive forms of therapy are being considered

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

Reports of imaging studies obtained within the past 12 months describing the degree of cartilage damage as determined by EITHER or BOTH of the following methods:

X-ray report that utilizes or can be correlated with the Kellgren-Lawrence grading system of osteoarthritis
MRI report from a radiologist that utilizes or can be correlated with the modified Outerbridge or similar classification system related to articular cartilage injury and osteoarthritis

See Appendix for a description of these grading systems.

General Recommendations

Tobacco cessation. Adherence to a tobacco cessation program resulting in abstinence from tobacco for at least 6 weeks prior to surgery is recommended.

Diabetes. It is recommended that a patient with history of diabetes maintain a hemoglobin A1C of 8% or less prior to any joint replacement surgery.

Body mass index (BMI). It is recommended that any patient with a BMI equal to or greater than 40 attempt weight reduction prior to surgery.

Total Knee Arthroplasty

Elective total knee arthroplasty may be considered medically necessary for EITHER of the following indications:

Primary or metastatic tumor with limb salvage surgery
Bicompartmental or tricompartmental joint damage or destruction due to osteoarthritis, inflammatory disease or other chronic conditions when ALL of the following requirements have been met:
- Imaging evidence of significant joint destruction and cartilage loss, defined as modified Outerbridge grade III – IV or Kellgren-Lawrence grade 3 – 4
- Knee arc of motion greater than 50 degrees
- Failure of at least 3 months of non-surgical conservative therapy (unless radiographs show Kellgren-Lawence grade 4)
- Functional limitation secondary to knee pathology which interferes with the ability to carry out age-appropriate daily activities

Unicompartmental Knee Arthroplasty/Partial Knee Replacement

Elective medial or lateral unicompartmental knee arthroplasty (UKA)/partial knee replacement (PKA) may be considered medically necessary when ALL of the following requirements are met:

Osteoarthritis isolated to the medial or lateral knee compartment with no degenerative changes in the opposite compartment
Intact anterior cruciate ligament
Less than 15 degrees of correctable varus deformity in both knees

Medial or lateral unicompartmental knee arthroplasty is contraindicated when ANY of the following conditions are present:

Inflammatory arthritis
Moderate to severe degenerative changes of the lateral facet of the PF joint when considering medial compartment replacement
Anterior cruciate ligament deficiency
Flexion contracture greater than 15 degrees
Fixed varus deformity greater than 10 degrees
Fixed valgus deformity greater than 15 degrees
Flexion less than 110 degrees
Previous meniscectomy in other compartment

Patellofemoral Arthroplasty

Elective patellofemoral arthroplasty may be considered medically necessary when ALL of the following requirements are met:

ONE of the following disease states:
- Advanced symptomatic primary or secondary isolated patellofemoral osteoarthritis (PFOA)
- Failed extensor mechanism unloading procedures (e.g., lateral retinacular release, reconstruction of the medal patellar femoral ligament, quadricepsplasty, and bony procedures for realignment involving the tibial tuberosity)
- Symptomatic patellofemoral cartilage defects greater than 4 cm² after a failed cartilage repair procedure, such as autologous chondrocyte implantation (ACI)
Failure of at least 3 months of non-surgical conservative therapy
Functional limitation secondary to knee pathology which interferes with the ability to carry out age-appropriate daily activities

Patellofemoral arthroplasty is contraindicated when ANY of the following conditions are present:

Tibiofemoral osteoarthritis
Inflammatory arthritis
Patellofemoral malalignment
Knee instability (ligaments and/or menisci injuries)
Limb malalignment (valgus deformity greater than 8 degrees or varus deformity greater than 5 degrees)
Fixed flexion contracture greater than 10 degrees

Primary Hinge Arthroplasty

Primary hinge arthroplasty may be considered medically necessary when ONE of the following requirements are met:

Global ligament instability
Severe bone loss or deformity
Absence or deficit of muscular control
Tumoral surgery (bone block resection with ligamentous insertions needed)
Congenital dislocation of knee
Ankylosis with severe instability after surgical exposition

Revision of Prior Knee Arthroplasty

Revision of prior knee arthroplasty is considered medically necessary when ONE or more of the following conditions are present:

Aseptic loosening
Substantial osteolysis of the distal femur, proximal tibia, or patella
Progressive soft tissue or bone reaction including bearing surface wear or symptomatic synovitis
Component instability, malalignment, failure, or recall
Displaced periprosthetic fracture or irreducible dislocation
Previous removal of knee prosthesis due to infection or catastrophic failure
Recurrent disabling pain or significant functional disability that persists despite at least 3 months of conservative therapy in conjunction with ANY of the following:
- Antalgic gait
- Abnormal findings confirmed by plain radiography or imaging studies such as implant malposition or impingement
- Knee stiffness

