Print

Date Printed: June 23, 2017: 11:44 AM

Private Property of Blue Cross and Blue Shield of Florida.
This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-20000-60

Original Effective Date: 10/15/16

Reviewed: 03/23/17

Revised: 04/15/17

Subject: Knee Arthroplasty

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates    
           

DESCRIPTION:

Arthroplasty describes the surgical replacement or reconstruction of a joint with implanted devices when the joint has been damaged by an arthritic or traumatic process. This guideline outlines the clinical indications for three types of knee arthroplasty procedures: total, partial/unicompartmental, and revision arthroplasty.

POSITION STATEMENT:

Total Knee Arthroplasty (TKA)

Total knee arthroplasty (TKA) meets the definition of medical necessity for treatment of the following knee joint pathology:

When both of the following criteria are met:

• Extensive disease or damage due to rheumatoid arthritis, fracture, or avascular necrosis confirmed by imaging (radiographs, MRI or other advanced imaging), AND

• Patient has pain and documented loss of function (NOTE: There is no indication to perform TKA in patients with severe disease but no symptoms.)

OR

When ALL of the following criteria are met:

• Pain that is persistent and severe, and/or patient has documented loss of function that has been present for at least 6 months resulting in a diminished quality of life, AND

• At least 3 months of non-operative care has failed to improve symptoms (non-operative care should include at least two or more of the following):

• Rest or activity modifications/limitations

• Weight reduction for patient with elevated BMI

• Protected weight-bearing with cane, walker or crutches

• Physical therapy modalities

• Supervised home exercise

• Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics

• Brace/orthosis

• Injections (e.g.,cortisone)

• Physical exam findings demonstrate one or more of the following:

• Tenderness

• Swelling/effusion

• Limited range of motion (decreased from uninvolved side or as compared to a normal joint)

• Flexion contracture

• Palpable or audible crepitus

• Instability and/or angular deformity, AND

• Radiographic findings show evidence of bicompartmental or tricompartmental advanced arthritic changes, documented by standing, weight-bearing radiographs which show Kellgren-Lawrence** grade 3 or grade 4 degeneration (NOTE: MRI should not be the primary tool used to determine the presence or severity of arthritic changes in the joint), AND

No injection into the joint within 3 months of surgery

NOTE: All requests for simultaneous bilateral total knee replacements will be reviewed on a case by case basis.

Contraindications

Absolute contraindication:

• Active infection (local or remote)

Relative contraindications:

• Prior infection at site (unless aspiration with cultures and serology [CBC with differential, ESR, CRP] demonstrates no infection)

NOTE: If prior infection at site, tissue biopsies should be sent intra-operatively to exclude latent/dormant infection.

• Extreme morbid obesity (BMI > 40)

• Extensor mechanism deficiency

• Neuropathic joint

• Severe peripheral vascular disease

• Compromised soft tissue envelope

• Uncontrolled comorbidities

Unicompartmental Knee Arthroplasty (UKA) [Partial Knee Arthroplasty (PKA)]

Unicompartmental knee arthroplasty (UKA) (partial arthroplasty, hemiarthroplasty, unicondylar knee arthroplasty, and bicondylar knee arthroplasty) meets the definition of medical necessity when ALL of the following criteria are met:

• Pain localized to the medial or lateral compartment is present for at least 6 months, AND

• At least 3 months of non-operative care has failed to improve symptoms (non-operative care should include at least two or more of the following):

• Rest or activity modifications/limitations

• Weight optimization

• Protected weight-bearing with cane, walker or crutches

• Physical therapy modalities

• Supervised home exercise

• Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics

• Brace/orthosis

• Injections: (e.g., cortisone), AND

• Total arc of motion (goniometer) > 90 degrees, AND

• Normal ACL or stable reconstructed ACL per physical exam test, AND

• Age > 50 years, AND

• Radiographic findings demonstrate only unicompartmental disease (with or without patellofemoral involvement), with evidence of degeneration equal to Kellgren-Lawrence** grade 3 or 4 (NOTE: MRI should not be the primary tool used to determine the presence or severity of arthritic changes in the joint), AND

• Contracture < 5 -10 degrees upon physical exam (goniometer), AND

• Angular deformity < 10 and passively correctable to neutral upon physical exam (goniometer), AND

• BMI < 40, AND

No injection into the joint within 3 months of surgery

Contraindications:

• Local or systemic active infection

• Inflammatory arthritis

• Angular deformity or contracture greater than indicated range

• Significant arthritic involvement of other knee compartments

• Ligamentous instability (at least ACL [anterior cruciate ligament])

• Poor bone quality or significant osteoporosis or osteopenia

• Meniscectomy of the opposite compartment

• Stiffness greater than indicated range of motion

Revision Arthroplasty

Revision total knee arthroplasty (TKA) meets the definition of medical necessity when the following criteria are met:

• Previous UKA/PKA or TKA joint, AND

• Infection ruled out by synovial fluid aspiration/biospy (cell count and/or culture) AND off antibiotics, AND

No injection into the joint within 3 months of surgery

OR

• When ALL of the following criteria are met:

