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Total Joint Replacement (Hip and Knee) for Medicare, MPM 20.13

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Total Joint Replacement (Hip and Knee) for Medicare, MPM 20.13 Medical Policy Subject: Total Joint Replacement (Hip and Knee) for Medicare Medical Policy #: 20.13 Original Effective Date: 07/22/2020 Status: New Policy Last Review Date: N/A Disclaimer Refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage. This may not be a benefit on all plans or the plan may have broader or more limited benefits than those listed in this Medical Policy. Description Lower Extremity Major Joint Replacement or Arthroplasty refers to the replacement of the hip or knee joint. The goal of total hip or knee replacement surgery is to relieve pain and improve or increase functional activity of the member. The surgical treatment (arthroplasty) is the replacement of the damaged joint with a prosthesis. The chief reasons for joint arthroplasty (total joint replacement) are osteoarthritis, rheumatoid arthritis, traumatic arthritis (result of a fracture), osteonecrosis, malignancy, and revisions of previous surgery. Treatment options include physical therapy, analgesics or anti- inflammatory medications. The aim is to improve functional status and relieve pain. Arthroplasty failures are caused by trauma, chronic progressive joint disease, prosthetic loosening and infection of the prosthetic joint Coverage Determination Prior Authorization is required for 27130, 27132, 27134, 27447, 27486, and 27487. Logon to Pres Online to submit a request: https://ds.phs.org/preslogin/index.jsp PHP follows LCD (L36007) for Lower Extremity Major Joint Replacement for both Hip and Knee for Medicare members Note: In addition to the below items (for both knee or hip) further documentation requirements are listed in the documentation Requirement section below. Content: I. TOTAL KNEE REPLACEMENT II. KNEE REVISION or REPEAT procedure III. TOTAL HIP ARTHROPLASTY (THA) IV. HIP REVISION or REPEAT procedure I. TOTAL KNEE REPLACEMENT The most common reason for total knee arthroplasty is arthritis of the knee joint. Types of arthritis include osteoarthritis, rheumatoid arthritis and traumatic arthritis (arthritis which occurs as a result of injury). Note: The following does not apply for unicompartmental knee replacement surgery. In the instance that the patient is undergoing a bilateral knee replacement, the criteria listed below would apply to the surgery of both knees when indicated. PHP will consider Total Knee Arthroplasty (TKA) medically reasonable and necessary when three or more of the following criteria are met: A. Radiographic evidence: Advanced joint disease validated by radiographic or magnetic resonance imaging (MRI), e.g., fracture or deterioration, distortion of joint surfaces, subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, narrowing, avascular necrosis; B. Unsuccessful therapy: Medical record shows unsuccessful conservative therapy clearly documented in the pre- procedure visits. Non-surgical medical management is usually implemented for 3 months or more to assess effectiveness. Conservative treatment as clinically appropriate for the patient’s current episode of care typically Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001] 1 includes one or more of the following: anti-inflammatory medications; analgesics; flexibility and muscle strengthening exercises with supervised physical therapy. C. Impaired ambulation continues: Pain with functional disability due to arthritis or trauma to the knee joint; activities of daily living (ADLs) are diminished despite compliance with plan of care including activity restrictions as is reasonable, assistive device use, weight reduction as appropriate or therapeutic injections into the knee as appropriate; D. Distinct structural abnormalities such as: • Distal femur fracture; • Proximal tibia fracture; • Malignancy of the distal femur, proximal tibia, knee joint or adjacent soft tissues; • Avascular or other form of osteonecrosis of the knee; • Rheumatologic changes precluding or inconsistent with rehabilitation E. Revision or repeat procedure: Failed previous joint replacement/arthroplasty necessitating revision as indicated by any of the following: • Loosening, fracture, or mechanical failure of one or more components; • Technical or functional failure of previous knee surgery, e.g. unicompartmental knee replacement; • Previous osteotomy or partial arthroplasty; • Infection; • Periprosthetic fracture or bone loss of distal femur, proximal tibia or patella; Implant or knee malalignment; • Bearing surface wear leading to symptomatic synovitis; • Tibiofemoral or extensor mechanism instability; or • Knee stiffness, arthrofibrosis or other destructive conditions that