MEDICAL POLICY

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APPENDIX
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Knee Arthroscopy in Adults

Number 7.01.549

Effective Date February 24, 2014

Revision Date(s) 02/10/14

Replaces N/A

Policy

 

Knee arthroscopy may be considered medically necessary only when applicable MCG™ (formerly Milliman Care Guidelines®) criteria are met. ORG: S-705 (ISC)

Arthroscopy for torn meniscus or other ligament tears with concomitant knee osteoarthritis* may be considered medically necessary only when the applicable MCG™ (formerly Milliman Care Guidelines®) and additional criteria are met. (See Policy Guidelines for modifications to MCG™ criteria.)

Arthroscopic debridement and/or lavage for the treatment of osteoarthritis of the knee is considered not medically necessary, except as noted in the Policy Guidelines section.

NOTE: Adult is defined as “individuals at or over 18 years of age”.

*For Members without a diagnosis of knee osteoarthritis, please utilize the MCG™ (formerly Milliman Care Guidelines®) for “Knee Arthroscopy” ORG: S-705 (ISC).

Related Policies

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1.03.501

Knee Braces

2.01.31

Intra-articular Hyaluronan Injections for Osteoarthritis

7.01.15

Meniscal Allograft and Other Meniscus Implants

Policy Guidelines

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MCG™ (formerly Milliman Care Guidelines®) is used as a tool to guide medical necessity determinations and utilization management decisions, per licensed agreement, for knee arthroscopy. The related MCG™ is: Knee Arthroscopy S-705 (ISC).

Modifications to MCG

The following are modifications to MCG™ criteria:

Torn Meniscus with Osteoarthritis

Addition to MCG™:

  • For members aged 50 and older, providers must submit an x-ray report to determine whether or not a member has concomitant knee osteoarthritis. For members under age 50, when there is a history of osteoarthritis, an x-ray report must be submitted and document the Kellgren-Lawrence (KL) score (see below for KL grading scale):
  • Kellgren-Lawrence Grade 1 or 2: arthroscopy for Kellgren-Lawrence Grade 1 or 2 is considered medically necessary if MCG™ criteria are met.
  • Kellgren-Lawrence Grade >3: arthroscopy for Kellgren-Lawrence Grade 3 or 4 is considered medically necessary only if 1 or more the following criteria are met:
  • Bucket handle tear of meniscus
  • Displaced or unstable symptomatic fragment on MRI
  • History of knee locking
  • Patient with acute traumatic tear with all of the following:
  1. Symptoms developing acutely (as opposed to over 24-48 hours)
  2. Acute difficulty bearing weight and/or acute instability
  3. Moderate to severe swelling/effusion.

Other Knee Ligament Tears with Osteoarthritis (Anterior Cruciate Ligament, Posterior Cruciate Ligament, Medial Collateral Ligament, Lateral Collateral Ligament)

Addition to MCG™:

  • For members aged 50 and older, providers must submit an x-ray report to determine whether or not a member has concomitant knee osteoarthritis. For members under age 50, when there is a history of osteoarthritis, an x-ray report must be submitted and document the Kellgren-Lawrence score (see below for KL grading scale):
  • Kellgren-Lawrence Grade 1 - 3: arthroscopy for Kellgren-Lawrence Grade 1-3 is considered medically necessary if MCG™ criteria are met.
  • Kellgren-Lawrence Grade 4: arthroscopy for Kellgren-Lawrence Grade 4 is considered medically necessary only if 1 or more the following criteria are met:
  • bucket handle tear of meniscus
  • displaced or unstable symptomatic fragment on MRI
  • history of knee locking
  • patient with acute traumatic tear with all of the following:
  1. symptoms developing acutely (as opposed to over 24-48 hours),
  2. acute difficulty bearing weight and/or acute instability
  3. moderate to severe swelling/effusion.

Kellgren-Lawrence Grading Scale

  • Grade 1: Doubtful narrowing of joint space and possible osteophytic lipping
  • Grade 2: Definite osteophytes, definite narrowing of joint space
  • Grade 3: Moderate multiple osteophytes, definite narrowing of joints 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

Note: The MCG™ manuals are proprietary and cannot be published and/or distributed. However, on an individual member basis, the Company can share a copy of the specific criteria used to make a utilization management decision. If you would like a copy of these criteria, you may request a copy of the criteria by calling the Customer Service number on the member’s health plan card.