Contraindications

All procedures listed

Skin infection at the surgical site
Systemic infection
Rapidly progressive neurologic disease
Extensor mechanism deficiency, not amendable to surgical correction
Neuropathic joint
Intra-articular corticosteroid injection within the past 6 weeks in the joint being replaced

Exclusions

Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to, the following:

Bi-unicompartmental knee arthroplasty (medial and lateral tibiofemoral compartments with absence of patellofemoral osteoarthritis)
Bicompartmental arthroplasty (medial and patellofemoral compartments of the knee)
Focal resurfacing of a single knee joint defect
Unicompartmental free-floating (unfixed) interpositional device

Selected References

1. American Academy of Orthopaedic Surgeons, Surgical Management of Osteoarthritis of the Knee, (2015) Rosemont IL, 661 pgs.

2. Davis AM, MacKay C. Osteoarthritis year in review: outcome of rehabilitation. Osteoarthritis and cartilage. 2013;21(10):1414-24.

3. Department of Veterans Affairs DoDN-SMoHaKOWG, VA/DoD clinical practice guideline for the non-surgical management of hip and knee osteoarthritis., (2014) Washington DC, 126.

4. Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Seminars in arthritis and rheumatism. 2014;43(6):701-12.

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

27437 Arthroplasty, patella; without prosthesis

27438 Arthroplasty, patella; with prosthesis

27440 Arthroplasty, knee; tibial plateau

27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy

27442 Arthroplasty, femoral condyles or tibial plateau(s), knee

27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy

27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type)

27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment

27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)

27486 Revision of total knee arthroplasty, with or without allograft; 1 component

27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component

27488 Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of spacer, knee

Knee Arthroscopy and Open Procedures

Description and Scope

Knee arthroscopy is a surgical procedure in which a fiberoptic camera is inserted into the knee joint through a small incision. In addition to allowing the surgeon to visualize the joint, arthroscopy may also be utilized for treatment of a variety of conditions involving the joint structures.

This guideline addresses knee arthroscopy when performed as an elective, non-emergent procedure and not as part of the care of an acute fracture.

Procedures to treat focal articular cartilage defects can be classified as:

Palliative (lavage, chondroplasty)
Reparative (microfracture, abrasion arthroplasty)
Restorative (autologous chondrocyte implantation, osteochondral allograft, or osteochondral autograft)*.

*See Treatment of Osteochondral Defects

Chondroplasty or debridement is a smoothing or shaving of symptomatic partial-thickness cartilage lesions or chondral flaps (unstable mechanical source of pain).

Microfracture involves drilling multiple holes through the subchondral bone to promote bleeding and fibrocartilage growth.

Abrasion Arthroplasty involves abrading the subchondral bone to the depth necessary to promote bleeding and fibrocartilage growth.

Both microfracture and abrasion arthroplasty are typically performed on lesions less than 4 cm².

Clinical Indications

The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.

General Requirements

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

Physical therapy requirement includes ANY of the following:
- Physical therapy rendered by a qualified provider of physical therapy services
- Supervised home treatment program that includes ALL of the following:
  - Participation in a patient-specific or tailored program
  - Initial active instruction by MD/DO/PT with redemonstration of patient ability to perform exercises
  - Compliance (documented or by clinician attestation on follow-up evaluation)
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative treatment requirement includes ANY of the following:
- Prescription strength anti-inflammatory medications and analgesics²
- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants²
- Intra-articular corticosteroid injection(s)²
- Alternative therapies such as acupuncture, chiropractic manipulation, massage therapy, activity modification, and/or a trial period of rest (e.g., from the aggravating/contributing factors) where applicable

¹ Additional condition or procedure-specific requirements may apply and can be found in the respective sections of the guideline.

² In the absence of contraindications

Failure of conservative management requires ALL of the following:

Patient has completed a full course of conservative management (as defined above) for the current episode of care
Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
More invasive forms of therapy are being considered

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

Knee Arthroscopy

Diagnostic arthroscopy

Diagnostic arthroscopy of the knee joint may be considered medically necessary for synovial biopsy or tissue harvest (chondrocyte) or when the involved joint demonstrates ALL of the following 4 requirements:

Presence of ONE of the following symptoms
- Significant pain and functional limitation
- Instability (e.g. giving way, catching, clicking, locking)
- Limited range of motion
Presence of ONE of the following physical exam findings
- Limited range of motion
- Joint swelling
- Inconclusive specific diagnostic exam maneuvers
- Local muscle weakness or atrophy
Inconclusive x-ray and/or advanced imaging studies
Failure of at least 6 weeks of conservative management

Exclusion: In-office diagnostic arthroscopy (e.g., mi-eye 2^®)

Meniscal repair or meniscectomy

Acute traumatic meniscal tear

Meniscal repair or meniscectomy may be indicated for acute traumatic meniscal tear (sudden onset of joint-line pain associated with significant knee injury) when ALL of the following requirements are met:

Moderate to severe pain associated with functional limitation, which interferes with the ability to carry out age-appropriate daily activities
Symptoms of catching, locking, or instability
Physical exam findings of at least TWO (2) of the following:
- Joint swelling or effusion
- Positive McMurray or Apley test
- Joint line tenderness
- Reduced range of motion
Imaging confirms features of an acute meniscal tear (e.g., root avulsion, longitudinal vertical, radial, flap, posterolateral root, bucket handle, posterior horn, and complex tears, or displaced meniscal fragment)

Partial meniscectomy may be medically necessary for symptomatic tears not amenable to repair, especially when the peripheral meniscal rim is intact.

