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Knee Arthroscopy in Adults

Number 7.01.549

Effective Date March 10, 2015

Revision Date(s) 03/10/15; 12/22/14; 08/11/14; 02/10/14

Replaces N/A

Policy

 

Note: This policy only applies to those aged 18 and over.

Knee arthroscopy may be considered medically necessary when specific criteria are met.

Policy Coverage Topic Listing:

Meniscus Tear without Osteoarthritis

Meniscus Tear with Osteoarthritis

Anterior Cruciate Ligament Tear without Osteoarthritis

Anterior Cruciate Ligament Tear with Osteoarthritis

Posterior Cruciate Ligament Tear without Osteoarthritis

Posterior Cruciate Ligament Tear with Osteoarthritis

Arthroscopic debridement, drainage, or lavage

Intra-Articular Joint Pathology

Osteochondral Defect

Patellar Compression Syndrome

Popliteal (Baker) Cyst

Synovial Disorders

Meniscus Tear without Osteoarthritis

Knee arthroscopy for repair of meniscus tear may be considered medically necessary when all of the following are met:

  • Evidence of torn meniscus, including at least one of the following:
  • Positive McMurray test, OR
  • Positive Apley test, OR
  • Joint line tenderness with palpation, OR
  • MRI demonstrates torn meniscus
  • Repair indicated by one or more of the following:
  • Functional impairment (e.g., knee locking, giving way, or decreased range of motion)
  • Symptoms have not responded to 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).
  • A medically necessary ACL repair has been approved.

Meniscus Tear with Osteoarthritis

Knee arthroscopy for knee osteoarthritis with concomitant meniscal tear may be considered medically necessary for members:

Age 50 and over when:

  • X-ray report documents a Kellgren-Lawrence (KL) grade 1 or 2, and all of the following (see Policy Guidelines for KL grading scale):
  • Evidence of one of the following:
  • Positive McMurray test, OR
  • Positive Apley test, OR
  • Joint line tenderness with palpation, OR
  • MRI demonstrates torn meniscus
  • Repair indicated by one or more of the following:
  • Functional impairment (e.g., knee locking, giving way, or decreased range of motion)
  • Symptoms have not responded to 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).
  • A medically necessary ACL repair has been approved.
  • X-ray report documents a KL grade >3 and one of the following are met(see Policy Guidelines for KL grading scale):
  • 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:
  • Symptoms developing acutely (as opposed to over 24-48 hours)
  • Acute difficulty bearing weight and/or acute instability
  • Moderate to severe swelling/effusion.

Under age 50 with a history of osteoarthritis when:

  • X-ray report documents a Kellgren-Lawrence (KL) grade 1 or 2, and all of the following (see Policy Guidelines for KL grading scale):
  • Positive McMurray test, OR
  • Positive Apley test, OR
  • Joint line tenderness with palpation, OR
  • MRI demonstrates torn meniscus
  • Repair indicated by one or more of the following:
  • Functional impairment (e.g., knee locking, giving way, or decreased range of motion)
  • Symptoms have not responded to 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).
  • A medically necessary ACL repair has been approved.
  • X-ray report documents a KL grade >3 and one of the following 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:
  • Symptoms developing acutely (as opposed to over 24-48 hours)
  • Acute difficulty bearing weight and/or acute instability
  • Moderate to severe swelling/effusion.

Anterior Cruciate Ligament Tear without Osteoarthritis

Knee arthroscopy for repair of anterior cruciate ligament tear (ACL) when all of the following criteria are met:

  • Evidence of torn ACL on exam or imaging as shown by one of the following:
  • Positive anterior drawer sign (laxity with anterior stress to knee)
  • Positive pivot shift test
  • Positive Lachman test
  • MRI demonstrates ACL tear
  • Repair indicated by one or more of the following:
  • ACL tear coincident with injury of other major ligament, including one or more of the following:
  • Medial collateral ligament
  • Posterior collateral ligament
  • Posterior cruciate ligament
  • Posterolateral ligamentous corner
  • Persistent instability despite 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).

Anterior Cruciate Ligament Tear with Osteoarthritis

Knee arthroscopy for anterior cruciate ligament tear with osteoarthritis may be considered medically necessary for members:

Age 50 and over when:

  • X-ray report documents Kellgren-Lawrence grade 1-3 osteoarthritis, AND both of the following:
  • Evidence of torn ACL on exam or imaging as shown by one of the following:
  • Positive anterior drawer sign (laxity with anterior stress to knee)
  • Positive pivot shift test
  • Positive Lachman test
  • MRI demonstrates ACL tear
  • Repair indicated by one of the following:
  • ACL tear coincident with injury of other major ligament, including one or more of the following:
  1. Medial collateral ligament
  2. Posterior collateral ligament
  3. Posterior cruciate ligament
  4. Posterolateral ligamentous corner
  • Persistent instability despite 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).

