Humana Hip, Knee and Shoulder Arthroscopic Surgeries Form
This procedure is not covered
Description
Arthroscopy is a minimally invasive surgical procedure used to visualize and treat a range of problems in a joint. The procedure involves the insertion of an arthroscope (small, thin tube containing a lens and light source) through a small incision into the joint. Other incisions may be made to allow the passage of instruments for cutting, grasping or probing. The arthroscope is attached to a camera which sends an image of the joint to a monitor allowing the surgeon to determine the type of injury and if correction is warranted.
The advantages of arthroscopic surgery include reduced postoperative morbidity, smaller incisions, less intense inflammatory response, improved visualization, reduced length of hospital stay and reduced complication rate. Arthroscopy also enables the surgeon to perform procedures that are difficult or impossible to perform through open arthrotomy.
Subacromial tissue spacer system
is a minimally invasive, shoulder spacer or balloon intended to be used as a temporary barrier between the humeral head and acromion or rotator cuff in individuals with massive rotator cuff tears (MRCTs). Purportedly, the spacer reduces friction and allows smooth gliding between acromion and the humeral head, therefore reducing pain and restoring joint function. The device is resorbed within 12 to 15 months. An example of a US Food & Drug Administration (FDA) approved spacer is the InSpace subacromial tissue spacer system.15,18,47 (Refer to Coverage Limitations section)
Thermal capsular shrinkage
, also known as thermal capsulorrhaphy, utilizes thermal energy/heat to shrink the tendons or ligaments of the synovial joint. Thermal capsulorrhaphy purportedly increases stability of the joint. It is theorized that when heat is applied to the tissue a molecular change occurs to the structure of collagen (the chief component of connective tissue, tendons and bones) causing the length of the collagen to shrink and tighten.
Examples of thermal capsular shrinkage devices include, but may not be limited to:
- ArthroCare system 2000 CAPS X ArthroWand
- ORA-50 electrothermal system and accessories
- VULCAN EAS electrothermal arthroscopy system and accessories
- VAPR II electrosurgical system
(Refer to Coverage Limitations section)
Needle arthroscopy
is a disposable minimally invasive diagnostic and therapeutic arthroscopy system that may be utilized in a physician’s office using local anesthesia, hospital bedside, surgical suite or treatment room. Needle arthroscopic systems purportedly are alternatives to MRI imaging or repeat arthroscopy. Systems include a camera handpiece and separate liquid crystal display (LCD) monitor attached via cable to display real time video while some systems may include additional instruments for therapeutic procedures such as extraction, injection and resection. Examples of needle arthroscopy systems that are FDA-approved are the Nanoscope, mi-eye, mi-eye 2, mi-eye 3 needlescope or Visionscope.14,15,46 (Refer to Coverage Limitations section)
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
For information regarding partial, resurfacing or total arthroplasty of the hip, knee or shoulder, please refer to Hip Arthroplasty, Knee Arthroplasty or Shoulder Arthroplasty Medical Coverage Policies.
Coverage Determination
Hip
Humana members may be eligible under the Plan for arthroscopy of the hip when the following criteria are met:
- Documentation including radiological interpretation and report for bony pathology (eg, routine radiographs) or soft tissue pathology (eg, computerized tomography [CT] scan and/or MRI); AND
- Failure of 3 months of conservative treatment* under the direction of a healthcare professional with ALL of the following:
- Ambulatory assistive device if medically appropriate; AND
- Intra-articular steroid injection if medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided 3 months prior to planned hip arthroscopic surgery; AND
- Modification of pain inducing activities; AND
- Nonsteroidal anti-inflammatory drugs (NSAIDs) if medically appropriate and not contraindicated; AND
- Physical therapy including a home exercise program (HEP);
*Failure of conservative treatments is not required in active infections or acute trauma with functional loss (effusion, focal tenderness, inability to bear weight, symptoms explained by radiographic findings [eg, fracture, soft tissue injury] or a visual deformity (eg, dislocation).