Meniscal repair may be medically necessary for symptomatic reducible tears that are peripheral (e.g., near the capsular attachment) and horizontal or longitudinal in nature.

Chronic degenerative meniscal tear

Meniscal repair or meniscectomy may be indicated for chronic degenerative meniscal tear (without any history of significant acute trauma) when ALL of the following are present:

Physical exam findings of at least TWO (2) of the following:
- Joint swelling or effusion
- Positive McMurray or Apley test
- Joint line tenderness
- Reduced range of motion
Persistent or frequent mechanical symptoms (catching, locking, or instability) or failure of conservative management for at least 3 months
Imaging demonstrating a meniscal tear consistent with the clinical presentation
X-ray findings demonstrating no more than moderate osteoarthritis as evidenced by imaging showing ONE of the following:
- Greater than or equal to 50% joint space preservation (mild to moderate)
- Less than or equal to grade 2 Kellgren-Lawrence
- Less than or equal to grade III modified Outerbridge changes

Meniscal repair or partial meniscectomy is considered not medically necessary when the above indications are not met.

Meniscal repair or partial meniscectomy is considered not medically necessary when meniscal tear is associated with Kellgren-Lawrence grade ≥ 3 or modified Outerbridge grade > III osteoarthritis of the knee. (Exception may be granted for patients under age 40).

Partial menisectomy is considered not medically necessary for degenerative tears (horizontal cleavage, intrameniscal linear MRI signal penetrating one or both surfaces of the meniscus) with no associated mechanical symptoms.

Chondroplasty/debridement

Chondroplasty/debridement when ALL of the following criteria are met:

Pain or mechanical symptoms
Partial thickness cartilage lesion or unstable chondral flap documented by MRI
Failure to respond to at least a 6-week course of conservative management in the absence of a chondral flap
Radiographic imaging consistent with Kellgren-Lawrence grade 2 or lower

Debridement/drainage/lavage

Debridement/drainage/lavage for ALL of the following conditions:

Rheumatoid arthritis with failure of medical management (DMARDs)
Septic joint or osteomyelitis
Septic prosthetic joint
Postoperative arthrofibrosis, with limited range of motion and failure of at least 8 weeks of conservative treatment

Exclusion: Debridement or lavage for isolated primary diagnosis of osteoarthritis of the knee

Arthroscopically assisted lysis of adhesions

Arthroscopically assisted lysis of adhesions may be medically necessary when ALL of the following criteria are met:

Ligamentous or joint reconstruction has been performed within the last 12 weeks
Physical exam demonstrates limited range of motion of the knee, defined as less than 105 degrees of flexion or a flexion contracture greater than 10 degrees
Range of motion of the knee has failed to improve despite 6 weeks of conservative management
Failure of prior manipulation under anesthesia or manipulation under anesthesia is planned concurrently

Manipulation under anesthesia (MUA)

Manipulation under anesthesia (MUA) may be medically necessary when ALL of the following criteria are met:

Physical exam demonstrates limited range of motion of the knee defined as less than 105 degrees of flexion or a flexion contracture greater than 10 degrees
Range of motion of the knee has failed to improve despite 6 weeks of conservative management
Ligamentous or joint reconstruction has been performed within the last 12 weeks

Anterior cruciate ligament (ACL) reconstruction

BOTH of the following are required:

A diagnosis of ACL tear as established by EITHER of the following:
- Exam findings of a positive anterior drawer sign, pivot shift test or Lachman test
- Report of CT or MRI which demonstrates an ACL tear
At least ONE of the following scenarios is present:
- ACL tear occurring in conjunction with a meniscal tear or ligamentous injury (i.e., medial or posterior collateral ligament, posterior cruciate ligament, or posterolateral corner ligamentous injury)
- The patient is involved in a physically demanding occupation (e.g., firefighter, law enforcement, construction), or regularly engages in activities which include cutting, jumping, and/or pivoting (e.g., skiing, basketball, football)
- Two (2) weeks of conservative care has been tried and failed (e.g., physical therapy, activity modification, oral analgesics)

Posterior cruciate ligament (PCL) repair or reconstruction

BOTH of the following are required:

