BCBSNJ Medical Policy for - (Surgery) Policy Number

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Horizon BCBSNJ
Uniform Medical Policy Manual	Section:	Surgery
	Policy Number:	164
	Effective Date:	02/01/2020

	Original Policy Date:	03/13/2018
	Last Review Date:	02/11/2020
	Date Published to Web:	08/01/2018

Subject:
Arthroscopy for Treatment of Knee Derangement

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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Arthroscopy as a treatment for derangement of the knee is a surgical procedure using a small camera that allows doctors to view the inside of the knee joint without making a large incision through the skin and other soft tissues. Arthroscopy is used to diagnose and treat a wide range of knee problems.

Background: Arthroscopic knee surgery has been performed for many reasons. In recent years, studies have shown the surgery performs no better than physical therapy for members with degenerative knee diseases. However, for other persons with knee pain or injury, the use of arthroscopy may be medically necessary.¹

Policy:
(NOTE:
Effective December 3, 2018, Horizon Blue Cross Blue Shield of New Jersey (“Horizon BCBSNJ”) contracted with TurningPoint Healthcare Solutions, LLC (TurningPoint) to manage our Surgical and Implantable Device Management Program (“the Program”). TurningPoint conducts Prior Authorization and Medical Necessity Determination reviews of certain orthopedic services to be provided to members included in the scope of the Program. The scope of the program includes members enrolled in the Horizon BCBSNJ plans for the effective dates noted below.

For services rendered December 3, 2018 and after, the Program includes members enrolled in Horizon BCBSNJ Fully Insured plans.

For services rendered July 15, 2019 and after, the Program includes members enrolled in Horizon BCBSNJ Medicare Advantage plans.

For services to be rendered January 20, 2020 and after, the Program will also include members enrolled in New Jersey State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans.

Please note that this policy’s criteria and guidelines only apply to members enrolled in plans that DO NOT participate in the Program. Visit our TurningPoint webpage for instructions on accessing the policy criteria and guidelines that TurningPoint will follow as they conduct PA/MND reviews as part of the Program. You may also call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., Eastern Time to request policy content.

(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)

1. Due to lack of sufficient evidence to establish safety and efficacy, in-office needle arthroscopy (IONA) is considered investigational

2. For arthroscopic knee surgery to be medically indicated, all of the following are required:
§ ALL of the following conservative measures (unless contraindicated) are attempted:

§ Use of assistive supports such as cane, walker, crutches

§ Weight Considerations:

§ Age less than 50 unless recent imaging shows absence of osteoarthritis
§ Imaging

§ Patient does NOT have one of the following:

(

NOTE

Also refer to a separate policy on 'Arthroscopic Debridement and Lavage as Treatment for Osteoarthritis of the Knee' - Policy #093 in the Surgery Section.)

NOTE: Documentation of the following required prior to approval:

And 1 or more of the following (adapted from MCG guidelines² ):
· Evaluation or treatment for intra-articular joint pathology indicated by 1 or more of the following:

ALL

· Treatment of osteochondral defect (e.g., osteochondritis dissecans) as indicated by ALL of the following:

1 or more

· Treatment of torn meniscus as indicated by ALL of the following:

1 or more

· Treatment or reconstruction of ACL as indicated by ALL of the following:

1 or more

· Treatment or reconstruction of posterior cruciate ligament tear as indicated by ALL of the following:

1 or more

· Repair or reconstruction of medial collateral ligament injury indicated by 1 or more of the following:

· Excision of popliteal (Baker) cyst indicated by ALL of the following:

· Synovectomy indicated to treat 1 or more of the following:

· Debridement, drainage, or lavage needed for 1 or more of the following:

ALL

· Lateral retinacular release for patellar compression syndrome indicated by 1 or more of the following:

· Articular cartilage lesion and ALL of the following:

· Arthroscopic-assisted fracture reduction

Medicare Coverage:
Medicare Advantage differs from the Horizon BCBSNJ Medical Policy regarding arthroscopic knee debridement, drainage, or lavage in individuals without severe osteoarthritis of the knee who present with symptoms other than pain alone; i.e., (1) mechanical symptoms that include, but are not limited to, locking, snapping, or popping (2) limb and knee joint alignment, and (3) less severe and/or early degenerative arthritis remain at local contractor discretion. Submission of one or all of the following documents is required to define the individual’s knee condition:
• Operative notes,
• Reports of standing x-rays, or,
• Arthroscopy results.