The Plan reserves the right to review and modify MCG (formerly Milliman Care Guidelines®) or Customized Guidelines at any time.

Description

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Arthroscopic lavage and cartilage debridement are operative treatments for osteoarthritis (OA). Lavage is a procedure in which intra-articular fluid is aspirated and the joint is washed out, removing inflammatory mediators, debris, or small loose bodies from the osteoarthritic knee. Articular debridement involves removal of cartilage or meniscal fragments, but also can include cartilage abrasion, excision of osteophytes and synovectomy. Debridement is intended to improve symptoms and joint function in patients with mechanical symptoms such as locking or catching of the knee.

Osteoarthritis (OA) affects about 21 million people in the United States. (1) By age 65 years, the majority of the population has radiographic evidence of osteoarthritis and 11% have symptomatic OA of the knee.

The presence of clinical symptoms of OA does not always correlate well with the degree of abnormality seen radiographically. It has been noted that approximately 40 percent of patients who have severe findings on x-ray film report no symptoms, and conversely, patients with clinical symptoms may show no significant radiological changes. (1)

Scope

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Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer service representative to determine whether there are any benefit limitations applicable to this service or supply. This medical policy does not apply to Medicare Advantage.

Benefit Application

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N/A

Rationale

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In 2002, Moseley et al. published a randomized placebo-controlled trial (RCT) to evaluate the efficacy of arthroscopy for osteoarthritis (OA) of the knee. (2) 180 patients were randomized to debridement (without abrasion or microfracture), lavage or placebo surgery. Placebo surgery involved a skin incision and simulated debridement without insertion of the arthroscope. Patients and assessors were blinded to treatment group. Neither treatment group reported less pain or better function than the placebo group at any time point over the 2-year follow-up.

A systematic review produced in 2007 for the Agency for Healthcare Research and Quality (AHRQ) by the Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center noted that generalizability of study results was limited by the lack of detail provided regarding the patient sample, the use of a single surgeon, and enrollment of patients at a single Veterans Affairs Medical Center. (1) The report concluded that “the existing evidence does not definitively show that arthroscopic lavage with or without debridement is no more effective than placebo. However, additional placebo-controlled RCTs showing clinically significant advantage for arthroscopy would be necessary to refute the Moseley results, which show equivalence between placebo and arthroscopy.”

A 2008 Cochrane review of arthroscopic debridement for knee OA assessed 3 RCTs, including the study by Moseley et al. and concluded that there is gold-level evidence that arthroscopic debridement has no benefit for undiscriminated OA (mechanical or inflammatory causes). (3) The other 2 studies included in the Cochrane review were of lower methodologic quality and compared arthroscopy with lavage. In one of the reviewed studies Chang et al. compared arthroscopy with closed needle lavage and found no significant between-group differences in pain, self-reported and observed functional status, and patient and physician global assessments. (4) This study was small (32 subjects) with only 3 months of follow-up. The second study was a randomized trial of 76 knees, 40 laparoscopic debridement and 36 washout, with mean follow-up time of 4.5 years and 4.3 years, respectively. (5) At 1 year, 32 of the debridement group and 5 of the washout group were pain-free. At 5 years, 19 of the survivors in the debridement group and 3 of the 26 in the washout group were free of pain. This study was noted by the Cochrane review to be at high risk of bias; specifically, outcome assessors were neither independent nor blinded, and pain was measured as success when absent and failure when present.

An updated systematic review of the evidence for joint lavage for OA of the knee was published by the Cochrane Musculoskeletal Group in May 2010 and was based on the literature to April 2009. (6) This review included 7 trials with 567 patients. The Cochrane review did not include the study described below by Kirkley et al., (7) since that trial focused on debridement. The authors concluded that joint lavage does not result in a benefit for patients with knee OA for pain relief or improvement in function.