A diagnosis of PCL tear as established by EITHER of the following:
- Exam findings of a positive posterior drawer sign, reversed pivot shift test, or posterior sag sign
- CT or MRI performed within the past 12 months demonstrating a PCL tear
Associated ligamentous injuries (i.e., injury to posterolateral corner of the knee, medial collateral ligament tear, ACL tear, avulsion fracture of fibular head or avulsion of the tibia distal to the lateral plateau)

Patellar compression syndrome (lateral patellofemoral impingement)

Lateral retinacular release may be medically necessary when ALL of the following criteria are met:

Positive lateral patellar tilt established on imaging (axial view)
Failure of at least 6 months of conservative management
Radiographic imaging consistent with Kellgren-Lawrence grade 2 or lower patellofemoral osteoarthirits
At least ONE of the following is present:
- Positive patella glide test
- Positive patella tilt test
- Lateral femoral trochlear or lateral patella facet cartilage lesion confirmed by imaging within the past 12 months, when symptoms are consistent with a cartilage defect

Exclusion: Central or medial tracking of the patella

Quadricepsplasty

Quadricepsplasty may be considered medically necessary for knee extension contracture secondary to prior femur/knee fracture or surgery when ALL of the following criteria are met:

Knee flexion less than 90 degrees
Failure of at least 12 weeks of conservative management
Failure of an arthroscopic lysis of adhesions

Distal realignment procedures

Distal realignment procedures (tibial tubercle transfer) for patellar instability (subluxation/dislocation) may be considered medically necessary in skeletally mature patients when ALL of the following are present:

Recurrent patellofemoral instability associated with pain that limits function
Failure of at least 12 weeks of conservative management that includes physical therapy
Radiographic imaging consistent with Kellgren-Lawrence grade 2 or lower patellofemoral osteoarthirits
Presence of at least ONE of the following:
- Tibial tubercle-trochlear groove (TT-TG) distance > 20 mm
- Patella alta (e.g., Caton-Deschamps index > 1.2)

Medial patellofemoral ligament (MPFL) reconstruction

Medial patellofemoral ligament reconstruction may be considered medically necessary when ALL of the following are present:

Recurrent patellofemoral instability associated with pain that limits function
Failure of at least 12 weeks of conservative management
Radiographic imaging consistent with Kellgren-Lawrence grade 2 or lower patellofemoral osteoarthirits
Presence of at least ONE of the following:
- Tibial tubercle-trochlear groove (TT-TG) distance < 20 mm
- Normal trochlear morphophology or Dejour type A dysplasia
- Absence of patella alta (e.g., Caton-Deschamps index < 1.2)
- Procedure performed in combination with distal realignment

Plica resection

Plica resection may be medically necessary when TWO (2) or more of the following criteria are met:

Presence of anteromedial knee joint line pain, especially medial femoral condyle
Audible clicking or snap during knee motion – painful arc 30 to 60 degrees
Pain with activities: ascending and descending stairs, squatting, rising from a chair, or sitting for extended periods
Positive Hughston plica test or positive duvet test (duvet between knees for relief)
Visible or palpable (tender) plica

AND

Exclusion of other causes of anteromedial knee pain
Failure of at least 12 weeks of conservative management

Excision of popliteal cyst

Posterior knee pain ≥ 4 on the VAS scale of at least 8 weeks’ duration

Synovectomy

Synovectomy for ANY of the following conditions:

Rheumatoid arthritis or other chronic inflammatory arthropathies with failure of conservative management
Hemophilic joint disease
Localized pigmented villonodular synovitis

Repair of osteochondral defect

See Treatment of Osteochondral Defects guideline.

Exclusions

Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to, the following:

Arthroscopic debridement or lavage for isolated primary diagnosis of osteoarthritis of the knee
In-office diagnostic arthroscopy (e.g., mi-eye 2^®)
Lateral retinacular release for central or medial tracking of the patella for patellar compression syndrome (lateral patellofemoral impingement)

Selected References

1. American Academy of Orthopaedic Surgeons, Surgical Management of Osteoarthritis of the Knee, (2015) Rosemont IL, 661 pgs.

2. American Academy of Orthopaedic Surgeons, Appropriate use criteria for the treatment of anterior cruciate ligament injuries, (2015) Rosemont IL, 35 pgs.

3. Beaufils P, Hulet C, Dhenain M, et al. Clinical practice guidelines for the management of meniscal lesions and isolated lesions of the anterior cruciate ligament of the knee in adults. Orthopaedics & traumatology, surgery & research : OTSR. 2009;95(6):437-42.

4. Health Quality Ontario. Arthroscopic Debridement of the Knee: An Evidence Update. Ont Health Technol Assess Ser. 2014;14(13):1-43.

5. Katz JN, Wright J, Spindler KP, et al. Predictors and Outcomes of Crossover to Surgery from Physical Therapy for Meniscal Tear and Osteoarthritis: A Randomized Trial Comparing Physical Therapy and Surgery. J Bone Joint Surg Am. 2016;98(22):1890-6.

