Hip Joint Surgery: Arthrotomy for Biopsy of the Sacroiliac Joint Or Hip Joint

Musculoskeletal Surgical Services: Hip Joint Surgery: Arthrotomy for biopsy of the sacroiliac joint or hip joint

POLICY INITIATED: 06/30/2019 MOST RECENT REVIEW: 06/30/2019 POLICY # HH-5629

Overview Statement The purpose of these clinical guidelines is to assist healthcare professionals in selecting the medical service that may be appropriate and supported by evidence to improve patient outcomes. These clinical guidelines neither preempt clinical judgment of trained professionals nor advise anyone on how to practice medicine. The healthcare professionals are responsible for all clinical decisions based on their assessment. These clinical guidelines do not provide authorization, certification, explanation of benefits, or guarantee of payment, nor do they substitute for, or constitute, medical advice. Federal and State law, as well as member benefit contract language, including definitions and specific contract provisions/exclusions, take precedence over clinical guidelines and must be considered first when determining eligibility for coverage. All final determinations on coverage and payment are the responsibility of the health plan. Nothing contained within this document can be interpreted to mean otherwise. Medical information is constantly evolving, and HealthHelp reserves the right to review and update these clinical guidelines periodically. No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from HealthHelp. All trademarks, product names, logos, and brand names are the property of their respective owners and are used for purposes of information/illustration only.

Associated Procedure Codes: Procedure Code Description Code Arthroscopy, hip, diagnostic with or without synovial biopsy (separate procedure) 29860 Arthroscopy, hip, surgical; with removal of loose body or foreign body 29861 Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage 29862 (chondroplasty), abrasion arthroplasty, and/or resection of labrum Arthroscopy, hip, surgical; with synovectomy 29863 Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) 29914

Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) 29915

Clinical Guidelines for Medical Necessity Review of Musculoskeletal Surgical Services. http://www.healthhelp.com | © 2019 HealthHelp. All rights reserved. 16945 Northchase Dr #1300, Houston, TX 77060 (281) 447-7000

Arthroscopy, hip, surgical; with labral repair 29916

Arthrotomy, with biopsy; sacroiliac joint 27050

Arthrotomy, with biopsy; hip joint 27054

Definition:

1. An arthroscopy is a minimally invasive surgical procedure involving visual examination of the interior of a joint with an arthroscope to diagnose or treat various conditions or injuries of a

joint and especially to repair or remove damaged or diseased tissue or bone. 14

2. Arthrotomy – Arthrotomy (opening the joint) is a procedure where the joint is opened to clean

out bone spurs, loose bodies, tumors, or to repair fractures.15

Guideline: . Requests for Arthrotomy for biopsy of the sacroiliac joint or hip joint will require review by the HealthHelp Medical Director for medical necessity.

References 1. Bardakos NV, Vasconcelos JC, Villar, RN. Early outcome of hip arthroscopy for femoroacetabular impingement The role of femoral osteoplasty in symptomatic improvement. Journal of Bone & Joint Surgery, British Volume. 2008;90(12): 1570-1575. 2. Egerton T, et al. Intraoperative cartilage degeneration predicts outcome 12 months after hip arthroscopy.Clinical Orthopaedics and Related Research. 2013;471(2): 593-599. 3. Kim K, et al. Influence of femoroacetabular impingement on results of hip arthroscopy in patients with early osteoarthritis. Clinical Orthopaedics and Related Research. 2007;456: 128-132. 4. Lynch TS, et al. Hip Arthroscopic Surgery Patient Evaluation, Current Indications, and Outcomes. The American Journal of Sports Medicine. 2013;41(5): 1174-1189. 5. Martin RL, Irrgang JJ, Sekiya JK. The diagnostic accuracy of a clinical examination in determining intraarticular hip pain for potential hip arthroscopy candidates. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2008;24(9):1013-1018. 6. Stevens MS, et al. The evidence for hip arthroscopy: grading the current indications. Arthroscopy: the Journal of Arthroscopic & Related Surgery. 2010;26(10):1370-1383. 7. Mullis BH, Dahners LE. Hip arthroscopy to remove loose bodies after traumatic dislocation. Journal of Orthopaedic Trauma. 2006;20(1): 22-26. 8. Mascarenhas R, Frank RM, Lee S, et al. Endoscopic Treatment of Greater Trochanteric Pain Syndrome of the Hip. JBJS REVIEWS. 2014;2(12):e2. · http://dx.doi.org/10.2106/JBJS.RVW.N.00026 1 9. Heyworth BE, et al. Radiologic and intraoperative findings in revision hip arthroscopy. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2007;23(12): 1295-1302. 10. DeSa D, Phillips M, Philippon MJ, et al. Ligamentum teres injuries of the hip: a systematic review examining surgical indications, treatment options, and outcomes. Arthroscopy. 2014;30(12):1634-41 (can’t access full journal) 11. Lynch TS, et al. Hip Arthroscopic Surgery Patient Evaluation, Current Indications, and Outcomes. The American Journal of Sports Medicine. 2013;41(5): 1174-1189. 12. Nepple JJ, et al. Clinical and radiographic predictors of intra-articular hip disease in arthroscopy. The American Journal of Sports Medicine. 2011;39(2): 296-303. 13. Martin RL, Irrgang JJ, Sekiya JK. The diagnostic accuracy of a clinical examination in determining intraarticular hip pain for potential hip arthroscopy candidates. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2008;24(9):1013-1018. 14. https://www.merriam-webster.com/dictionary/arthroscopy 15. https://www.hss.edu/conditions_hip-arthroscopy.asp