In September 2008, Kirkley et al. (7) published a single-center RCT comparing surgical lavage and/or arthroscopic debridement (without abrasion or microfracture) together with optimized physical and medical therapy, or physical and medical therapy alone. Patients with more than 5 degrees of misalignment were excluded. Both men and women were included. Seven experienced arthroscopists performed lavage, debridement, or both at their discretion. Between January 1999 and August 2005, 277 patients were assessed for eligibility; 58 were not eligible (most [38%] because of substantial misalignment) and 31 declined participation. Ninety-two patients were randomly assigned to the surgery arm and 86 were assigned to physical and medical therapy alone. Ten withdrew consent (2 in the surgery and 8 in the control group). Six in the surgery group did not undergo surgery. Data from these patients was included in the intent to treat analysis. The primary outcome was total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score. Secondary outcomes included the Short Form-36 (SF-36) Physical Component Summary score. After 2 years, the mean (SD) WOMAC score for the surgery group was 874 (624) as compared with 897 (583) for the control group (absolute difference [surgery-group score minus control-group score], -23 (605); 95% confidence interval [CI], -208 to 161; P=0.22). The SF-36 Physical Component Summary scores were 37.0 and 37.2, respectively (absolute difference, -0.2; 95% CI, -3.6 to 3.2; P=0.93). Analyses of WOMAC scores at interim visits and other secondary outcomes also failed to show superiority of surgery. Prespecified analyses of subgroups were performed for patients with less severe disease (Kellgren-Lawrence grade 2) at baseline and patients with mechanical symptoms of catching or locking, and no significant difference between treatment groups was found. A post-hoc analysis of patients with more severe radiographic disease (Kellgren-Lawrence grade 3 or 4) also found no benefit of surgery.

In March 2013, Katz et al. (8) published a multicenter, randomized, controlled trial comparing arthroscopic partial meniscectomy surgery and postoperative physical therapy to a standardized physical therapy regimen (with the option to cross over to surgery) for symptomatic patients with a ;meniscal tear and concomitant mild-to-moderate osteoarthritis. They enrolled symptomatic patients 45 years of age or older with a meniscal tear as well as osteoarthritis detected on MRI or x-ray. The primary outcome was the difference between the study groups with respect to the change in the score on the physical-function scale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) from baseline to 6 months after randomization. They found no significant differences in the magnitude of improvement in functional status and pain after 6 and 12 months between patients assigned to arthroscopic partial meniscectomy with postoperative physical therapy and patients assigned to a standardized physical-therapy regimen. At 6 months the WOMAC score was 20.9 points (95% confidence interval [CI], 17.9 to 23.9) in the surgical group and 18.5 (95% CI: 15.6 to 21.5) in the physical-therapy group (mean difference, 2.4 points; 95% CI: -1.8 to 6.5). At 6 months, 51 active participants in the study who were assigned to physical therapy alone (30%) had undergone surgery, and 9 patients assigned to physical therapy alone (30%) had undergone surgery, and 9 patients assigned to surgery (6%) had not undergone surgery. The results at 12 months were similar to those at 6 months.

Practice Guidelines and Position Statements

The Osteoarthritis Research Society International (OARSI) convened 16 experts from primary care, rheumatology, orthopedics, and evidence-based medicine from 6 countries including the United States to develop consensus recommendations for management of hip and knee OA. (9) OARSI concluded that “the roles of joint lavage and arthroscopic debridement are controversial and that, although some studies have demonstrated short-term symptom relief, others suggest that improvement in symptoms could be attributable to a placebo effect.”

Guideline recommendations from the American Academy of Orthopaedic Surgeons (AAOS) clinical practice guideline, “Treatment of Osteoarthritis of the Knee”. 2nd edition, May 2013(10)

RECOMMENDATION 11

  • We cannot suggest that the practitioner use needle lavage for patients with symptomatic osteoarthritis of the knee.
  • Strength of Recommendation: Moderate
  • Description: A Moderate recommendation means that the benefits exceed the potential harm (or that the potential harm clearly exceeds the benefits in the case of a negative recommendation), but the quality/applicability of the supporting evidence is not as strong.

RECOMMENDATION 12

  • We cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.
  • Strength of Recommendation: Strong
  • Description: A strong recommendation means that the quality of the supporting evidence is high. A Harms analysis on this recommendation was not performed.