6. Khan M, Evaniew N, Bedi A, et al. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. Cmaj. 2014;186(14):1057-64.

7. Monk AP, Davies LJ, Hopewell S, et al. Surgical versus conservative interventions for treating anterior cruciate ligament injuries. Cochrane Database Syst Rev. 2016;4:CD011166.

8. Osteras H. A 12-week medical exercise therapy program leads to significant improvement in knee function after degenerative meniscectomy: a randomized controlled trial with one year follow-up. J Bodywork Mov Ther. 2014;18(3):374-82.

9. Papalia R, Osti L, Del Buono A, et al. Management of combined ACL-MCL tears: a systematic review. Br Med Bull. 2010;93:201-15.

10. Petersen W, Achtnich A, Lattermann C, et al. The Treatment of Non-Traumatic Meniscus Lesions. Dtsch. 2015;112(42):705-13.

11. Smith TO, Postle K, Penny F, et al. Is reconstruction the best management strategy for anterior cruciate ligament rupture? A systematic review and meta-analysis comparing anterior cruciate ligament reconstruction versus non-operative treatment. Knee. 2014;21(2):462-70.

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

27331 Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign bodies

27332 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial OR lateral

27333 Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND lateral

27334 Arthrotomy, with synovectomy, knee; anterior OR posterior

27335 Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area

27403 Arthrotomy with meniscus repair, knee

27405 Repair, primary, torn ligament and/or capsule, knee; collateral

27407 Repair, primary, torn ligament and/or capsule, knee; cruciate

27409 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments

27418 Anterior tibial tubercleplasty (eg, Maquet type procedure)

27420 Reconstruction of dislocating patella; (eg, Hauser type procedure)

27422 Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, Campbell, Goldwaite type procedure)

27424 Reconstruction of dislocating patella; with patellectomy

27425 Lateral retinacular release, open

27427 Ligamentous reconstruction (augmentation), knee; extra-articular

27428 Ligamentous reconstruction (augmentation), knee; intra-articular (open)

27429 Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular

27430 Quadricepsplasty (eg, Bennett or Thompson type)

27570 Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)

29870 Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)

29871 Arthroscopy, knee, surgical; for infection, lavage and drainage

29873 Arthroscopy, knee, surgical; with lateral release

29874 Arthroscopy, knee, surgical; for removal of loose body or foreign body (e.g., osteochondritis dissecans fragmentation, chondral fragmentation)

29875 Arthroscopy, knee, surgical; synovectomy, limited (e.g., plica or shelf resection) (separate procedure)

29876 Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (e.g., medial or lateral)

29877 Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)

29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture

29880 Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

29881 Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

29882 Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)

29883 Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)

29884 Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)

29885 Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion)

29886 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion

29887 Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation

29888 Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

29889 Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction

G0289 Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee

Meniscal Allograft Transplantation of the Knee

Description

Meniscal allograft transplantation of the knee is a surgical procedure used to restore normal meniscal function by replacing a damaged or absent meniscus with donor cadaver allograft cartilage. The procedure is an option for a subset of patients who have pain or disability attributed to insufficient cushioning and lubrication of the joint.

A significant subset of these patients have undergone one or more procedures to remove portions of the meniscus due to tears or other injury. The goal of the procedure is reduction in pain, prevention of degenerative changes to the cartilage and subchondral bone, and restoration of the mechanical properties of the knee joint.

Clinical Indications

The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.

General Requirements

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

Operative report of a prior arthroscopic procedure and/or MRI of the knee performed within the past 12 months. The provider shall submit a detailed and specific imaging report that correlates with clinical findings of the requested procedure. In the absence of the detailed report, the provider will be required to submit a report from an independent radiologist. The results of all imaging studies should correlate with the clinical findings in support of the requested procedure.

Physical therapy requirement includes ANY of the following:
- Physical therapy rendered by a qualified provider of physical therapy services
- Supervised home treatment program which includes flexibility and muscle strengthening exercises that includes ALL of the following:
  - Participation in a patient-specific or tailored program
  - Initial active instruction by MD/DO/PT with redemonstration of patient ability to perform exercises
  - Compliance (documented or by clinician attestation on follow-up evaluation)
- Exception to the physical therapy requirement in unusual circumstances (for instance intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative treatment requirement includes ANY of the following:
- Prescription strength anti-inflammatory medications and analgesics²
- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants²
- Intra-articular corticosteroid injection(s)²
- Alternative therapies such as acupuncture, chiropractic manipulation, massage therapy, activity modification, and/or a trial period of rest (e.g., from the aggravating/contributing factors) where applicable

¹ Additional condition or procedure-specific requirements may apply and can be found in the respective sections of the guideline.

