Musculoskeletal Surgery: Arthroplasty Form

Health New England Commercial Clinical Policy

Effective Date

Last Reviewed

Original Document

Reference

Musculoskeletal Surgery: Arthroplasty - Medical Policy
Updated Revision Effective: January 1, 2025 Policy Number:

UM405POL

Approval Date: 6/18/24

Line(s) of Business:

Commercial
Medicare Advantage
Medicaid (BeHealthy)

Description

Introduction

Joint replacement, also known as arthroplasty, is a surgical procedure in which parts of an arthritic or damaged joint are removed and replaced with a metal, plastic, or ceramic device called a prosthesis. The prosthesis is designed to replicate the movement of a normal, healthy joint. Hip and knee replacements are the most commonly performed joint replacements, but replacement surgery can be performed on other joints, as well, including the ankle, wrist, shoulder, and elbow.

Shoulder Arthroplasty

The replacement of the glenohumeral joint is called a shoulder arthroplasty. It can be either a total shoulder arthroplasty (TSA), where both the glenoid and humerus are replaced, a partial arthroplasty of the humerus only (hemiarthroplasty [HA]), or a partial resurfacing of the humerus (humeral head resurfacing [HHR, HR]). In general, these arthroplasty procedures are reserved for end stage arthritis of the shoulder joint, including functional loss of motion, pain, and disability. The choice of arthroplasty is dependent upon surgeon philosophy, experience, and skill. Successful outcome, regardless of procedure, is more likely with high volume (> 20 per year) shoulder specialists. Revision shoulder arthroplasty is most commonly required because of technical problems encountered at the time of surgery, such as insertion of the wrong size components, improper technique, and poor surgical exposure.

Reverse Total Shoulder Arthroplasty (RTSA) involves placing the ball on the glenoid side (glenosphere and baseplate) of the joint and the socket on the humeral side. It works by moving the center of joint rotation medial and downward and increasing deltoid tension to facilitate active abduction and elevation of the arm. The original purpose of a RTSA was to allow basic function of a pseudoparalytic shoulder from a non-repairable chronic rotator cuff tear with arthropathy (or arthritis) in an inactive person over age 65. Complication rates have steadily decreased as surgeons become more familiar with this procedure and technical advances have

been made. Indications have expanded to include younger individuals, malunions, nonunions, failed arthroplasty, and irreparable cuff tears.

Hip Arthroplasty

Arthritis is the most common cause of chronic hip pain and disability. Degenerative, age-related osteoarthritis causes cartilage to wear away and eventually the bones within the joint rub against each other causing pain and stiffness. In a total hip replacement, the femoral head and acetabulum are removed and replaced with prosthetic components. In hip resurfacing arthroplasty, a metal cup is placed in the acetabulum and a metal cap is placed over the head of the femur with limited removal of the femoral head and neck. In some cases, the hip prosthesis may wear out or loosen. If loosening is painful, a second surgery, such as a revision or conversion may be necessary. In this procedure some or all of the components of the original replacement prosthesis are removed and replaced with new ones. Hemiarthroplasty or partial hip replacement involves the reconstruction of the femoral head but not the acetabulum. This procedure is indicated for select traumatic events.

Knee Arthroplasty

A normal knee functions as a hinge joint between the femur and the tibia. The surfaces where these bones meet can become worn out over time, due to arthritis or other conditions, which can cause pain and swelling. Total knee arthroplasty replaces and reconstructs all articular joint surfaces. In some cases, only one surface within the knee develops arthritis and associated pain and functional loss. In these cases, a partial knee replacement may be necessary to remove and reconstruct only the damaged region of the knee. In some cases, the knee prosthesis may wear out or loosen. If loosening is painful, a revision surgery may be necessary. In this procedure some or all of the components of the original replacement prosthesis are removed and replaced with new ones. Unicompartmental knee arthroplasty (UKA) is also called partial replacement, hemiarthroplasty, unicondylar knee, or bicondylar knee arthroplasty. This procedure involves reconstruction of either the medial or lateral weight bearing compartment of the knee and/or patellofemoral joint. Medial UKA is performed more frequently than lateral procedures. Revision arthroplasty describes surgical reconstruction due to failure or complication of a previous arthroplasty.

