Subject:
Ultrasonic Guidance for Knee Joint Injection or Aspiration
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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The use of ultrasonic guidance for injection into the knee joint is becoming more common. However, at this time, this has not been shown to improve clinical outcomes.
Related Policies
- Sodium Hyaluronate Injections (Policy #015 in the Treatment Section)
Policy:
(NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)
A. The use of ultrasonic guidance for injection into the knee joint is medically necessary when:
1. The failure of the initial attempt at the knee joint injection where the provider is unable to aspirate any fluid;
2. The size of the member's knee (due to morbid obesity or disease process) leading to difficulty palpating physiological landmarks in order to accurately inject/aspirate the knee without ultrasonic guidance;
3. Draining a popliteal (Baker's) cyst.
B. The use of ultrasonic guidance for injection into the knee joint in any other circumstances is not considered medically necessary.
Medicare Coverage:
Per NCD 220.5, uses for ultrasound diagnostic procedures not listed in Category I or II of NCD 220.5 are left to local MAC discretion. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for ultrasonic guidance for injection into the knee joint. However, per Local Coverage Determination L35427, ultrasound imaging procedures may be considered reasonable and necessary for the purpose of needle guidance for viscosupplementation injection. If needle guidance is utilized, the documentation must support that the presentation of the individual’s affected knee on the day of the procedure makes needle insertion problematic. In addition, if the injection is noncovered, then any associated procedure code(s) (e.g., intra-articular injection, fluoroscopy, ultrasound) would be considered not medically reasonable and necessary. For additional information, refer to National Coverage Determination (NCD) for Ultrasound Diagnostic Procedures (220.5). Available to be accessed at CMS National Coverage Determinations (NCDs) Alphabetical Index search page: https://www.cms.gov/medicare-coverage-database/indexes/ncd-alphabetical-index.aspx. and Local Coverage Determination (LCD): Hyaluronan Acid Therapies for Osteoarthritis of the Knee (L35427). Available to be accessed at Novitas Solutions, Inc., Medical Policy Search page: https://www.novitas-solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00024370
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.
[INFORMATIONAL NOTE: Various studies have documented that the use of ultrasonic guidance has become more common. Early studies document that this improves accuracy of needle placement, but there are not a sufficient number of studies that show they improve patient outcomes.
Official Disability Guidelines (ODG) do not recommend the use of ultrasonic guidance for the knee except for the circumstances noted above.
A clinical trial, Ultrasound Guided Knee Injections in Musculoskeletal Medicine has completed to determine whether the use of ultrasound improves accuracy and patient outcomes. No publications found at this time regarding the trial; posted results indicate that there is no significant difference in member results with guidance vs no guidance.
| NCT No. | Trial Name | Planned Enrollment | Completion Date |
| NCT03293238 | Ultrasound Guided Knee Injections in Musculoskeletal Medicine (PRISMM) | 120
*63 actual enrollment* | February 2018 |
]
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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:
Ultrasonic Guidance for Knee Joint Injection or Aspiration
Ultrasonic Guidance for Large Joint Injection or Aspiration
Joint Injection, Ultrasonic Guidance
Large Joint injection, Knee, Ultrasonic Guidance
Knee Injection, Ultrasonic Guidance
Joint Aspiration, Knee, Ultrasonic Guidance
Aspiration, Knee, Ultrasonic Guidance
Arthrocentesis, Knee, Ultrasonic Guidance
References:
1. ClinicalTrials.gov NCT03293238 Ultrasound Guided Knee Injections in Musculoskeletal Medicine.
2. Official Disability Guidelines (ODG-MDG) ODG-TWG Knee and Leg (accessed 12/3/2018)
3. Daniels EW, Cole D, Jacobs B, Phillips SF. Existing Evidence on Ultrasound-Guided Injections in Sports Medicine. Orthop J Sports Med. 2018 Feb; 6(2): 2325967118756576. Published online 2018 Feb 22. doi: [10.1177/2325967118756576]
4. Wu T, Dong Y, Song Hx, Fu Y, Li JH. Ultrasound-guided versus landmark in knee arthrocentesis: A systematic review. Semin Arthritis Rheum. 2016 Apr;45(5):627-32. doi: 10.1016/j.semarthrit.2015.10.011. Epub 2015 Dec 17.
5. Bookman JS, Pereira DS. Ultrasound guidance for intra-articular knee and shoulder injections: a review. Bull Hosp Jt Dis (2013). 2014;72(4):266-70.
6. Lueders DR, Smith J, Sellon JL. Ultrasound-Guided Knee Procedures. Phys Med Rehabil Clin N Am. 2016 Aug;27(3):631-48. doi: 10.1016/j.pmr.2016.04.010.
7. Bruyn GAW. Musculoskeletal ultrasonography: Guided injection and aspiration of joints and related structures. In UpToDate. Shmerling RH, Curtis MR (eds.) UpToDate, Waltham, MA. (Accessed on December 7, 2018.)
8. Bruyn GAW. Musculoskeletal ultrasonography: Guided injection and aspiration of joints and related structures. In UpToDate. Shmerling RH, Curtis MR (eds.) UpToDate, Waltham, MA. (Accessed on January 14, 2020.)
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*
* 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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