² In the absence of contraindications

Failure of conservative management requires ALL of the following:

Patient has completed a full course of conservative management (as defined above) for the current episode of care
Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
More invasive forms of therapy are being considered

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

Meniscal Allograft Transplantation of the Knee

Meniscal allograft transplantation of the knee may be considered medically necessary as a treatment for individuals with significant partial (more than 50%) or complete loss of the meniscus, as documented by previous operative reports, MRI, or diagnostic arthroscopy, when ALL of the following criteria are met:

Age 55 or younger and skeletally mature
Knee pain refractory to conservative treatment
Ligamentous stability either prior to surgery or achieved concurrently with meniscal transplantation
Normal alignment without varus or valgus deformities
Mild to moderate articular damage (Outerbridge grade II or less)

Exclusions

Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to, the following:

Treatment for asymptomatic individuals with partial or complete loss of the meniscus
Use of other meniscal implants incorporating materials such as collagen and polyurethane

Selected References

1. American Academy of Orthopaedic Surgeons, Appropriate use criteria for the treatment of anterior cruciate ligament injuries, (2015) Rosemont IL, 35 pgs.

2. Beaufils P, Hulet C, Dhenain M, et al. Clinical practice guidelines for the management of meniscal lesions and isolated lesions of the anterior cruciate ligament of the knee in adults. Orthopaedics & traumatology, surgery & research : OTSR. 2009;95(6):437-42.

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

29868 Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral

G0428 Collagen meniscus implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex)

Treatment of Osteochondral Defects

Description and Scope

Articular cartilage lesions in weight-bearing joints often fail to heal spontaneously and may be associated with pain, loss of function, and long-term complications such as osteoarthritis. A number of surgical techniques have been developed to treat these lesions, but an established therapy with long-term efficacy remains elusive.

The most widely used are bone marrow stimulation techniques to induce an influx of mesenchymal stem cells into the defect. Other techniques involve transplantation of osteochondral tissue from non-weight bearing sites, autologous chrondrocyte transplant, and use of synthetic bone filler material or scaffolds.

This guideline addresses treatment of osteochondral defects of the knee, ankle, and other joints using the following procedures or devices:

Autologous chondrocyte transplant (ACT)
Minced cartilage repair
Osteochondral allograft
Osteochondral autograft (OATS/mosaicplasty)
Resorbable synthetic bone filler materials
Microfracture

Clinical Indications

The following general requirements apply to all indications except where they differ from the specific requirements. The specific requirements take precedence over any stated general requirement.

General Requirements

Documentation supporting medical necessity should be submitted at the time of the request and must include the following components:

Physical therapy requirement includes ANY of the following:
- Physical therapy rendered by a qualified provider of physical therapy services
- Supervised home treatment program that includes ALL of the following:
  - Participation in a patient-specific or tailored program
  - Initial active instruction by MD/DO/PT with redemonstration of patient ability to perform exercises
  - Compliance (documented or by clinician attestation on follow-up evaluation)
- Exception to the physical therapy requirement in unusual circumstances (for instance, intractable pain so severe that physical therapy is not possible) when clearly documented in the medical record
Complementary conservative treatment requirement includes ANY of the following:
- Prescription strength anti-inflammatory medications and analgesics²
- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants²
- Intra-articular corticosteroid injection(s)²
- Alternative therapies such as acupuncture, chiropractic manipulation, massage therapy, activity modification, and/or a trial period of rest (e.g., from the aggravating/contributing factors) where applicable

¹ Additional condition or procedure-specific requirements may apply and can be found in the respective sections of the guideline.

² In the absence of contraindications

Failure of conservative management requires ALL of the following:

Patient has completed a full course of conservative management (as defined above) for the current episode of care
Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
More invasive forms of therapy are being considered

Documentation of compliance with a plan of therapy that includes elements from these areas is required where conservative management is appropriate.

Patient Selection Requirements

Candidates for procedures included in this guideline must meet ALL of the following requirements:

Skeletal maturity as documented by closure of growth plates
Disabling localized knee or ankle pain for at least 3 months, which has failed to respond to conservative treatment
Body Mass Index (BMI) less than or equal to 35
Absence of localized or systemic infection
No history of cancer in the bones, cartilage, fat or muscle of the affected limb
Willingness and ability to comply with post-operative weight-bearing restrictions and rehabilitation

Lesion and joint characteristics must include ALL of the following:

The lesion must be discrete, single, and involve only one side of the joint.
The lesion is largely contained with near normal surrounding articular cartilage and articulating cartilage.
The joint space is normal, without evidence of inflammation or degenerative changes.
The knee or ankle is stable, with functionally intact menisci (knee) and ligaments and normal alignment.

Corrective procedures (e.g., ligament or tendon repair, osteotomy for realignment, meniscal allograft transplant or repair) may be performed in combination with, or prior to, transplantation.

