Humana Hip, Knee and Shoulder Arthroscopic Surgeries - Medicare Advantage Form

Please refer to CMS website for the most current applicable CMS Online Manual System (IOMs)/National Coverage Determination (NCD)/ Local Coverage Determination (LCD)/Local Coverage Article (LCA)/ Transmittals.

Jurisdiction

• Type: Title, ID Number, Medicare Administrative, Applicable States/Territories

NCD

Arthroscopic Lavage and Arthroscopic Debridement for, 150.9, (MACs)

1. LCA: the Osteoarthritic Knee Billing and Coding: Arthroscopic Lavage and Arthroscopic Octeoarthritc Knee: Medical Policy Article, a, J6 - National Government Services, Inc. (Part A/B MAC), IL, MN, WI CT, NY, ME, MA, NH, RI, VT
2. LCA: sgeane Aeon 8 P Debridement for the Osteoarthritic Knee, AS54061, Noridian Healthcare Solutions, LLC , AM, Guam, Northern Mariana Islands
3. LCA: ping anc poate Arthroscopic 8 P Debridement for the Osteoarthritic Knee, A54063, JF - Noridian Healthcare Solutions, LLC, AK, AZ, ID, MT, ND, OR, SD, UT, WA, WY
4. LCA: Billing and Coding: Thermal Capsulorrhaphy, AS53435, JJ-PalmettoGBA | Part A/B MAC (Part A/ ), AL, GA, TN
5. LCA: JM - Palmetto GBA (Part A/B MAC), NC, SC, VA, WV

Description

Arthroscopy is a minimally invasive surgical procedure used to examine, diagnose and treat joints. Arthroscopic surgery involves the insertion of an arthroscope and small surgical instruments through several small skin incisions into the joint for examination, shaving of bone spurs or removal of damaged cartilage as needed. These surgical procedures, previously performed through a large open incision, can now be done with smaller incisions and with a reduction in tissue damage while still performing the critical element of the surgery.

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. Disadvantages of arthroscopy include that the equipment required can be extensive and expensive.

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Arthroscopic hip surgery gives the surgeon access to the central compartment which includes the articular surfaces of the femoral head and acetabulum, labrum and ligamentum teres as well as the peripheral compartment which includes the femoral neck, the surrounding capsule and synovium.

Knee arthroscopic techniques have been used in the United States since the early 1970’s as both diagnostic and therapeutic procedures to treat various disorders of the knee joint. The role of this procedure expanded greatly and was one of the first minimally invasive procedures that became available to orthopedic surgeons. Arthroscopy of the knee can be done as the essential initial step before proceeding to operative arthroscopy or open arthrotomy.

Shoulder arthroscopy was developed in the mid-1980’s as a technique to treat shoulder disorders. Sports medicine, arthroscopic instruments and techniques rapidly expanded the role of arthroscopic surgery to treat intra-articular as well as extra-articular shoulder disorders.

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.

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.

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Humana follows the CMS requirements that only allows coverage and payment for services that are reasonable and necessary for the diagnosis and treatment of illness or injury or to improve the functioning of a malformed body member except as specifically allowed by Medicare.

Please refer to the above CMS guidance for Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee and Thermal Capsulorrhaphy.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider the following criteria:

Hip, Knee and Shoulder Arthroscopic Surgeries

The use of the criteria in this Medicare Advantage Medical Coverage Policy provides clinical benefits highly likely to outweigh any clinical harms. Services that do not meet the criteria above are not medically necessary and thus do not provide a clinical benefit. Medically unnecessary services carry risks of adverse outcomes and may interfere with the pursuit of other treatments which have demonstrated efficacy.

In interpreting or supplementing the criteria above and in order to determine medical necessity consistently, Humana may consider MCG Guidelines.

Coverage Limitations

US Government Publishing Office. Electronic code of federal regulations: part 411 – 42 CFR § 411.15 - Particular services excluded from coverage