Ankle Arthroplasty Ankle Arthroplasty or Total Ankle Replacement is performed as a treatment for end-stage ankle arthritis. It is typically indicated in older, lower demand individuals, as the lifespan of the ankle replacement is uncertain. Patients that have arthritis (or fusions) involving the joints below the ankle (subtalar, talonavicular and calcaneocuboid joints) may benefit from an ankle replacement, as it will help to preserve some hindfoot motion. Relatively young, active patients typically do not do well with ankle replacements in the long run due to an unacceptably high failure rate. These younger patients are usually best served with a well-performed ankle fusion. The procedure depends on the type of prosthesis that is used. In all ankle replacements, the arthritic surface of the distal tibia is removed, as is the arthritic surface of the top surface talus. Typically, only the tibial surface and some of the talar dome are removed. The resected areas of bone are then replaced with the prosthesis. The prosthesis typically has a metal surface on the tibia, and talar sides with a polyethylene surface attached to the tibial component.

 Line of Business

Commercial:

 HNE has adopted InterQual* criteria for the following procedures:

o CP:Procedures, Joint Replacement, Shoulder o CP:Procedures, Removal and Replacement, Total Joint Replacement (TJR), Shoulder o CP:Procedures, Total Joint Replacement (TJR), Hip o CP:Procedures, Removal and Replacement, Total Joint Replacement (TJR), Hip o CP:Procedures, Total Joint Replacement (TJR), Knee o CP:Procedures, Removal and Replacement, Total Joint Replacement (TJR), Knee o CP:Procedures, Unicondylar or Patellofemoral Knee Replacement o CP:Procedures, Total Joint Replacement (TJR), Ankle

 Refer to criteria under Policy section in this medical policy for the following procedures:

o Hip Resurfacing Arthroplasty

Medicaid- BeHealthy:

 HNE has adopted InterQual* criteria for the following procedures:

 Refer to criteria under Policy section in this medical policy for the following procedures:

o Hip Resurfacing Arthroplasty

Medicare:

 HNE has adopted InterQual* criteria for the following procedures:

o CP:Procedures, Joint Replacement, Shoulder o CP:Procedures, Removal and Replacement, Total Joint Replacement (TJR), Shoulder o CP:Procedures, Unicondylar or Patellofemoral Knee Replacement o CP:Procedures, Total Joint Replacement (TJR), Ankle

 Refer to criteria under Policy section in this medical policy for the following procedures:

o Hip Resurfacing Arthroplasty

 Medicare does not have a National Coverage Determination (NCD) or a Local Coverage Determination (LCD) for above procedures.

 The following National Coverage Determination (NCD) or Local Coverage Determination (LCD) can be found at MCD Search (cms.gov):

o LCD L36039, Total Joint Arthroplasty

If you are a registered Health New England provider click here: https://www.hnedirect.com/login/ to access the Provider website. If you do not have access to the portal call (413) 787-4004 to obtain a copy.
Policy

I. Shoulder Joint
A. Health New England has adopted following InterQual criteria for Total Joint Replacement (TJR) of Shoulder (arthroplasty), Hemiarthroplasty of Shoulder, Partial Shoulder Arthroplasty, Reverse TJR of Shoulder (Arthroplasty).
o CP:Procedures, Joint Replacement, Shoulder
o For members under 18 years of age, the request will be reviewed on a case-by-case basis

B. Health New England has adopted following InterQual criteria for Revision Shoulder Arthroplasty.
o CP:Procedures, Removal and Replacement, Total Joint Replacement (TJR), Shoulder
o For members under 18 years of age, the request will be reviewed on a case-by-case basis

C. Shoulder joint procedures are NOT COVERED in the following situations:
1. Totality shoulder arthroplasty is considered NOT MEDICALLY NECESSARY when ANY of the following are present:
a. Total shoulder arthroplasty that doesn’t meet InterQual criteria; OR b. Evidence of active local or systemic infection; OR c. Paralytic disorder of the shoulder (e.g., flail shoulder due to irreversible brachial plexus palsy, spinal cord injury, or neuromuscular disease); OR d. Charcot joint.
1. Hemi-arthroplasty (replacement) is considered NOT MEDICALLY NECESSARY for ANY of the following:
a. Hemi-arthroplasty that doesn’t meet InterQual criteria; OR b. Evidence of active local or systemic infection; OR
c. Paralytic disorder of the shoulder (e.g., flail shoulder due to irreversible brachial plexus palsy, spinal cord injury, or neuromuscular disease); OR

d. Charcot joint; OR e. Advanced destructive degenerative joint disease (e.g., rheumatoid arthritis or osteoarthritis) resulting in marked narrowing of the joint space; OR
f. Rotator cuff tear arthropathy (e.g., severe rotator cuff tearing and end-stage arthritic disease).

