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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.

02-20000-65

Original Effective Date: 10/15/16

Reviewed: 03/23/17

Revised: 04/15/17

Subject: Knee Arthroscopy and Open, Non-Arthroplasty Knee Repair

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:

This guideline describes surgical indications of both arthroscopy as well as open, non-arthroplasty knee surgery. Arthroscopy introduces a fiber-optic camera into the knee joint through a small incision for diagnostic visualization purposes. Other instruments may then be introduced to remove, repair, or reconstruct intra-articular and extra-articular joint pathology. Surgical indications are based on relevant subjective clinical symptoms, objective physical exam and radiologic findings, and response to previous non-operative treatments when medically appropriate. Open, non-arthroplasty knee surgeries are performed instead of an arthroscopy as dictated by the type and severity of injury and/or disease, and surgeon skill and experience.

POSITION STATEMENT:

Diagnostic Knee Arthroscopy

Diagnostic knee arthroscopy meets the definition of medical necessity when ALL of the following criteria are met:

• At least 3 months of knee pain with documented loss of function (deviation from normal knee function, which may include painful weight bearing, unstable articulation, and/or inadequate range of motion (>10 degrees flexion contracture or < 90 degrees flexion, or both) to accomplish activities of daily living (ADLs), recreational activity, and/or employment (documentation of missed days of work or modifications of work status due to injury/pain are required), AND

• At least 12 weeks of non-operative care* that has failed to improve symptoms, AND

• Clinical documentation of painful weight bearing, joint line tenderness, effusion and/or limited motion compared to pre-symptomatic joint range, AND

• Indeterminate radiographs AND MRI findings

Debridement with or without Chondroplasty

Debridement with or without chondroplasty meets the definition of medical necessity when ALL of the following criteria are met:

• Knee pain with documented loss of function (deviation from normal knee function, which may include painful weight bearing, unstable articulation, and/or inadequate range of motion (>10 degrees flexion contracture or < 90 degrees flexion, or both) to accomplish activities of daily living (ADLs), recreational activity, and/or employment (documentation of missed days of work or modifications of work status due to injury/pain required), AND

• At least 12 weeks of non-operative care* that has failed to improve symptoms, AND

• MRI results show evidence of unstable chondral flap, AND

• Recurrent (more than 2) or persistent effusions

OR

When both of the following criteria are met:

• Arthrofibrosis as evidenced by physical exam findings of painful stiffness and loss of motion due to proliferation of scar tissue in and around the joint (NOTE: Imaging is not necessary, but historically has been used to determine the diagnosis, AND

• At least 6 weeks of supervised or self-directed physical therapy that has failed to improve symptoms

OR

Debridement chondroplasty for patellofemoral chondrosis meets the definition of medical necessity when ALL of the following criteria are met:

• Anterior knee pain and loss of function (deviation from normal pain-free weight bearing, stable articulation, and/or range of motion to accomplish activities of daily living (ADLs), recreational activity, and/or employment), AND

• Other extra-articular or intra-articular sources of pain or dysfunction have been excluded (referred pain, radicular pain, tendinitis, bursitis, neuroma), AND

• Physical exam localizes tenderness to the patellofemoral joint with pain aggravated by activities that load the joint (single leg squat, ascending > descending stairs, and being in seated position for extended periods of time with knee flexed), AND

• Imaging is performed (radiographs, MRI, or CT) to measure tibial tubercle—trochlear groove distance

• At least 12 weeks of non-operative care* has failed to improve symptoms, AND

• No evidence of osteoarthritis (Kellgren-Lawrence** grade 3 to 4 based on standing or weight-bearing radiographs and patellofemoral views

NOTE: Arthroscopic debridement with or without chondroplasty for osteoarthritis of the knee does not meet the definition of medical necessity unless above criteria are met.