Per NCD 150.9, the clinical effectiveness of arthroscopic lavage and arthroscopic debridement for the severe osteoarthritic knee has not been verified by scientifically controlled studies. The following procedures are not considered reasonable or necessary in treatment of the osteoarthritic knee and are not covered:
• 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. Outerbridge is the most commonly used clinical scale that classifies the severity of joint degeneration of the knee by compartments and grades. 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.)

For additional information and eligibility, refer to National Coverage Determination (NCD) for Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (150.9). Available at: https://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=285&ncdver=1&bc=AAAAQAAAAAAA&

Medicaid Coverage:

For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.

[RATIONALE: The causes of pain in the knee joint are many. They can be due to acute injury or unknown etiology. Effusion may or may not be present. Studies have been done showing that in many cases, improvement will occur with non-surgical means.

For children/teens, According to Up to Date (accessed Feb 2018), [b]ased upon observational studies, the most common indications for arthroscopy in children with acute knee injuries include ACL tears, meniscal lesions, osteochondral fractures, and tibial intercondylar eminence fractures. Arthroscopy is the most accurate method of diagnosing the cause of internal derangement in patients with a knee effusion. False-positive results are rare, and with the exception of posterior meniscus injuries, false-negative results are also rare. Arthroscopy is used selectively, as an adjunct to the history, physical examination, and MRI when there is a diagnostic dilemma. The only absolute indication for arthroscopy is mechanical disruption of normal knee function. (bolding added)³

In adults, arthroscopy should generally occur after conservative measures have failed. Even for meniscal repairs, arthroscopy is not always necessary. According to Up to Date (Feb 2018) The long-term outcome of patients with meniscal tears varies according to the type of tear and the underlying condition of the knee. The prognosis is good for patients with tears amenable to nonsurgical management. Among patients treated surgically, younger patients with isolated tears generally do well. According to a retrospective review of 362 medial and 109 lateral isolated arthroscopic meniscectomies, factors associated with a favorable prognosis include: age less than 35 years, a vertical tear, no cartilage damage, and an intact meniscal rim upon completion of the procedure .
Degenerative tears appear to be associated with a worse prognosis. In a small retrospective study of patients over 50 who underwent arthroscopic meniscectomy, 90 percent of those with nondegenerative tears (i.e., acute meniscal injury) had good results at six year follow-up, compared with only 20 percent of patients with degenerative tears (i.e., chronic meniscal injury).

Depending upon the type and extent, meniscal injury may predispose patients to the development of osteoarthritis over the long term. Meniscus repair leads to higher rates of return to sport and a lower long-term risk of osteoarthritis compared to partial meniscectomy.]⁴

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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Arthroscopy for Treatment of Knee Derangement
Arthroscopy, Knee
Knee Surgery, Arthroscopy
Knee Arthroscopy

References:
1. Siemieniuk, R. A. C., et al. (2017). "Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline." BMJ 357: j1982.

2. Milliman Care Guidelines 21^st edition (2017) Knee Arthroscopy

3. Hergenroeder AC. Approach to acute knee pain and injury in children and skeletally immature adolescents. In: UpToDate, Wiley JF (Ed), UpToDate, Waltham, MA. (Accessed on February 9, 2018.)

4. Cardone DA, Jacobs BC. Meniscal injury of the knee. In: UpToDate, Grayzel J (Ed), UpToDate, Waltham, MA. (Accessed on February 9, 2018.)

5. Zhang K, Crum RJ, Samuelsson K, Cadet E, Ayeni OR, de Sa D. In-Office Needle Arthroscopy: A Systematic Review of Indications and Clinical Utility. Arthroscopy. 2019 Sep;35(9):2709-2721.

6. Gill TJ, Safran M, Mandelbaum B, Huber B, Gambardella R, Xerogeanes J. A Prospective, Blinded, Multicenter Clinical Trial to Compare the Efficacy, Accuracy, and Safety of In-Office Diagnostic Arthroscopy With Magnetic Resonance Imaging and Surgical Diagnostic Arthroscopy. Arthroscopy. 2018 Aug;34(8):2429-2435. doi: 10.1016/j.arthro.2018.03.010

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

29870

HCPCS
G0289

* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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