OR

  • X-ray report documents Kellgren-Lawrence Grade 4 and one of the following 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:
  • Symptoms developing acutely (as opposed to over 24-48 hours),
  • Acute difficulty bearing weight and/or acute instability
  • Moderate to severe swelling/effusion.

Under age 50 with a history of osteoarthritis when:

  • X-ray report documents Kellgren-Lawrence grade 1-3 osteoarthritis, AND both of the following:
  • Evidence of torn ACL on exam or imaging as shown by one of the following:
  • Positive anterior drawer sign (laxity with anterior stress to knee)
  • Positive pivot shift test
  • Positive Lachman test
  • MRI demonstrates ACL tear
  • Repair indicated by one of the following:
  • ACL tear coincident with injury of other major ligament, including one or more of the following:
  1. Medial collateral ligament
  2. Posterior collateral ligament
  3. Posterior cruciate ligament
  4. Posterolateral ligamentous corner
  • Persistent instability despite 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).

OR

  • X-ray report documents Kellgren-Lawrence Grade 4 and one of the following 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:
  • Symptoms developing acutely (as opposed to over 24-48 hours),
  • Acute difficulty bearing weight and/or acute instability
  • Moderate to severe swelling/effusion.

Posterior Cruciate Ligament Tear without Osteoarthritis

Knee arthroscopy for repair or reconstruction of posterior cruciate ligament tear when all of the following criteria are met:

  • Evidence of torn PCL with at least one of the following:
  • Positive posterior drawer sign for laxity of the PCL
  • Positive reversed pivot shift test
  • Positive posterior sag sign
  • Diagnostic imaging demonstrates PCL tear
  • PCL tear occurred with other injuries, such as injury to the posterolateral corner of the knee, medial collateral ligament tear, ACL tear, avulsion fracture of fibular head or avulsion of the tibia distal to the lateral plateau

Posterior Cruciate Ligament Tear with Osteoarthritis

Knee arthroscopy for repair or reconstruction of posterior cruciate ligament tear with knee osteoarthritis may be considered medically necessary for members:

Age 50 and over when:

  • X-ray report documents Kellgren-Lawrence grade 1-3 osteoarthritis, AND
  • Evidence of torn PCL with at least one of the following:
  • Positive posterior drawer sign for laxity of the PCL
  • Positive reversed pivot shift test
  • Positive posterior sag sign
  • Diagnostic imaging demonstrates PCL tear
  • PCL tear occurred with other injuries, such as injury to the posterolateral corner of the knee, medial collateral ligament tear, ACL tear, avulsion fracture of fibular head or avulsion of the tibia distal to the lateral plateau

OR

  • X-ray report documents Kellgren-Lawrence Grade 4 and one of the following 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:
  • Symptoms developing acutely (as opposed to over 24-48 hours),
  • Acute difficulty bearing weight and/or acute instability
  • Moderate to severe swelling/effusion.

Under age 50 with a history of osteoarthritis when:

  • X-ray report documents Kellgren-Lawrence grade 1-3 osteoarthritis, AND
  • Evidence of torn PCL with at least one of the following:
  • Positive posterior drawer sign for laxity of the PCL
  • Positive reversed pivot shift test
  • Positive posterior sag sign
  • Diagnostic imaging demonstrates PCL tear
  • PCL tear occurred with other injuries, such as injury to the posterolateral corner of the knee, medial collateral ligament tear, ACL tear, avulsion fracture of fibular head or avulsion of the tibia distal to the lateral plateau

OR

  • X-ray report documents Kellgren-Lawrence Grade 4 and one of the following 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:
  • Symptoms developing acutely (as opposed to over 24-48 hours),
  • Acute difficulty bearing weight and/or acute instability
  • Moderate to severe swelling/effusion.

Arthroscopic debridement, drainage, or lavage

Arthroscopic debridement, drainage, or lavage of the knee may be considered medically necessary when one of the following are present:

  • Rheumatoid arthritis
  • Septic joint or osteomyelitis
  • Septic prosthetic joint
  • Arthrofibrosis (e.g. after anterior cruciate ligament repair or total knee arthroplasty) as indicated by all of the following:
  • Loss of range of motion
  • Nonoperative care (e.g. physical therapy) has been tried and failed.

Arthroscopic debridement, drainage and/or lavage for the treatment of osteoarthritis of the knee is considered not medically necessary, except when specifically noted.