Meniscectomy/Meniscal Repair

Meniscectomy and/or meniscal repair meets the definition of medical necessity when the following criteria are met:

• Symptomatic meniscal tear confirmed by MRI results that show a peripheral longitudinal tear in a vascular zone, associated with pain and mechanical symptoms upon physical exam

OR

• When both of the following criteria are met:

• Pediatric or adolescent patient has pain and mechanical symptoms upon physical exam, AND

• MRI results show unstable tear

OR

• When at least 3 of the following 5 criteria are met:

1. History of "catching" or "locking" as reported by the patient

2. Knee joint line pain with forced hyperextension upon physical exam

3. Knee joint line pain with maximum flexion upon physical exam

4. Knee pain or an audible click with McMurray's maneuver upon physical exam

5. Joint line tenderness to palpation upon physical exam, AND

• At least 6 weeks of non-operative care* has failed to improve symptoms, AND

• One of the following radiographic findings:

• Radiographic findings without moderate or severe osteoarthritic changes, OR

• MRI results confirm meniscal tear in patients < 30 years of age, OR

• MRI results confirm displaced tear (any age)

OR

• Meniscus tear encountered during another medically necessary arthroscopic procedure

Meniscectomy and meniscal repair absolute contraindications

• Arthroscopic meniscectomy or meniscal repair does not meet the definition of medical necessity in the presence of Kellgren-Lawrence** grade 4 osteoarthritis.

Meniscectomy and meniscal repair relative contraindications

• Meniscectomy or meniscal repair does not meet the definition of medical necessity in the presence of Kellgren-Lawrence** grade 3 osteoarthritis unless acute onset with effusion, locking (NOTE: locking only; this does not include catching, popping, cracking), and MRI evidence of bucket-handle or displaced meniscal fragment that correlates with the correct compartment (i.e. medial tenderness and locking for a medial tear)

• If grade 3 changes are present, only a meniscectomy may be indicated, not meniscal repair. If evidence of meniscal extrusion on coronal MRI with or without subchondral edema, arthroscopy is relatively contraindicated, even if tear is present.

• BMI > 35

Ligament Reconstruction/Repair

Anterior Cruciate Ligament (ACL) Reconstruction with Allograft or Autograft

ACL reconstruction or repair meets the definition of medical necessity when ALL of the following criteria are met:

• Knee instability (defined subjectively as "giving way", "giving out", "buckling", or two-fist sign) with clinical findings of instability (Lachman’s 1A, 1B, 2A, 2B, 3A, 3B, anterior drawer test, pivot shift test, or instrumented (KT-1000 or KT-2000) laxity of greater than 3 mm side-side difference), AND

• MRI results confirm complete ACL tear, AND

• Patient has no evidence of severe arthritis (Kellgren-Lawrence** grade 3 or 4)

OR

• When ONE of the following criteria are met:

• MRI results confirm ACL tear associated with other ligamentous instability or repairable meniscus, OR

• MRI results confirm partial or complete ACL tear AND patient has persistent symptoms despite at least 12 weeks of non-operative care*, OR

• Acute ACL tear confirmed by MRI in a high demand occupation or competitive athlete [as quantified by Marx activity score for athletics (any score greater than 4), and Tegner activity score for athletics and/or high demand occupation (score greater than 2)], AND

• Patient has no evidence of severe arthritis (Kellgren-Lawrence** grade 3 or 4)

• Tears in patients less than age 13 will be reviewed on a case by case basis

Posterior Cruciate Ligament (PCL) Reconstruction

Posterior cruciate ligament (PCL) reconstruction or repair meets the definition of medical necessity when the following criteria are met:

• Knee instability (defined subjectively as "giving way", "giving out", "buckling", or two-fist sign) with clinical findings of a positive posterior drawer test, posterior sag test, quadriceps active test, dial test at 90 degrees knee flexion, or reverse pivot shift test, AND

• MRI results confirm complete PCL tear, AND

• Failed non-operative care* (including bracing in full extension foracute PCL tears), AND

• Absence of medial and patellofemoral Kellgren-Lawrence** grade 3 to 4 changes in chronic tears

OR

• Pediatric and adolescent tears in patients with open physes or open growth plates

OR

• Symptomatic partial tears with persistent instability despite non-operative care*

OR

• Incidental Kellgren-Lawrence** grade 2 to 3 osteoarthritis in acute or subacute tears with unstable joint

OR

• Tears in patients less than age 13

Collateral Ligament Repair or Reconstruction

Collateral ligament repair or reconstruction should rarely occur independent of additional repair or reconstruction surgery.