AND any of the following:
- Articular surface disorders; OR
- Evaluation for acute trauma (eg, dislocation); OR
- Femoroacetabular impingement (FAI) syndrome along with associated cartilage and/or labral injury and ALL of the following:
- Absence of advanced osteoarthritis (Tonnis grade 2 or 3); AND
- Moderate to severe persistent hip or groin pain that limits activity and is worsened by flexion activities (eg, squatting or prolonged sitting); AND
- Positive impingement sign with pain while hip is flexed to 90 degrees, adducted and internally rotated; AND
- Radiographic confirmation (CT, MRI or X-rays) of FAI with evidence of cam impingement (alpha angle greater than 50 degrees), pincer impingement (coxa profunda or acetabular retroversion) or both; OR
- Intra-articular loose body; OR
- Labral reconstruction with an allograft or autograft; OR
- Labral tears; OR
- Lavage for intra-articular infections; OR
- Ligamentum teres injury; OR
- Microfracture; OR
- Pathological synovial disease (eg, synovectomy)
Humana members may be eligible under the Plan for arthroscopy of the hip for greater trochanteric pain syndrome (formally trochanteric bursitis) for following:
- Radiographic evidence of gluteal tear on MRI; OR
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Radiographic evidence on MRI of ANY of the following:
- Bursal effusions; OR
- Enthesopathies (problem with attachment of a ligament or tendon onto the bone); OR
- Fatty degeneration; OR
- Muscle atrophy; OR
- Tendinosis; AND
- Failure of 6 months of conservative treatment under the direction of a healthcare professional with ALL of the following:
- Local non-systemic glucocorticoid injection (not intramuscular) if medically appropriate and not contraindicated; AND
- Modification of pain inducing activities; AND
- Nonsteroidal anti-inflammatory drugs (NSAIDs) if medically appropriate and not contraindicated; AND
- Physical therapy including a home exercise program (HEP)
Iliopsoas tendon release surgery (hip flexor tenotomy) is considered integral to the primary FAI procedure and not separately reimbursable.
Coverage Limitations
Humana members may NOT be eligible under the Plan for arthroscopy of the hip for any indications other than those listed above including, but not limited to, the following:
- Advanced arthritis; OR
Hip, Knee and Shoulder Arthroscopic Surgeries
Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0540-013
Page: 6 of 24
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Capsular laxity
This is considered NOT medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.
Humana members may NOT be eligible under the Plan for capsular plication for the treatment of FAI or hip instability. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.
Coverage Determination
Knee
Humana members may be eligible under the Plan for arthroscopy of the knee when the following criteria are met:
- Documentation including radiological interpretation and report for bony pathology (eg, routine radiographs) or soft tissue pathology (eg, CT scan and/or MRI); AND
- Failure of 3 months of conservative treatment* under the direction of a healthcare professional with ALL of the following:
- Intra-articular steroid injection if medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided 3 months prior to planned knee arthroscopic surgery; AND
- Modification of pain inducing activities; AND
- Nonsteroidal anti-inflammatory drugs (NSAIDs) if medically appropriate and not contraindicated; AND
- Orthotics (knee brace) if medically appropriate; AND
- Physical therapy including a home exercise program (HEP);
*Failure of conservative treatment is not required in active infections or acute trauma with functional loss (effusion, focal tenderness, inability to bear weight,
Hip, Knee and Shoulder Arthroscopic Surgeries
Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0540-013
Page: 7 of 24
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
symptoms explained by radiographic findings [eg, fracture, soft tissue injury] or a visual deformity [eg, dislocation]).
AND any of the following:
- Articular cartilage lesions; OR
- Debridement; OR
- Diagnostic arthroscopy with knee pain and/or mechanical symptoms of the knee are indicative of intra-articular pathology; OR
- Evaluation of unexplained pain in individuals who have undergone joint arthroplasty; OR
- Intra-articular adhesions; OR
- Intra-articular fracture treatment; OR
- Intra-articular ligament injuries (for information regarding coverage determination/limitations for allograft ligament reconstruction, please refer to Allograft Transplantation of the Knee Medical Coverage Policy); OR
- Lavage for intra-articular infections; OR
- Microfracture; OR
- Patellar compression syndrome; OR
- Pathological synovial disease (eg, synovectomy); OR
- Removal of loose body; OR
- Repair or removal of torn meniscal tissue with functional disability, pain or mechanical symptoms (for information regarding coverage determination/ limitations for meniscal allograft implants, please refer to Allograft Transplantation of the Knee Medical Coverage Policy); OR
Hip, Knee and Shoulder Arthroscopic Surgeries
Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0540-013
Page: 8 of 24
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Treatment of osteochondral lesions (for information regarding coverage determination/limitations for chondrocyte and osteochondral allograft/autograft transplantation and subchondral defects, please refer to Osteochondral and Subchondral Defects Surgery Medical Coverage Policy)
Note: The criteria for arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.
Coverage Limitations
Humana members may NOT be eligible under the Plan for arthroscopy of the knee for any indications other than those listed above including, but may not be limited to, the following:
- Advanced, isolated arthritis; OR
- Debridement for advanced osteoarthritis Tonnis grade 2 or 3; OR
- Extra-articular knee injuries; OR
- Nonsymptomatic chronic meniscal tears
This is considered NOT medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.
Humana members may NOT be eligible under the Plan for the following:
- Needle arthroscopy for in office diagnosis and therapeutic treatment of a joint; OR
- Subchondroplasty (for information regarding coverage limitations for subchondral defects, please refer to Osteochondral and Subchondral Defects Surgery Medical Coverage Policy)
These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.