Intra-Articular Joint Pathology

Knee arthroscopy for evaluation or treatment of intra-articular joint pathology may be considered medically necessary when any of the following criteria are met:

  • Mechanical symptoms, which includes locking, catching, and giving way
  • Loose or foreign body, demonstrated on imaging studies
  • Symptomatic torn plica
  • Symptomatic intact plica that has not responded to 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).
  • Chronic knee pain, effusion, or instability and all of the following:
  • Unknown etiology, AND
  • Imaging studies are nondiagnostic, AND
  • Diagnostic arthrocentesis with synovial fluid analysis was nondiagnostic or not indicated, AND
  • Other etiologies of knee pain or arthritis have been ruled out, AND
  • Symptoms have not responded to 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).

Osteochondral Defect

Knee arthroscopy for REPAIR OF OSTEOCHONDRAL DEFECT, including osteochondritis dissecans may be considered medically necessary when all of the following criteria are met:

  • Osteochondral defect is demonstrated on imaging studies, AND
  • One of the following clinical conditions is present:
  • Displaced osteochondral lesion
  • Presence of loose body
  • Nondisplaced osteochondral lesion in adult

Patellar Compression Syndrome

Knee arthroscopy for LATERAL RETINACULAR RELEASE FOR PATELLAR COMPRESSION SYNDROME may be considered medically necessary when one of the following criteria are met:

  • Positive patella glide test
  • Positive patella tilt test
  • Articular cartilage lesion and ALL of the following:
  • Symptoms attributed to chondral injury
  • Demonstrated cartilage defect on MRI or imaging
  • Symptoms have not responded to 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).

Popliteal (Baker) Cyst

Knee arthroscopy for EXCISION OF POPLITEAL (BAKER) CYST may be considered medically necessary when all of the following criteria are met:

  • Visible or palpable bulge in popliteal fossa on clinical exam, or diagnostic imaging demonstrates presence of the cyst, AND
  • Symptoms have not responded to 8 weeks of conservative care (e.g., physical therapy, activity modification, oral analgesics).

Synovial Disorders

Knee arthroscopy for synovectomy may be considered medically necessary when one of the following criteria are met:

  • Rheumatoid arthritis, OR
  • Hemophilic joint disease, OR
  • Localized pigmented villonodular synovitis, OR
  • Other chronic inflammatory conditions (e.g., antibiotic-resistant Lyme arthritis).

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

7.01.550

Knee Arthroplasty

Policy Guidelines

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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

Description

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Knee arthroscopy is a surgical procedure performed through small incisions. During the procedure, the surgeon inserts an arthroscope into the knee joint. The arthroscope sends the image to a monitor so the structures of the knee can be observed in great detail. The arthroscope is used to feel, repair or remove damaged tissue. To do this, small surgical instruments are inserted through separate incisions around the knee.

Knee arthroscopy is most commonly used for: removal or repair of torn meniscal cartilage, reconstruction of a torn anterior cruciate ligament, and trimming of torn pieces of articular cartilage, removal of loose fragments of bone or cartilage, and removal of inflamed synovial tissue.

This policy addresses knee arthroscopy in the adult population only, age greater than 18.

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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Intra-articular Joint Pathology

Synovial plicae are membranous inward folds of the synovial lining of the knee joint capsula. Such folds are regularly found in the human knee, but most are asymptomatic and of little clinical consequence. However, they can become symptomatic and cause knee pain. Medial plica irritation of the knee is a common source of anterior knee pain. The main complaint is an intermittent, dull, aching pain in the area medial to the patella above the joint line and in the supramedial patellar area. Pain increases with activity, especially when knee flexion and extension are required. Treatment includes physiotherapy, reducing activity, and rest. In cases that do not respond initially to an exercise program, corticosteroid injections and non-steroidal antiinflammatory medication are given. Results of conservative treatment seem to be more appropriate in young patients with a short duration of symptoms. If conservative treatment fails, surgical treatment using arthroscopy is appropriate. During arthroscopy, excision of the whole plica should be achieved.(2)

Osteochondral Dissecans

Juvenile osteochondritis dissecans (JOCD) has been a recognized entity for more than 100 years. Despite long recognition of OCD, the natural history and most effective therapies are poorly understood. Although conclusive evidence of an exact cause is lacking, there is widespread agreement that JOCD is related to repetitive trauma. Patients with JOCD present with vague pain and occasionally, mechanical symptoms. The diagnosis of JOCD can be confirmed on plain radiographs. Magnetic resonance imaging has emerged as the study of choice to evaluate the stability of the lesion and integrity of the overlying articular cartilage. Treatment decisions are based on the stability of the lesion. Stable JOCD lesions should be treated initially with activity modification and possibly, immobilization. Unstable lesions and stable lesions not responding to an initial course of nonoperative therapy should be surgically treated. Surgical treatment is based on the radiographic and arthroscopic characteristics of the lesion. Multiple techniques from simple arthroscopic drilling and fixation to salvage techniques for cartilage restoration are discussed in this review. (3)