Articular Cartilage Restoration/Repair

Skeletally Immature Indications

Articular cartilage restoration or repair for skeletally immature patients meets the definition of medical necessity:

• When ALL of the following criteria are met:

• Skeletally immature patient, AND

• Patient is symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion), AND

• Radiographic findings (any radiograph AND MRI) of a displaced lesion

OR

• When ALL of the following criteria are met:

• Skeletally immature patient, AND

• Patient is symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion), AND

• At least 12 weeks of non-operative care* has failed to improve symptoms, AND

• Radiographic findings (any radiograph AND MRI) of a stable osteochondral lesion

OR

• When ALL of the following criteria are met:

• Skeletally immature, AND

• Asymptomatic, AND

• At least 12 weeks of non-operative care* has failed to improve lesion stability or size, AND

• Radiographic findings (any radiograph AND MRI) of an unstable osteochondral lesion

AND

Exclude patients with evidence of meniscal deficiency and/or malalignment IF these are not being addressed (meniscal transplant and/or lateral release/patellar realignment procedure) at the same time as the cartilage restoration procedure.

Skeletally Mature Indications (by surgical approach)

Reparative marrow stimulation techniques (microfracture & drilling) meet the definition of medical necessity when ALL of the following criteria are met:

• Skeletally mature adult, AND

• MRI confirms a full-thickness weight-bearing lesion that is < 2.5 sq.cm, AND

• Patient is symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion), AND

• Patient is less than 50 years of age, AND

• BMI < 35, AND

• Physical exam findings and/or imaging results confirm knee has stable ligaments, AND

• No evidence of prior meniscectomy in same compartment (medial femoral condyle full thickness lesion and prior medial meniscectomy) unless concurrent meniscal transplant performed

OR

Restorative techniques (abrasion arthroplasty, osteochondral autograft transfer or transplantation (OATS), mosaicplasty, osteochondral allograft implantation) meet the definition of medical necessity when ALL of the following criteria are met:

• Skeletally mature adult, AND

• MRI results confirm a full thickness chondral or osteochondral lesion of the femoral condyles or trochlea > 2.5 cm, AND

• Patient is less than 50 years of age, AND

• Patient has been symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion) for at least 6 months, AND

• At least 6 months of non-operative care* has failed to improve symptoms, AND

• MRI and/or physical findings confirm knee has normal alignment (+/- 3 degrees from neutral on full-length mechanical axis long-leg x-ray (unless concurrent or staged tibial or femoral osteotomy performed), and stability (unless concurrent ligamentous repair or reconstruction performed), AND

• BMI < 35, AND

• MRI shows no evidence of significant osteoarthritis (greater than Kellgren-Lawrence** grade 2), AND

• No prior meniscectomy in same compartment (unless concurrent or staged meniscal transplant performed)

OR

Surgical intervention for the treatment of patellofemoral chondrosis (osteochondral autograft transfer or transplantation (OATS), microfracture, osteochondral allograft implantation, debridement chondroplasty, tibial tubercle osteotomy) meets the definition of medical necessity when ALL of the following criteria are met:

• Anterior knee pain and loss of function (deviation from normal knee function, which may include painful weight bearing, unstable articulation, and/or inadequate range of motion (>10 degrees flexion contracture or < 90 degrees flexion, or both) to accomplish activities of daily living (ADLs), recreational activity, and/or employment (documentation of missed days of work or modifications of work status due to injury/pain required), AND

• Other extra-articular or intra-articular sources of pain or dysfunction have been excluded (referred pain, radicular pain, tendinitis, bursitis, neuroma), AND

• Physical exam localizes tenderness to the patellofemoral joint with pain aggravated by activities that load the joint (single leg squat, descending > ascending stairs or stair climbing, and being in seated position for extended periods of time with knee flexed), AND