Hip, Knee and Shoulder Arthroscopic Surgeries
Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0540-013
Page: 9 of 24
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Coverage Determination
Shoulder
Humana members may be eligible under the Plan for arthroscopy of the shoulder when the following criteria are met:
- Documentation including radiological interpretation and report for bony pathology (eg, routine radiographs) or soft tissue pathology (eg, CT scan and/or MRI); AND
- Failure of 3 months of conservative treatment* under the direction of a healthcare professional with ALL of the following:
- Intra-articular steroid injection if medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided 3 months prior to planned shoulder arthroscopic surgery; AND
- Modification of pain inducing activities; AND
- Nonsteroidal anti-inflammatory drugs (NSAIDs) if medically appropriate and not contraindicated; AND
- Physical therapy including a home exercise program (HEP);
*Failure of conservative treatment is not required in active infections or acute trauma with functional loss (eg, focal tenderness, loss of motion, symptoms explained by radiographic findings [eg, fracture, soft tissue injury] or a visual deformity [eg, dislocation]).
AND any of the following:
- Arthritis of the acromial-clavicular joint, with persistent pain or decreased function; OR
- Calcific tendonitis; OR
- Capsular instability/laxity with documented subluxation or dislocation of the shoulder joint; OR
- Debridement; OR
- Intra-articular fracture reduction; OR
- Lavage for intra-articular infections; OR
- Long head of biceps pathology (eg, bicep tendonitis); OR
- Loose intra-articular body; OR
- Pathological synovial disease (eg, synovectomy); OR
- Scapulothoracic bursitis; OR
- Subacromial impingement syndrome (eg, subacromial decompression and acromioplasty); OR
- Superior labrum anterior to posterior (SLAP) tear repair
Humana members may be eligible under the Plan for arthroscopy of the shoulder for capsular adhesions (eg, adhesive capsulitis [frozen shoulder]), with or without manipulation under anesthesia, when the following criteria are met:
- Documentation of routine radiographs (posteroanterior, external rotation, Y-outlet and axillary views) absent of bone pathology findings; AND
- Failure of 6 months of conservative treatment under the direction of a healthcare professional with ALL the following:
- Intra-articular steroid injection if medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided 3 months prior to planned shoulder arthroscopic surgery; AND
- Modification of pain inducing activities; AND
- Nonsteroidal anti-inflammatory drugs (NSAIDs) if medically appropriate and not contraindicated; AND
Hip, Knee and Shoulder Arthroscopic Surgeries
Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0540-013
Page: 10 of 24
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Hip, Knee and Shoulder Arthroscopic Surgeries
Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0540-013
Page: 11 of 24
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Physical therapy including a home exercise program (HEP); AND
- Pain or decreased function of active and passive shoulder motion
Humana members may be eligible under the Plan for arthroscopy of the shoulder for rotator cuff tears when the following criteria are met:
- Acute (within 6 weeks of injury) full thickness tear due to traumatic injury with all of the following:
- interpretation and report for bony pathology (eg, routine radiographs) or soft tissue pathology (eg, CT scan and/or MRI); AND
- Pain and functional loss; OR
- Chronic full or partial thickness tears with all of the following:
- interpretation and report for bony pathology (eg, routine radiographs) or soft tissue pathology (eg, CT scan and/or MRI); AND
- Failure of 6 weeks of conservative treatment under the direction of a healthcare professional with ALL of the following:
- Intra-articular steroid injection if medically appropriate and not contraindicated. Intra-articular steroid injections should be avoided 6 weeks prior to planned shoulder arthroscopic surgery; AND
- Modification of pain inducing activities; AND
- Nonsteroidal anti-inflammatory drugs (NSAIDs) if medically appropriate andnot contraindicated; AND
- Physical therapy including a home exercise program (HEP); AND
- Pain and functional loss
Hip, Knee and Shoulder Arthroscopic Surgeries
Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0540-013
Page: 12 of 24
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
Coverage Limitations
Humana members may NOT be eligible under the Plan for arthroscopy of the shoulder for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.
Humana members may NOT be eligible under the Plan for a subacromial tissue spacer system (eg, InSpace). This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.
Humana members may NOT be eligible under the Plan for thermal capsular shrinkage (thermal capsulorrhaphy) of a joint capsule, ligament or tendon as a stand-alone treatment or adjunct to surgery for laxity, unidirectional or multidirectional instability. This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.
Medical Alternatives
Alternatives to arthroscopies include, but may not be limited to, the following:
- Open surgical procedure
Alternatives to thermal capsular shrinkage (thermal capsulorrhaphy) include, but may not be limited to, the following:
Hip, Knee and Shoulder Arthroscopic Surgeries
Effective Date: 12/14/2023
Revision Date: 12/14/2023
Review Date: 12/14/2023
Policy Number: HUM-0540-013
Page: 13 of 24
Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.
Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.
- Arthroscopic or open surgery, which may include:
- Bankart tack
- Capsular shift
- Open Bankart
- Suretac
- Suture anchor
- Transglenoid suture
- Bracing
- Physical therapy (please refer to Physical Therapy and Occupational Therapy Medical Coverage Policy)
- Prescription drug therapy
Physician consultation is advised to make an informed decision based on an individual’s health needs
Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.