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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.

02-20000-23

Original Effective Date: 03/15/03

Reviewed: 03/22/12

Revised: 11/01/15

Subject: Thermal Capsulorrhaphy as a Treatment of Joint Instability

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:

Shoulder instability is a relative common occurrence, reported in 2% to 8% of the population and may result from a single traumatic event (i.e., subluxation or dislocation), repeated microtrauma, or constitutional ligamentous laxity, resulting in deformation and/or damage in the glenohumeral capsule and ligaments. Shoulder instability may be categorized according to the movement of the humeral head (i.e., anterior, posterior, inferior, or multidirectional instability). Multidirectional instability most frequently consists of anterior and inferior subluxation or dislocation.

Initial treatment of shoulder subluxation or dislocation is conservative in nature followed by range-of-motion and strengthening exercises. However, if instability persists, either activity modifications or surgical treatment may be considered. Activity modification may be appropriate for patients who can identify a single motion that aggravates instability, such as overhead throwing motions. Surgical treatment may be considered in those who are unwilling to give up specific activities (i.e., related to sports) or when instability occurs frequently or during daily activities.

Surgery consists of inspection of the shoulder joint with repair, reattachment, or tightening of the labrum, ligaments, or capsule performed either with sutures or sutures attached to absorbable tacks or anchors. While arthroscopic approaches have been investigated over the past decade, their degree of success has been controversial due to a higher rate of recurrent instability compared with open techniques, thought to be related in part to the lack of restoration of capsular tension. Recent reports of arthroscopic techniques have described various suturing techniques for tightening the capsule, which require mastery of technically difficult arthroscopic intra-articular knot tying.

Thermal capsulorrhaphy has been proposed as a technically simpler arthroscopic technique for tightening the capsule and ligaments. The technique is based on the observation that the use of nonablative levels of radiofrequency thermal energy can alter the collagen in the glenohumeral ligaments and/or capsule, resulting in their shrinkage and a decrease in capsular volume, both thought to restore capsular tension. Thermal capsulorrhaphy may be used in conjunction with arthroscopic repair of torn ligaments or other structures (i.e., repair of Bankart or superior labrum anterior and posterior [SLAP] lesion). In addition, thermal capsulorrhaphy has also been investigated as an arthroscopic treatment of glenohumeral laxity, a common injury among overhead athletes, such as baseball players, resulting in internal impingement of the posterior rotator cuff against the glenoid labrum. Internal impingement is often accompanied by posterior rotator cuff tearing and labral injury. Thermal capsulorrhaphy has also been proposed as a sole arthroscopic treatment. For example, the technique may be considered in patients with chronic shoulder pain without recognized instability, based on the theory that the pain may be related to occult or microinstability. This diagnosis may be considered when a diagnostic arthroscopy reveals only lax ligaments and is commonly seen among baseball players. Finally, thermal capsulorrhaphy may be considered in patients with congenital ligamentous laxity, such as Ehlers-Danlos or Marfan's syndrome.

While thermal capsulorrhaphy was initially investigated using laser energy, radiofrequency probes are now more commonly used.

POSITION STATEMENT:

Thermal capsulorrhaphy, used alone or in combination with other arthroscopic procedures, is considered experimental or investigational for treatment of joint instability, including, but not limited to the shoulder, knee and elbow. The literature consists primarily of case series studies with small study populations. The available peer-reviewed literature is insufficient to permit conclusions regarding the effect of this procedure on net health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

The CPT code book specifically directs users to use a non-specific CPT code (29999) to describe thermal capsulorrhaphy. Thus CPT code 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) should not be used to describe thermal capsulorrhaphy.

HCPCS Coding:

S2300

Arthroscopy, shoulder, surgical; with thermally induced capsulorrhaphy (investigational)

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:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Glenohumeral: of, relating to, or connecting the glenoid cavity and the humerus (shoulder joint).

Microtrauma: a very slight injury or lesion.

RELATED GUIDELINES:

None applicable.