Torn Meniscus

The menisci have an essential function in force transmission across the knee. Injuries to the menisci are common. The indications for repair should be expanded, as the results of partial meniscectomy may deteriorate over time. Tears in younger, higher demand patients should be prepared to optimize the healing environment and be meticulously repaired, particularly in the setting of concurrent anterior cruciate ligament reconstruction. Partial meniscectomy is a suitable option for lower demand or older patients.(4)

Torn Ligaments

The multiple ligament-injured knee is a complex problem in orthopedic surgery. These injuries may or may not present as acute knee dislocations, and careful assessment of the extremity vascular and neurologic status is essential because of the possibility of arterial and/or venous compromise, and nerve injury. These complex injuries require a systematic approach to evaluation and treatment. Physical examination and imaging studies enable the surgeon to make a correct diagnosis and formulate a treatment plan. Knee stability is improved postoperatively when evaluated with knee ligament rating scales, arthrometer testing, and stress radiographic analysis. Surgical timing depends on the injured ligaments, vascular status of the extremity, reduction stability, and the overall health of the patient. The use of allograft tissue is preferred because of the strength of these large grafts, and the absence of donor site morbidity.(5)

The optimal treatment of posterior cruciate ligament ruptures remains controversial despite numerous recent basic science advances on the topic. The current literature on the anatomy, biomechanics, and clinical outcomes of posterior cruciate ligament reconstruction is reviewed. Recent studies have quantified the anatomic location and biomechanical contribution of each of the 2 posterior cruciate ligament bundles on tunnel placement and knee kinematics during reconstruction. Additional laboratory and cadaveric studies have suggested double-bundle reconstructions of the posterior cruciate ligament may better restore normal knee kinematics than single-bundle reconstructions although clinical outcomes have not revealed such a difference. Tibial inlay posterior cruciate ligament reconstructions (either open or arthroscopic) are preferred by many authors to avoid the "killer turn" and graft laxity with cyclic loading. Posterior cruciate ligament reconstruction improves subjective patient outcomes and return to sport although stability and knee kinematics may not return to normal.(6)

Popliteal (Baker) Cyst

Popliteal (Baker) cysts, meniscal cysts, proximal tibiofibular joint cysts, and cruciate ligament ganglion cysts are cystic masses commonly found about the knee. Popliteal cysts form when a bursa swells with synovial fluid, with or without a clear inciting etiology. Presentation ranges from asymptomatic to painful, limited knee motion. Management varies based on symptomatology and etiology. Meniscal cysts form within or adjacent to the menisci. These collections of synovial fluid are thought to develop from translocation of synovial cells or extravasation of synovial fluid into the meniscus through a tear. Joint-line pain and swelling are common symptoms. Management entails partial meniscectomy with cyst decompression or excision. Proximal tibiofibular joint cysts are rare, and their etiology remains unclear. Pain and swelling secondary to local tissue invasion is common, and management consists of surgical excision. Cruciate ligament ganglion cysts have no clear etiology but are associated with mucoid degeneration of the anterior and posterior cruciate ligaments, knee trauma, and synovial translocation into these ligaments. Knee pain and limited range of motion, especially with exercise, are common presenting symptoms. In symptomatic cases, arthroscopic excision is commonly performed. (7)

Synovial Disorders

Collectively, benign synovial disorders are not uncommon, and they may be seen in general orthopaedic practices. Symptoms are nonspecific, often delaying diagnosis. In fact, synovial chondromatosis, pigmented villonodular synovitis, synovial hemangioma, and lipoma arborescens often mimic each other as well as other, more common joint disorders in presentation, making diagnosis extremely difficult. It is important to diagnose these disorders correctly in order to provide appropriate treatment and avoid secondary sequelae, such as bone erosion and cartilage degeneration.(8)

Patellar Compression Syndrome

Authors have described the use of an isolated lateral retinacular release for the treatment of patellar instability. This review analyzes the published long-term results of this procedure for the treatment of patellar instability. The isolated use of a lateral retinacular release of the patella has not proven to be of long-term benefit for the treatment of patellar instability. It may be used as an adjunct procedure to a proximal or distal realignment of the extensor mechanism. Various pitfalls of a lateral release for patellar instability are discussed.(9)

Osteoarthritis

In 2002, Moseley et al. published a randomized placebo-controlled trial (RCT) to evaluate the efficacy of arthroscopy for osteoarthritis (OA) of the knee. (11) 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. (10) 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). (12) 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. (13) 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. (14) 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. (15) This review included 7 trials with 567 patients. The Cochrane review did not include the study described below by Kirkley et al., (16) 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. (17) 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. (18) 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. 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 (19)

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.