RECOMMENDATION 13

  • We are unable to recommend for or against arthroscopic partial meniscectomy in patients with osteoarthritis of the knee with a torn meniscus.
  • Strength of Recommendation: Inconclusive
  • Description: An inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.

Centers for Medicare and Medicaid Services Coveraage Position

The Centers for Medicare & Medicaid Services (CMS) determined that the following procedures are not considered reasonable or necessary in treatment of the osteoarthritic knee and are not covered by the Medicare program:

  • Arthroscopic lavage used alone for the osteoarthritic knee;
  • Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,
  • Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritis (Severe osteoarthritis is defined in the Outerbridge classification scale, grades III and IV. Grade I is defined as softening or blistering of joint cartilage. Grade II is defined as fragmentation or fissuring in an area <1 cm. Grade III presents clinically with cartilage fragmentation or fissuring in an area >1 cm. Grade IV refers to cartilage erosion down to the bone. Grades III and IV are characteristic of severe osteoarthritis.)

References

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  1. Samson DJ, Grant MD, Ratko TA, et al. Treatment of Primary and Secondary Osteoarthritis of the Knee. Evidence Report/Technology Assessment No. 157 (Prepared by Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-based Practice Center under Contract No. 290-02-0026). AHRQ Publication No. 07-E012. Rockville, MD: Agency for Healthcare Research and Quality. September 2007. Available online at http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1b.chapter.92496. Accessed May 31, 2013.
  2. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002; 347(2):81-8.
  3. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, et al. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev 2008; (1):CDD005118.
  4. Chang RW, Falconer J, Stulberd SD, et al. A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee. Arthritis Rheum 1993; 36(3):289-96.
  5. Hubbard MJ. Articular debridement versus washout for degeneration of the medial femoral condyle. A five-year study. J Bone Joint Surg Br 1996; 78(2):217-9.
  6. Reichenbach S, Rutjes AW, Nuesch E et al. Joint lavage for osteoarthritis of the knee. Cochrane Database Syst Rev 2010; (5):CD007320.
  7. Kirkley A, Birmingham TB, Litchfield RB, et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2008; 359(11):1097-107.
  8. Katz JN, Brophy RH, Chaissom CE, et al. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. N Engl J Med 2013, 368(18):1675-1684.
  9. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis. Part KK: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16(2):137-62.
  10. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee. 2013, 2nd edition. Available online at: http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf. Last accessed May 31, 2013.
  11. MCG™ - 17th Edition (formerly Milliman Care Guidelines®): Inpatient and Surgical Care – Knee Arthroscopy, ORG: S-705 (ISC). Available online at: http://cgi.careguidelines.com/login-careweb.htm. Last accessed on July 3, 2013.
  12. Englund M, Guermazi A, Gale D, et al. Incidental Meniscal Findings on Knee MRI in Middle-Aged and Elderly Persons. N Eng J Med 2008; 359(11):1108-1115.
  13. Anderson, B. Meniscal Injury of the Knee. Available on-line. UpToDate, Fields, K (Ed), UpToDate®, Waltham, MA, 2013.
  14. Blue Cross and Blue Shield Association. Arthroscopic Debridement and Lavage as Treatment for Osteoarthritis of the Knee. Medical Policy Reference Manual, Policy 7.01.117, 2012.
  15. Reviewed by Board Certified Orthopedic specialists, June 2013.

Coding

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Codes

Number

Description

CPT

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)

 

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 (medical 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 (medical OR lateral)

 

29883

Arthroscopy, knee, surgical; with meniscus repair (medical 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

Type of Service

Surgery

 

Place of Service

Ambulatory, Outpatient surgery

 

Appendix

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N/A

History

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Date

Reason

07/08/13

New policy. Add to Surgery Section. New policy effective December 1, 2013, following a 90-day hold for provider notification.

10/17/13

Update Related Policies. Add policy 1.03.501.

02/24/14

Minor update. Clarification made to policy coverage for members under 50 with a history of osteoarthritis which now requires documentation via x-ray; KL4 score criteria as not medically necessary removed from this patient pool for torn meniscus.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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