OTHER:

Other terms used to describe thermal capsulorrhaphy:

Thermal capsular shrinkage

Thermal shrinkage therapy

Thermal shrinkage of the joint capsule

Thermal capsular shrinkage, arthroscopic

Thermal arthroscopy

Electrothermal therapy

Electrothermal arthroscopy

Electrothermally-assisted capsule shift

Electrothermally-assisted capsulorrhaphy (ETAC)

REFERENCES:

  1. American Academy of Orthopaedic Surgeons, Advisory Statement: Use of Thermal Modalities (Lasers and Radiofrequency Devices) in Orthopaedic Surgery, June 2003.
  2. Blue Cross Blue Shield Association Medical Policy Reference Manual 7.01.82 Thermal Capsulorrhaphy as a Treatment of Shoulder Instability, June 2011.
  3. Coobs BR, LaPrade RF. Severe Chondrolysis of the Glenohumeral Joint After Shoulder Thermal Capsulorrhaphy: A Case Report and Literature Review. Am J Orthop. 2009;38(2):E34-E37.
  4. ECRI. HTAIS Hotline Service Custom Reports Thermal Capsulorrhaphy (Shrinkage) for Shoulder Instability, (Updated 03/24/08).
  5. ECRI. HTAIS Hotline Service Custom Reports Thermal Shrinkage of the Anterior Cruciate Ligament (ACL) for Knee Instability, (Updated 03/13/08).
  6. Hayes, Inc. Hayes Alert. Thermal Capsulorrhaphy for Glenohumeral Instability. Lansdale, PA: Hayes, Inc.; November 2000.
  7. Hayes, Inc. Hayes Medical Technology Directory. Thermal Shrinkage for Cruciate Ligament Injury. Lansdale, PA: Hayes, Inc.; April 2003. Update performed 02/23/07.
  8. Hayes, Inc. Hayes Medical Technology Directory. Thermal Capsulorrhaphy for Shoulder Instability. Lansdale, PA: Hayes, Inc.; 10/06; update 10/21/07.
  9. Johnson SM, Robinson CM. Shoulder Instability in Patients with Joint Hyperlaxity. J Bone Joint Surg Am. 2010;92:1545-57.
  10. Mohtadi NG, Hollinshead RM, Ceponis PJ, Chan DS, Fick GH. A multi-centre randomized controlled trial comparing electrothermal arthroscopic capsulorrhaphy versus open inferior capsular shift for patients with shoulder instability: protocol implementation and interim performance: lessons learned from conducting a multi-centre RCT [ISRCTN68224911; NCT00251160]. Trials. 2006 Feb 2; 7: 4.
  11. Washington State Department of Labor and Industries. Thermal shrinkage for the treatment of shoulder instability and anterior cruciate ligament laxity. Olympia, WA: Washington State Department of Labor and Industries (WSDLI), 2003:19.
  12. Zheng N, Davis BR, Andrews JR. The effects of thermal capsulorrhaphy of medial parapatellar capsule on patellar lateral displacement. Journal of Orthopaedic Surgery and Research 2008, 3:45.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 03/22/12.

GUIDELINE UPDATE INFORMATION:

03/15/03

New Medical Coverage Guideline.

04/15/04

Review and revision of guideline; consisting of updated references.  Also changed name of guideline from Thermal Capsulorrhaphy as a Treatment of Joint Instability to Thermal Capsulorrhaphy as a Treatment of Joint Instability.

04/15/05

Review and revision of guideline consisting of updated references.

04/15/06

Review and revision of guideline consisting of updated references.

04/15/07

Review and revision of guideline consisting of updated references.

06/15/07

Reformatted guideline.

04/15/08

Scheduled review; no change in position statement. Update references.

04/15/09

Scheduled review; no change in position statement. Update references.

04/15/10

Annual review; no change in position statement. References updated.

04/15/12

Scheduled review; no change in position statement. Revised description, CPT coding section and other names used to describe thermal capsulorrhaphy. Updated references.

05/11/14

Revision: Program Exceptions section updated.

11/01/15

Revision: ICD-9 Codes deleted.

Date Printed: October 20, 2017: 08:41 AM