The American Association of Orthopaedic Surgeons’ clinical practice guideline on the management of anterior cruciate ligament injuries (AAOS, 2014) concluded there is limited evidence in patients with combined ACL tears and reparable meniscus tears, but it supports that the practitioner might repair these meniscus tears when combined with ACL reconstruction because it improves patient outcomes.

Centers for Medicare and Medicaid Services Coverage 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. Sznajderman T, Smorgick Y, Lindner D, Beer Y, Agar G. Medial plica syndrome. Israel Medical Association Journal 2009;11(1):54-7.
  2. Polousky JD. Juvenile osteochondritis dissecans. Sports Medicine and Arthroscopy Review 2011;19(1):56-63.
  3. Shybut T, Strauss EJ. Surgical management of meniscal tears. Bulletin of the NYU Hospital for Joint Diseases 2011;69(1):56-62.
  4. Fanelli GC, Beck JD, Edson CJ. Combined PCL-ACL lateral and medial side injuries: treatment and results. Sports Medicine and Arthroscopy Review 2011;19(2):120-30.
  5. Voos JE, Mauro CS, Wente T, Warren RF, Wickiewicz TL. Posterior cruciate ligament: anatomy, biomechanics, and outcomes. American Journal of Sports Medicine 2012;40(1):222-31.
  6. Stein D, Cantlon M, MacKay B, Heolscher C. Cysts about the knee: evaluation and management. J Am Acad Orthop Surg 2013 Aug; 21(8):469-79.
  7. Adelani MA, Wupperman RM, Holt GE. Benign synovial disorders. Journal of the American Academy of Orthopedic Surgeons 2008;16(5):268-75.
  8. Lattermann C, Toth J, Bach BR. The role of lateral retinacular release in the treatment of patellar instability. Sports Medicine and Arthroscopy Review 2007;15(2):57-60.
  9. 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/nlmcatalog/?term=Treatment%20of%20Primary%20and%20Secondary%20Osteoarthritis%20of%20the%20Knee.%20Evidence%20Report/Technology%20Assessment%20No.%20157. Accessed Dece,ber 18, 2014.
  10. 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.
  11. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, et al. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev 2008; (1):CDD005118.
  12. 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.
  13. 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.
  14. Reichenbach S, Rutjes AW, Nuesch E et al. Joint lavage for osteoarthritis of the knee. Cochrane Database Syst Rev 2010; (5):CD007320.
  15. 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.
  16. 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.
  17. 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.
  18. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee. 2013, 2nd edition. Available online at: http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdfLast accessed December 19, 2014.
  19. 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.
  20. Anderson, B. Meniscal Injury of the Knee. Available on-line. UpToDate, Fields, K (Ed), UpToDateĀ®, Waltham, MA, 2013.
  21. American Academy of Orthopaedic Surgeons (AAOS). Clinical practice guideline on management of anterior cruciate ligament injuries. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2014 Sep 5. Available at: http://www.aaos.org/Research/guidelines/ACLGuidelineFINAL.pdf
  22. 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, 2014.
  23. 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

[TOP]

Date

Reason

07/08/13

New policy. Add to Surgery Section. New policy effective December 1, 2013, follows 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.

07/14/14

Policy rewrite. Removed the word “adults” from title. Added criteria and rationale for intra-articular joint pathology, osteochondral dissecans, meniscus repair, ligament repair, popliteal cysts, synovectomy debridement, drainage and lavage. References 2-9 added.

08/11/14

Interim review. Minor update. Re-ordered policy statements and removed information on medial collateral ligament and lateral collateral ligaments.

09/17/14

Update Related Policies. Add 7.01.550.

12/22/14

Interim update. Removed reference #1.

02/10/15

Annual Review. Statements added indicating a meniscus tear may be repaired at the same time as an ACL repair when the ACL meets medically necessity criteria. Removed all policy statements for pediatric and adolescent. Added Adult to title. Reference 21 added.

03/24/15

Minor update. Add link for ACL with osteoarthritis to the navigational links for policy coverage topics.

03/30/15

Clarification only: “Over age 50” replaced throughout the policy statement with “age 50 and older”.


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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