• Symptomatic UKA/PKA or TKA as evidenced by persistent, severe disabling pain and loss of function, AND

• Any of the following upon physical exam:

• Tenderness to palpation objectively attributable to the implant

• Swelling or effusion

• Pain on weight-bearing or motion

• Instability on stress-testing

• Abnormal or limited motion (compared to usual function)

• Palpable or audible crepitus associated with reproducible pain, AND

• Aseptic loosening, osteolysis confirmed on radiographic or advanced imaging (nuclear medicine bone scan, CT scan, MRI), AND

No injection into the joint within 3 months of surgery

Contraindications

Absolute contraindications:

• Local or systemic active infection

Relative contraindications:

• Deficiency of the extensor mechanism

• Neuropathic joint

• Unstable or poorly controlled comorbidities

• Severe peripheral vascular disease

• Compromised soft-tissue envelope (revision may be performed in conjunction with plastic surgical consultation for soft tissue coverage via pedicle flaps or other acceptable procedure)

The following procedures are considered experimental or investigational, as there is a lack of clinical scientific evidence published in peer-reviewed literature to permit conclusions on safety and net health outcomes:

• Procedures utilizing computer-navigated or patient-specific or gender-specific instrumentation

• Bicompartmental arthroplasty

• Robot-assisted TKA (Makoplasty)

**Kellgren-Lawrence Grading System:

Grade 0: No radiographic features of osteoarthritis

Grade 1: Possible joint space narrowing and osteophyte formation

Grade 2: Definite osteophyte formation with possible joint space narrowing

Grade 3: Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour

Grade 4: Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour

BILLING/CODING INFORMATION:

CPT Coding

27438

Arthroplasty, patella; with prosthesis

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

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline review date: Major Joint Replacement (Hip and Knee) (L33618), located at fcso.com.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

Autologous Chondrocyte Implantation (ACI), 02-20000-17

Meniscal Allograft Transplantation, 02-20000-25

Computer Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure, 02-20000-30

Knee Arthroscopy and Open, Non-Arthroplasty Knee Repair, 02-20000-65

OTHER:

None applicable.

REFERENCES:

  1. AHRQ National Guideline Clearinghouse. NGC 108059: American Academy of Orthopaedic Surgeons clinical practice guideline on surgical management of osteoarthritis of the knee. American Academy of Orthopaedic Surgeons. December 4, 2015.
  2. Belmont PJ, et al. Thirty-Day Postoperative Complications and Mortality Following Total Knee Arthroplasty Incidence and Risk Factors Among a National Sample of 15,321 Patients. The Journal of Bone & Joint Surgery 96.1 (2014): 20-26.
  3. Blue Cross Blue Shield Medical Policy Reference Manual. 7.01.144, Patient-Specific Cutting Guides and Custom Knee Implants (September 2015).
  4. Blue Cross Blue Shield Medical Policy Reference Manual. 7.01.96, Computer-Assisted Musculoskeletal Surgical Navigational Orthopedic Procedure (June 2015).
  5. Cram P, et al. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA 308.12 (2012): 1227-1236.
  6. Della Valle CJ. (2010). Javad Parvizi, MD. J Am Acad Orthop Surg, 18, 771-772.
  7. Fernandes L, et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Annals of the rheumatic diseases 72.7 (2013): 1125-1135.
  8. First Coast Service Options (FCSO). Local Coverage Determination (LCD): Major Joint Replacement (Hip and Knee) (L33618) (October 1, 2015).
  9. Gossec L, et al. The role of pain and functional impairment in the decision to recommend total joint replacement in hip and knee osteoarthritis: an international cross-sectional study of 1909 patients. Report of the OARSI-OMERACT Task Force on total joint replacement. Osteoarthritis and Cartilage 19.2 (2011): 147-154.
  10. Hochberg MC, et al. American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand, hip, and knee. Arthritis care & research 64.4 (2012): 465-474.
  11. InterQual® 2014. CP: Procedures. Total Joint Replacement (TJR), Knee.
  12. Losina E, et al. The dramatic increase in total knee replacement utilization rates in the United States cannot be fully explained by growth in population size and the obesity epidemic. The Journal of Bone & Joint Surgery 94.3 (2012): 201-207.
  13. National Imaging Associates, Inc. Knee Arthroplasty Clinical Guideline, 2016.
  14. National Imaging Associates, Inc. Knee Arthroplasty Clinical Guideline, 2017.
  15. National Institute for Health and Care Excellence (NICE). Interventional procedure guidance [IPG345]: Mini-incision surgery for total knee replacement. May 2010. Accessed at https://www.nice.org.uk.
  16. Thomsen MG, et al. Indications for knee arthroplasty have remained consistent over time. Dan Med J 59 (2012): A4492.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/23/17.

GUIDELINE UPDATE INFORMATION:

10/15/16

New Medical Coverage Guideline.

04/15/17

Revision: updated criteria for total knee arthroplasty; unicompartmental knee arthroplasty (UKA) (partial arthroplasty, hemiarthroplasty, unicondylar knee arthroplasty, and bicondylar knee arthroplasty); and revision arthroplasty. Updated references.

Date Printed: June 23, 2017: 11:44 AM