• Radiologic imaging shows patellofemoral chondrosis graded 3 or 4 by the Outerbridge Classification*** or ICRS**** classification, AND

• At least 6 months of non-operative care* has failed to improve symptoms, AND

• No evidence of osteoarthritis (defined as Kellgren-Lawrence** grade 3 to 4 based on standing or weight-bearing radiographs) in the medial/lateral compartments

Synovectomy (major [2+ compartments], minor [1 compartment])

Synovectomy meets the definition of medical necessity when ALL of the following criteria are met:

• Proliferative rheumatoid synovium (in patients with established rheumatoid arthritis according to the American College of Rheumatology Guidelines*****), AND

• Not responsive to disease modifying drug (DMARD) therapy for at least 6 months, and at least 6 weeks of non-operative care* that has failed to improve symptoms, AND

• At least one instance of aspiration of joint effusion and cortisone injection (if no evidence of infection)

OR

• Hemarthrosis from injury, coagulopathy or bleeding disorder confirmed by physical exam, joint aspiration, and/or MRI

OR

When ALL of the following criteria are met:

• Proliferative pigmented villonodular synovitis, synovial chondromatosis, sarcoid synovitis, or similar proliferative synovial disease; traumatic hypertrophic synovitis confirmed by history, MRI or biopsy, AND

• At least 6 weeks of non-operative care* has failed to improve symptoms, AND

• At least one instance of aspiration of joint effusion and injection of cortisone (if no evidence of infection)

OR

When ALL of the following criteria are met:

• Detection of painful plica confirmed by physical exam and MRI findings, AND

• At least 12 weeks of non-operative care* has failed to improve symptoms, AND

• At least one instance of aspiration of joint effusion OR single injection of cortisone (effusion may not be present with symptomatic plica)

Loose Body Removal

Loose body removal meets the definition of medical necessity when the following criteria are met:

• Removal of loose body or foreign object that causes limitation or loss of function (deviation from normal knee function, which may include painful weight bearing, unstable articulation, and/or inadequate range of motion (>10 degrees flexion contracture or < 90 degrees flexion, or both) to accomplish activities of daily living (ADLs), recreational activity, and/or employment (documentation of missed days of work or modifications of work status due to injury/pain required)

Lateral Release/Patellar Realignment

Surgical intervention for the treatment of lateral patellar compression syndrome meets the definition of medical necessity when ALL of the following criteria are met:

• Evidence of lateral patellar tilt from radiologic images (patellofemoral view: mercer merchant (45 degrees flexion); and/or skyline (60-90 degrees flexion); and/or sunrise (60-90 degrees flexion), AND

• Associated lateral patella facet Kellgren-Lawrence** changes grade 1, 2, or 3, AND

• Reproducible isolated lateral patellofemoral pain with patellar tile test, AND

• At least 6 months of non-operative care* failed to improve symptoms, including appropriate hamstring/IT band stretching and patellar mobilization techniques, AND

• No evidence of patellar dislocation without documented patellar tilt, AND

• No evidence of medial patellofemoral changes (Kellgren-Lawrence** grade 2 osteoarthritis or higher)

Surgical intervention for the treatment of patellar malalignment and/or patellar instability meets the definition of medical necessity when the following criteria are met:

• Acute traumatic patellar dislocation is associated with an osteochondral fracture, loose body, vastus medialus obliquus/medial patellofemoral ligament muscle avulsion, or other intra-articular injury that requires urgent operative management, OR

• Repeat (greater than 2) patellar dislocations or subluxations have occurred despite 6 months of non-operative care* with radiologic confirmation of MPFL (medial patellofemoral ligament) deficiency, OR

• Physical exam has patellofemoral tenderness and abnormal articulation of the patella in the femoral trochlear groove (patellar apprehension with positive J sign), AND

• Radiologic images rule out fracture or loose body, and show abnormal articulation, trochlear dysplasia, or other abnormality related to malalignment, AND

• CT scan or MRI rules out other abnormality to malalignment (tibial tubercle-trochlear groove (TT-TG) distance > 20 millimeters), AND

• At least 6 months of non-operative care* failed to improve symptoms

Lysis of Adhesions for Arthrofibrosis of the knee

Surgical indications are based on relevant clinical symptoms, physical exam, radiologic findings, time from primary surgery, and response to conservative management when medically appropriate. Improved range of motion may be accomplished through arthroscopically-assisted or open lysis of adhesions with general anesthesia, regional anesthesia, or sedation.