Osteochondral Allograft Transplantation

Cartilaginous defects of the knee

Osteochondral allograft transplantation to treat cartilaginous defects of the knee may be considered medically necessary when BOTH of the following criteria are met:

Size of the cartilage defect is greater than or equal to 2 cm² in total area, as documented by MRI or arthroscopy
Condition involves a focal, full thickness, (grade III or IV) isolated defect of the weight-bearing surface of the medial or lateral femoral condyles or trochlear region (trochlear groove of the femur)

Cartilaginous defects of the talus

Osteochondral allograft transplantation to treat cartilaginous defects of the talus may be considered medically necessary when EITHER of the following criteria are met:

Large (area > 1.5 cm²) or cystic (volume > 3.0 cm³) osteochondral lesions of the talus when autografting would be inadequate due to lesion size, depth, or location
Revision surgery after failed prior marrow stimulation for large (area > 1.5 cm²) or cystic (volume > 3.0 cm³) osteochondral lesions of the talus when autografting would be inadequate due to lesion size, depth, or location

Osteochondral Autograft Transplantation or Microfracture

Cartilaginous defects of the knee

Osteochondral autograft transplantation or microfracture, either osteochondral autograft transplant (OAT) or autologous mosaicplasty, to treat cartilaginous defects of the knee may be considered medically necessary when ALL of the following criteria are met:

Size of the cartilage defect is between 1.0 cm and 2.5 cm² in total area, as documented by MRI or arthroscopy
Condition involves a focal, full thickness, (grade III or IV) isolated defect of the knee involving the weight bearing surface of the medial or lateral femoral condyles or trochlear region (trochlear groove of the femur)
Absence of “kissing” knee lesions (lesion must be single and involve only one side of the joint)

Cartilaginous defects of the talus

Osteochondral autograft transplantation or microfracture, either osteochondral autograft transplant (OAT) or autologous mosaicplasty, to treat cartilaginous defects of the talus may be considered medically necessary when EITHER of the following criteria is met:

Large (area > 1.5 cm²) or cystic (volume > 3.0 cm³) osteochondral lesions of the talus
Revision surgery after failed marrow stimulation for osteochondral lesions of the talus

Autologous Chondrocyte Implantation

Cartilaginous defects of the knee/patella

Autologous chondrocyte implantation (ACI) to treat cartilaginous defects of the knee/patella may be considered medically necessary when ALL of the following criteria are met:

Presence of a primary chondral defect or failed prior surgical procedure to correct the defect
Size of the cartilage defect is greater than or equal to 1.5 cm² in total area, as documented by MRI or arthroscopy
Condition involves a focal, full thickness, (grade III or IV) isolated defect of the knee involving the weight bearing surface of the medial or lateral femoral condyles or patellofemoral region (includes trochlear region, trochlear groove, and patella)
The defect involves only the cartilage and not the subchondral bone*

*Exception to this requirement: the treatment of osteochondritis dissecans (OCD) associated with a bony defect of 10 mm or less in depth, which has failed prior conservative treatment. OCD lesions associated with a bony lesion greater than 10 mm in depth must also undergo corrective bone grafting).

Contraindications

All procedures listed

Known allergy to gentamicin
Known sensitivity to bovine cultures

Exclusions

Indications other than those addressed in this guideline are considered not medically necessary including, but not limited to, the following:

Use of non-autologous mosaicplasty using resorbable synthetic bone filler materials, including but not limited to plugs and granules, to repair osteochondral defects of the knee or ankle
Use of minced articular cartilage (whether synthetic, allograft or autograft) to repair osteochondral defects of the knee or ankle
Use of decellularized osteochondral allograft plugs (e.g., Chondrofix^®) or reduced osteochondral allograft discs (e.g., ProChondrix^®, Cartiform^®) to repair osteochondral defects of the knee or ankle

Codes

The following code list is not meant to be all-inclusive. Authorization requirements will vary by health plan. Please consult the applicable health plan for guidance on specific procedure codes.

Specific CPT codes for services should be used when available. Nonspecific or not otherwise classified codes may be subject to additional documentation requirements and review.

CPT/HCPCS

27412 Autologous chondrocyte implantation, knee

27415 Osteochondral allograft, knee, open [when specified as osteochondral allograft]

27416 Osteochondral autograft(s), knee, open (e.g., mosaicplasty) includes harvesting of autograft[s])

28446 Open osteochondral autograft, talus (includes obtaining graft[s])

29866 Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft)

29867 Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty)

29879 Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture

29892 Arthroscopically aided repair of large osteochondritis disssecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy)

J7330 Autologous cultured chondrocytes, implant

S2112 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)