render the knee impaired to the extent to preclude employment or functional activities. *See below for additional information on revision or repeat procedure. II. KNEE REVISION or REPEAT procedure Revision or repeat procedure: Failed previous knee arthroplasty necessitating revision as indicated by the following: • Loosening, fracture, or mechanical failure of one or more components; • Technical or functional failure of previous knee surgery, e.g. unicompartmental knee replacement; • Previous osteotomy or partial arthroplasty; • Infection; • Periprosthetic fracture or bone loss of distal femur, proximal tibia or patella; Implant or knee malalignment; • Bearing surface wear leading to symptomatic synovitis; • Tibiofemoral or extensor mechanism instability; or • Knee stiffness, arthrofibrosis or other destructive conditions that render the knee impaired to the extent to preclude employment or functional activities III. TOTAL HIP ARTHROPLASTY (THA) Total hip arthroplasty is most often performed due to severe pain caused by osteoarthritis of the hip joint. Rheumatoid arthritis, traumatic arthritis, malignancy involving the hip joint and osteonecrosis of the femoral head are also indications for hip replacement surgery. NOTE: In the instance that the patient is undergoing a bilateral hip replacement, the criteria listed below would apply to the surgery of both hips when indicated. PHP will consider Total Hip Arthroplasty (THA) medically reasonable and necessary when three or more of the following indications are met: A. Radiographic evidence: Advanced joint disease demonstrated by radiographic supported evidence or when conventional radiography is not adequate, magnetic resonance imaging (MRI) supported evidence (subchondral cysts, subchondral sclerosis, periarticular osteophytes, joint subluxation, joint space narrowing, avascular necrosis); B. Impaired ambulation continues: Pain and functional disability from injury due to trauma or arthritis of the joint; activities of daily living (ADLs) are diminished despite completing a plan of care with activity restrictions as is reasonable, assistive device use, appropriate weight reduction, flexibility and muscle strengthening exercises with supervised physical therapy. Not every Presbyterian health plan contains the same benefits. Please refer to the member’s specific benefit plan and Schedule of Benefits to determine coverage [MPMPPC051001] 2 C. Unsuccessful therapy: Medical record shows unsuccessful conservative therapy clearly documented in the pre- procedure visits. Non-surgical medical management is usually implemented for 3 months or more to assess effectiveness. Conservative treatment, as clinically appropriate for the patient’s current episode of care, typically includes one or more of the following: anti-inflammatory medications, analgesics, or therapeutic injections when appropriate, with physical therapy or assist devices. D. Distinct structural abnormalities 1. Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur; 2. Avascular necrosis (osteonecrosis of femoral head); 3. Fracture of the femoral neck; Acetabular fracture; 4. Non-union or failure of previous hip fracture surgery; Mal-union of acetabular or proximal femur fracture; IV. HIP REVISION or REPEAT procedure Failed previous Hip Arthroplasty necessitating revision as indicated by the following: • Loosening, fracture or mechanical failure of the implant; • Instability of one or more components; • Recurrent or irreducible dislocation; • Infection; • Displaced periprosthetic fracture; • Clinically significant leg length inequality; • Progressive soft tissue or bone reaction or substantial bone loss, • Clinically significant audible noise; or • Bearing surface wear leading to symptomatic synovitis • Other disease or destructive process that renders the hip impaired to the extent to preclude employment or functional activities Limitations The following are considered not reasonable and necessary: 1. When the following contraindications are present: • Active infection of the hip or knee joint or active systemic bacteremia • Active skin infection or open wound within the planned surgical site of the hip or knee • Progressive neurological disease, etiologic for pain, instability or disability 2. Unicompartmental Knee Replacement: For knee joint replacement surgery specific to unicompartmental (damage confined to one compartment) knee replacement done for patients with osteoarthritis of the knee; the coverage outlined in this policy do not apply to unicompartmental knee replacement surgery Documentation Requirements Note: The medical records should contain enough detailed information to support the determination that major joint replacement surgery was reasonable and necessary for the patient.
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