Lysis of adhesions for arthrofibrosis of the knee meets the definition of medical necessity when the following criteria are met:

• Physical exam findings demonstrate inadequate range of motion of the knee, defined as less than 105 degrees of flexion, AND

• Failure to improve range of motion of the knee despite 6 weeks (12 visits) of documented physical therapy, AND

• Patient is more than 12 weeks after ligamentous or joint reconstruction, or resolved infection

OR

• Patient is more than 12 weeks after trauma, or resolved infection, AND

• Patient has native knee, AND

• Manipulation under anesthesia is also performed

*Non-operative Care

Non-operative care* is defined as a combination of two or more of the following:

• Rest or activity modifications/limitations

• Ice/heat

• Protected weight bearing

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

• Brace/orthosis

• Physical therapy modalities

• Supervised home exercise

• Weight optimization

• Injections (e.g, cortisone)

**Kellgren-Lawrence Grading System

Grade 0: No radiographic features of osteoarthritis

Grade 1: Doubtful joint space narrowing and possible osteophytic lipping

Grade 2: Definite osteophyte formation with possible joint space narrowing on anteroposterior weight-bearing radiograph

Grade 3: Multiple osteophytes, definite narrowing of joint space, some sclerosis and possible bony deformity

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

***Outerbridge Arthroscopic Grading System

Grade 0: Normal cartilage

Grade I: Softening and swelling/blistering

Grade II: Partial thickness defect, fissures < 1.5cm diameter/wide

Grade III: Fissures /defects down to subchondral bone with intact calcified cartilage layer, diameter > 1.5cm

Grade IV: Exposed subchondral bone

****The International Cartilage Research Society (ICRS)

Grade 0: Normal cartilage

Grade I: Nearly normal. Superficial lesions.

A. Soft indentation

B. And/or superficial fissures and cracks

Grade II: Abnormal. Lesions extending down to <50% of cartilage depth

Grade III: Severely abnormal

A. Cartilage defects extending down >50% of cartilage depth

B. And down to calcified layer

C. And down to, but not through the subchondral bone

D. And blisters

Grade IV: Severely abnormal (through the subchondral bone)

A. Penetration of subchondral bone but not across entire diameter of defect

B. Penetration of subchondral bone across the full diameter of the defect

***** American College of Rheumatology Guidelines

2010 ACR/EULAR: Classification Criteria for RA

JOINT DISTRIBUTION (0‐5)

1 large joint

0

2‐10 large joints

1

1‐3 small joints (large joints not counted)

2

4‐10 small joints (large joints not counted)

3

>10 joints (at least one small joint)

5

SEROLOGY (0‐3)

Negative RF AND negative ACPA

0

Low positive RF OR low positive ACPA

2

High positive RF OR high positive ACPA

3

SYMPTOM DURATION (0‐1)

<6 weeks

0

≥6 weeks 1

1

ACUTE PHASE REACTANTS (0‐1)

Normal CRP AND normal ESR

0

Abnormal CRP OR abnormal ESR

1

≥6 = definite RA

BILLING/CODING INFORMATION:

CPT Coding

27332

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

27333

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

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

27415

Osteochondral allograft, knee, open

27416

Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])

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

29866

Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])

29867

Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

29870

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

29873

Arthroscopy, knee, surgical; with lateral release

29874

Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)

29875

Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)

29876

Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, 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)

29888

Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

29889

Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction

HCPCS Coding

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

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 National Coverage Determination (NCD) was reviewed on the last guideline review date: Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (150.9), located at cms.gov.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

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

Meniscal Allograft Transplantation, 02-20000-25

Knee Arthroplasty, 02-20000-60

OTHER:

None applicable.

