Clinical UM Guideline
|Guideline #:||CG-SURG-43||Current Effective Date:||01/13/2015|
|Status:||Revised||Last Review Date:||11/13/2014|
This document addresses knee arthroscopy surgery when done primarily for therapeutic intervention of confirmed pathology.
Knee arthroscopy is considered to be medically necessary (after the appropriate diagnostic imaging has been completed first) for any of the following:
Not Medically Necessary:
Knee arthroscopy is considered to be not medically necessary for osteoarthritis of the knee, meniscal tear in chronic degenerative knee joint (excluding mechanical symptoms, such as locked knee or giving way), isolated medial or collateral ligament injury or when the above criteria are not met.
The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
|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 (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 or 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 fixaiton (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|
|29999||Unlisted procedure, arthroscopy [when specified as arthroscopic knee lavage as a separate procedure]|
|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|
|ICD-9 Diagnosis||[For dates of service prior to 10/01/2015]|
|ICD-10 Diagnosis||[For dates of service on or after 10/01/2015]|
An arthroscopy is a surgical procedure in which a joint is viewed using a small camera. Arthroscopy gives doctors a clear view of the inside of the knee. This helps them diagnose and treat knee problems. Arthroscopy is done through small incisions. The arthroscope (a small camera instrument about the size of a pencil) is inserted into the knee joint. The arthroscope sends the image to a television monitor. On the monitor, the surgeon can see the structures of the knee in great detail. The surgeon can use arthroscopy to feel, repair or remove damaged tissue. To do this, small surgical instruments are inserted through other incisions around the knee.
A study by Vermesan and colleagues (2013) followed 120 participants with non-traumatic symptomatic knee pain who had degenerative lesions of the cartilage and meniscus. The participants were randomized to receive either intra-articular steroid injections or arthroscopic debridement. At the 1-month follow-up, 79% of the participants in the arthroscopic group showed improvement in knee symptoms and 61% in the intra-articular steroid group showed improvement in knee symptoms. At 1-year follow-up, 48 participants from the injection group and 50 participants from the arthroscopy group were available and 5 participants (42%) had been converted to a total knee replacement. This particular study did not take into account the influence of physical therapy or the amount of oral non-steroidal anti-inflammatory drugs from the 1-month to 1-year follow-up.
Katz and colleagues (2013) reported on a multicenter, randomized, controlled trial of 351 participants who had knee symptoms consistent with a meniscus tear. The participants were randomized to receive either arthroscopic surgery and post-operative physical therapy or standard physical therapy regimen. Evaluations were done at 6 and 12 months. The primary outcome was the difference between the groups using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score 6 months after randomization. At the 6 month follow-up, the surgical group had a mean improvement WOMAC score of 20.9 points and the physical therapy group had an 18.5 point score. At 6 months, 51 participants who initially were randomized to the physical therapy group only had undergone surgery and 9 participants assigned to surgery had not undergone surgery. Results at 12 months were similar to the 6 month results. This study has several limitations including potential for bias, it was unblended, and the trial was conducted as academic referral centers so the findings may not be generalized to community settings.
Herrlin and colleagues (2013) reported on a prospective randomized trial which evaluated the outcome of a 2-year and 5-year follow-up in which arthroscopic knee surgery followed by exercise therapy was superior to exercise therapy alone when treating meniscal tears. A total of 96 participants were included. All participants had x-rays before randomization and after 5 years. Both groups showed significant clinical improvements from baseline at the 24 and 60 months follow-up. The authors reported that arthroscopic surgery followed by exercise therapy was not superior to exercise therapy alone. However, one-third of the participants from the exercise group still had disabling knee symptoms after exercise therapy but improved to the same level as the rest of the participants after arthroscopic surgery.
Sihvonen and colleagues (2013) reported on a multicenter, randomized, double-blind, sham controlled trial of 146 participants who had knee symptoms consistent with a meniscus tear. The participants were randomized to receive either arthroscopic partial menisectomy or sham surgery. Primary outcomes were the changes in the Lysholm and Western Ontario Meniscal Evaluation Tool (WOMET) scores and in knee pain after exercise at 12 months following the procedure. The Lysholm scores improved by at least 11.5 points, the WOMET scores improved by at least 15.5 points and the score for knee pain after exercise improved by at least 2 points. There were no significant differences between groups in the number of participants who required subsequent knee surgery. Two participants in the menisectomy surgery group required subsequent surgery compared to 5 participants in the sham surgery group.
A study by Cho (2012) reported on the efficacy of arthroscopic excision of popliteal cysts. A total of 105 participants had direct arthroscopic excision and were followed up over 2 years. At the 2-year mark, participants had either an ultrasound or magnetic resonance imaging (MRI) exam to detect the recurrence of cysts. There were no complaints of pain, swelling or functional impairment more than 2 years after surgery. No recurrence of cysts was found on either ultrasound or MRI.
A retrospective review by Aurégan and colleagues (2012) reported on recurrence rates and functional outcomes after primary arthroscopic synovectomy of the knee. A total of 23 participants had primary arthroscopic synovectomy. After a mean follow-up of 7 years, 2 participants had recurrence of disease after 2 and 5 years respectively. Using the Tegner-Lysholm score to evaluate functional outcomes, the score of the participants was improved and the mean Ogilvie-Harris score indicated excellent function.
Anterior cruciate ligament: One of the four ligaments that connect the femur and tibia and gives the knee joint stability. This ligament is in the center of the knee and limits rotation and the forward movement of the tibia.
Meniscus: Pads of connective tissue which separate the bones of the knee.
Popliteal cyst: A buildup of joint fluid that forms a cyst behind the knee.
Posterior cruciate ligament: One of the four ligaments that connect the femur and tibia and gives the knee joint stability. This ligament is in the center of the knee and limits backward movement of the tibia.
Peer Reviewed Publications:
|Websites for Additional Information|
|Revised||11/13/2014||Medical Policy & Technology Assessment Committee (MPTAC) review. Clarification to criteria for treatment of osteochondral defect; removed reference to age and changed to growth plate closure instead. Clarification to Not Medically Necessary statement, excluded mechanical symptoms. Updated References.|
|New||08/14/2014||MPTAC review. Initial document development.|