Appendix

Kellgren-Lawrence grading system for radiographic assessment of cartilage damage
Grade	Description
0	Normal
1	Doubtful narrowing of joint space and possible osteophytic lipping
2	Definite osteophytes, definite narrowing of joint space
3	Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour
4	Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour
Modified Outerbridge grading system for MRI assessment of cartilage damage
Grade	Description
0	Normal
I	Signal intensity alterations with an intact surface of the articular cartilage compared with the surrounding normal cartilage
II	Partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter
III	Fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm
IV	Exposed subchondral bone head
Tönnis grading system for radiographic assessment of osteoarthritis
Grade	Description
0	No signs of osteoarthritis
1	Mild: increased sclerosis, slight narrowing of the joint space, no or slight loss of head sphericity
2	Moderate: small cysts, moderate narrowing of the joint space, and moderate loss of head sphericity
3	Severe: large cysts, severe narrowing or obliteration of the joint space, severe deformity of the head

History

Status	Review Date	Effective Date	Action
Archived	–	09/11/2022* *Not archived for Indiana Medicaid	Archived for commercial, Medicare, and Medicaid members (except Indiana Medicaid). Not to be used for dates of service on or after 09/11/2022.
Revised	12/03/2020	09/12/2021 (11/07/21 for Indiana Medicaid)	Independent Multispecialty Physician Panel (IMPP) review. Aligned conservative care definitions across musculoskeletal surgery and extremity imaging guidelines. Added a more rigorous definition of the supervised home PT requirement for cervical and lumbar surgery, and removed cognitive behavioral therapy as a conservative care modality. New indication for diagnostic shoulder, hip, and knee arthroscopy. Removed massive tear as a contraindication for rotator cuff repair. Added recurrent subluxation as a new indication for capsulorrhaphy. Added new criteria and removed foreign body criteria for synovectomy. New indication for debridement. Removed rotator cuff tear as a criterion for tenodesis/tenotomy in select patients. For primary total hip arthroplasty and total knee arthroplasty, added an exception to conservative management for end-stage osteoarthritis. For hip arthroscopy, modified conservative management requirements; added an exception to full conservative management based on alpha angle; removed age as an exclusion for FAIS but further defined radiographic exclusions. For knee arthroplasty, added degenerative change of the patellofemoral joint as a contraindication. For knee arthroscopy, more expansive approach to physical exam findings; aligned with criteria for MUA; added radiographic criteria for distal realignment procedures and MPFL reconstruction. New criteria for plica resection.
Revised	07/08/2020	03/14/2021	IMPP review. For knee arthroscopy and open procedures, added indications for quadricepsplasty, distal realignment procedures for patellar instability (subluxation/dislocation), and medial patellofemoral ligament reconstruction. Added CPT codes 23000, 23020, 27418, 27420, 27422, 27424, and 27430.
Updated	–	01/01/2021	2021 Annual CPT code update: descriptions changed for 23466, 29822, and 29823.
Revised	08/12/2019	05/17/2020	IMPP review. Added steroid injection within the past 6 weeks as a contraindication for shoulder and hip arthroplasty. For shoulder arthroscopy, added exclusions for xenografts, platelet rich plasma, and subacromial decompression, and removed indication for subacromial impingement with rotator cuff tear. Added new labral tear indication for hip arthroscopy. For knee arthroscopy, added new chondroplasty indication, narrowed use of lateral release to lateral compression as a cause for anterior knee pain or chondromalacia patella, added conservative management and advanced osteoarthritis exclusion for patellar compression syndrome. Added CPT codes 27425 and 27570.
Revised	11/28/2018	06/29/2019	IMPP review. All sections: Clarified conservative management options and removed nicotine-free documentation requirement. For shoulder arthroscopy, updated criteria for subacromial impingement syndrome and tendinopathy of the long head of the biceps. New indication for synovectomy/debridement. Added steroid injection exclusion for shoulder, hip, and knee arthroplasty. Updated criteria for primary and revision total hip arthroplasty; new guideline for resection arthroplasty. For hip arthroscopy, expanded appropriate techniques for FAI surgery to include acetabuloplasty and femoroplasty, added radiographic and clinical criteria to include FAIS-related symptoms. New guideline for elective patellofemoral arthroplasty, and added clinical scenarios for revision of prior knee arthroplasty. For knee arthroscopy, changes to meniscal repair/meniscectomy, and new guideline for arthroscopically assisted lysis of adhesions and manipulation under anesthesia. Meniscal allograft transplantation: Added exclusion for collagen meniscal implants. New criteria for talar osteochondral defects, allow patellar surface autologous chondrocyte implantation, and exclude use of decellularized osteochondral allograft plugs and reduced osteochondral allograft discs to repair osteochondral defects. Added CPT codes 27120, 27122, 27437, 27445, 27488, 28446, 29871, and 29892. Added HCPCS code G0428.
Revised	07/11/2018	03/09/2019	IMPP review. Added the General Clinical Guideline.
Updated	–	01/01/2019	2019 Annual CPT and HCPCS code updates: added 23700, G0289, G0428, J7330, and S2112.
Created	07/17/2017	11/01/2017	IMPP review. Original effective date.