REFERENCES:

  1. Abrams GD, Frank RM, Gupta AK, Harris JD, McCormick FM, Cole BJ. Trends in meniscus repair and meniscectomy in the United States, 2005-2011. The American journal of sports medicine. 2013 Jul 17:0363546513495641.
  2. AHRQ National Guideline Clearinghouse. Guideline Summary NGC009018: Knee disorders. American College of Occupational and Environmental Medicine (2011).
  3. AHRQ National Guideline Clearinghouse. Guideline Summary NGC010527: American Academy of Orthopaedic Surgeons clinical practice guideline on management of anterior cruciate ligament injuries. September 2014.
  4. Bark S, Piontek T, Behrens P, Mkalaluh S, Varoga D, Gille J. Enhanced microfracture techniques in cartilage knee surgery: Fact or fiction?. World journal of orthopedics. 2014 Sep 18;5(4):444.
  5. Blue Cross Blue Shield Association Medical Policy Reference Manual. Policy 7.01.48, Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions. October 2015.
  6. Blue Cross Blue Shield Association Medical Policy Reference Manual. Policy 7.01.78, Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions. June 2015.
  7. Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) for Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (150.9) (06/11/04).
  8. Enad JG. Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty. Arthroscopy Techniques. 2014 Oct;3(5):e611.
  9. Herrlin SV, Wange PO, Lapidus G, Hållander M, Werner S, Weidenhielm L. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up.
  10. Järvinen TL, Sihvonen R, Englund M. Arthroscopy for degenerative knee—a difficult habit to break?. Acta Orthopaedica. 2014 Jun;85(3):215.
  11. Katz JN, Brophy RH, Chaisson CE, De Chaves L, Cole BJ, Dahm DL, Donnell-Fink LA, Guermazi A, Haas AK, Jones MH, Levy BA. Surgery versus physical therapy for a meniscal tear and osteoarthritis. New England Journal of Medicine. 2013 May 2;368(18):1675-84.
  12. Katz JN, Brownlee SA, Jones MH. The role of arthroscopy in the management of knee osteoarthritis. Best practice & research. Clinical rheumatology. 2014 Feb;28(1):143.
  13. Mayr HO, Rueschenschmidt M, Seil R, Dejour D, Bernstein A, Suedkamp N, Stoehr A. Indications for and results of arthroscopy in the arthritic knee: a European survey. International Orthopaedics. 2013 Jul;37(7):1263.
  14. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis and cartilage/OARS, Osteoarthritis Research Society. 2014 Mar;22(3):363.
  15. National Imaging Associates, Inc. Knee Arthroscopy; Open, Non-Arthroplasty Knee Repair & Manipulation Procedures Clinical Guideline, 2016.
  16. National Imaging Associates, Inc. Knee Arthroscopy; Open, Non-Arthroplasty Knee Repair & Manipulation Procedures Clinical Guideline, 2017.
  17. National Institute for Health and Care Excellence (NICE). Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis (August 2007). Accessed at https://www.nice.org.uk.
  18. Pujol N, Colombet P, Cucurulo T, Graveleau N, Hulet C, Panisset JC, Potel JF, Servien E, Sonnery-Cottet B, Trojani C, Djian P. Natural history of partial anterior cruciate ligament tears: A systematic literature review. Orthopaedics & Traumatology: Surgery & Research. 2012;8(98):S160-4.
  19. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TL, Finnish DM. Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscal tear. The New England journal of medicine. 2013 Dec 26;369(26):2515.
  20. Steadman JR, Briggs KK, Matheny LM, Ellis HB. Ten-year survivorship after knee arthroscopy in patients with Kellgren-Lawrence grade 3 and grade 4 osteoarthritis of the knee. Arthroscopy: the journal of arthroscopic & related surgery: official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2013 Feb;29(2):220.

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: minor changes to lateral release/patellar realignment criteria (mercer merchant view changed to 45 degrees flexion). Updated references.

Date Printed: December 18, 2017: 03:29 PM