Reverse total shoulder arthroplasty (replacement) is considered NOT MEDICALLY NECESSARY for ANY of the following:
a. Reverse total shoulder arthroplasty that doesn’t meet InterQual criteria; OR b. Evidence of active local or systemic infection; OR c. Paralytic disorder of the shoulder (e.g., flail shoulder due to irreversible brachial plexus palsy, spinal cord injury, or neuromuscular disease); OR d. Deltoid deficiency (e.g., axillary nerve palsy); OR e. Charcot joint.

II. Hip Joint
A. Health New England has adopted following InterQual criteria for Total Hip Arthroplasty.
o CP:Procedures, Total Joint Replacement (TJR), Hip
o For members under 18 years of age, the request will be reviewed on a case-by-case basis

B. Health New England has adopted following InterQual criteria for Revision Hip Arthroplasty.
o CP:Procedures, Removal and Replacement, Total Joint Replacement (TJR), Hip
o For members under 18 years of age, the request will be reviewed on a case-by-case basis

C. Hip Resurfacing Arthroplasty may be considered MEDICALLY NECESSARY when ALL of the following criteria are met:
Pain and documented loss of function are present for at least 12 weeks; AND
12 weeks of non-operative treatment have failed to improve symptoms; AND
Physical exam has typical findings of hip pathology as evidenced by ONE or MORE of the following:  Painful, limited range of motion or antalgic gait.  Contracture.  Crepitus.  Leg length difference; AND
Imaging demonstrates advanced hip joint pathology of at least Tönnis grade 2 or 3, OR avascular necrosis involving less than 50% of the femoral head [see grading table under Definitions]; AND
Male patient is less than 65 years old or female patient is less than 55 years old; AND
BMI < 40; AND
No corticosteroid injection into the joint within 12 weeks of surgery.

D. Hip joint procedures are NOT COVERED in the following situations:

Total Hip Arthroplasty that doesn’t meet InterQual criteria is considered NOT MEDICALLY NECESSARY.
Revision Hip Arthroplasty that doesn’t meet InterQual criteria is considered NOT MEDICALLY NECESSARY.
Hip Resurfacing Arthroplasty that doesn’t meet above criteria is considered NOT MEDICALLY NECESSARY.

III. Knee Joint
A. Health New England has adopted following InterQual criteria for Total Knee Arthroplasty.
o CP:Procedures, Total Joint Replacement (TJR), Knee
o For members under 18 years of age, the request will be reviewed on a case-by-case basis

B. Health New England has adopted following InterQual criteria for Revision Knee Arthroplasty.
o CP:Procedures, Removal and Replacement, Total Joint Replacement (TJR), Knee
o For members under 18 years of age, the request will be reviewed on a case-by-case basis

C. Health New England has adopted following InterQual criteria for Hemiarthroplasty, Partial Knee Replacement, Unicompartmental Arthroplasty, Unicondylar Knee Arthroplasty.
o CP:Procedures, Unicondylar or Patellofemoral Knee Replacement
o For members under 18 years of age, the request will be reviewed on a case-by-case basis

D. Knee joint procedures are NOT COVERED in the following situations:
Total knee arthroplasty that doesn’t meet InterQual criteria is considered NOT MEDICALLY NECESSARY.
Revision knee arthroplasty that doesn’t meet InterQual criteria is considered NOT MEDICALLY NECESSARY.
HNE consider following procedures to be INVESTIGATIONAL or EXPERIMENTAL:

a. Procedures utilizing computer-navigated or patient-specific or gender-specific instrumentation.
b. Bicompartmental arthroplasty. c. Robot-assisted TKA (Makoplasty).

IV. Ankle Joint

A. Health New England has adopted following InterQual criteria for Total Ankle Arthroplasty.

o CP:Procedures, Total Joint Replacement (TJR), Ankle

o For members under 18 years of age, the request will be reviewed on a case-by-case basis

B. Ankle joint procedure is NOT COVERED in the following situation:

Ankle arthroplasty that doesn’t meet InterQual criteria is considered NOT MEDICALLY NECESSARY.

Policy Guidelines and Definitions

Definitions:
Tönnis Classification of Osteoarthritis by Radiographic Changes
Grade Description 0 No signs of osteoarthritis 1 Mild: Increased sclerosis, slight narrowing of the joint space, no or slight loss of head sphericity 2 Moderate: Small cysts, moderate narrowing of the joint space, moderate loss of head sphericity 3 Severe: Large cysts, severe narrowing or obliteration of the joint space, severe deformity of the head

Coding Guidance
Code
Description
PA Shoulder 23470 Arthroplasty, glenohumeral joint; hemiarthroplasty Yes 23472 Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder)) Yes 23473 Revision of total shoulder arthroplasty, including allograft when performed; humeral or glenoid component Yes

Code
Description
PA 23474 Revision of total shoulder arthroplasty, including allograft when performed; humeral and glenoid component Yes Hip 27130 Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft (use for hip resurfacing) Yes 27132 Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft Yes 27134 Revision of total hip arthroplasty; both components, with or without autograft or allograft Yes 27137 Revision of total hip arthroplasty; acetabular component only, with or without autograft or allograft Yes 27138 Revision of total hip arthroplasty; femoral component only, with or without allograft Yes Knee 27438 Arthroplasty, patella; with prosthesis Yes 27445 Arthroplasty, knee, hinge prosthesis (eg, Walldius type) Yes 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment Yes 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty) Yes 27486 Revision of total knee arthroplasty, with or without allograft; 1 component Yes 27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component Yes Ankle 27700 Arthroplasty, ankle Yes 27702 Arthroplasty, ankle; with implant (total ankle) Yes

Note: CPT/HCPCS codes are included for informational purposes and may not be all inclusive. Inclusion or exclusion of a CPT/HCPCS code(s) does not signify or imply that the service described by the code is a covered or non-covered health service. Benefit coverage for health services is determined by the member’s specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee of payment. Other policies and coverage determination guidelines may apply.

References

Local Coverage Determination (LCD): Total Joint Arthroplasty (L36039). LCD - Total Joint Arthroplasty (L36039) (cms.gov)

MassHealth: Guidelines for Medical Necessity Determination for Knee Arthroplasty. download (mass.gov)

Lorenzetti AJ, Stone GP, Simon P, Frankle MA. Biomechanics of Reverse Shoulder Arthroplasty: Current Concepts. Instr Course Lect. 2016;65:127-43. Biomechanics of Reverse Shoulder Arthroplasty: Current Concepts - PubMed (nih.gov)

Policy Implementation

Approved by the Medical and Pharmacy Policy Committee

Kate McIntosh MD MBA

Chief Medical Officer

Saad Usmani MD MBA

Medical Director

Date Update 9/11/2012 Initial Policy Date 08/2023 No changes 4/2024 Line of Business section added. 5/2024 Name changed from Total Ankle Replacement to Musculoskeletal Surgery: Arthroplasty Added criteria and codes for shoulder, hip and knee joint replacement and revision; ankle joint replacement.
References updated.

Medical Criteria Disclaimer

Property of Health New England. All rights reserved. The treating physician or primary care provider must submit to Health New England the clinical evidence that the patient meets the criteria for the treatment, testing or surgical procedure. Without this documentation and information, Health New England will not be able to properly review the request for prior authorization. The clinical review criteria reflect how Health New England determines whether certain services or supplies are medically necessary. Health New England established the clinical review criteria based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).
Health New England expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit program defines which services are covered. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered and/or paid for by Health New England, as some programs exclude coverage for services or supplies that Health New England considers medically necessary. If there is a discrepancy between this guideline and a member's benefits program, the benefits program will govern. In addition, coverage may be mandated by applicable legal requirements of a state, the Federal Government or the Centers for Medicare & Medicaid Services (CMS) for Medicare and Medicaid members. All coding and web site links are accurate at time of publication. Health New England has adopted the herein policy in providing management, administrative and other services to its Health Plan.

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Musculoskeletal Surgery: Arthroplasty Form

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