Shoulder Joint Surgery: Arthrotomy

Musculoskeletal Surgical Services: Open Surgical Procedures; Shoulder Joint Surgery: Arthrotomy

POLICY INITIATED: 06/30/2019 MOST RECENT REVIEW: 06/30/2019 POLICY # HH-5606

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 Incision and drainage, shoulder area; infected bursa 23031 Incision, bone cortex (eg, osteomyelitis or bone abscess), shoulder area 23035 Arthrotomy, glenohumeral joint, including exploration, drainage, or removal of 23040 foreign body Arthrotomy, acromioclavicular, sternoclavicular joint, including exploration, drainage, 23044 or removal of foreign body Arthrotomy, glenohumeral joint, including biopsy 23100 Arthrotomy, acromioclavicular joint or sternoclavicular joint, including biopsy and/or 23101 excision of torn cartilage

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Arthrotomy, glenohumeral joint, with joint exploration, with or without removal of 23107 loose or foreign body Claviculectomy; partial 23120 Claviculectomy; total 23125 Acromioplasty or acromionectomy, partial, with or without coracoacromial ligament 23130 release Excision or curettage of bone cyst or benign tumor of clavicle or scapula; 23140 Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with 23145 autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of clavicle or scapula; with 23146 allograft Excision or curettage of bone cyst or benign tumor of proximal humerus; 23150 Excision or curettage of bone cyst or benign tumor of proximal humerus; with 23155 autograft (includes obtaining graft) Excision or curettage of bone cyst or benign tumor of proximal humerus; with 23156 allograft Sequestrectomy (eg, for osteomyelitis or bone abscess), clavicle 23170 Sequestrectomy (eg, for osteomyelitis or bone abscess), scapula 23172 Sequestrectomy (eg, for osteomyelitis or bone abscess), humeral head to surgical 23174 neck Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, 23180 osteomyelitis), clavicle Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, 23182 osteomyelitis), scapula Partial excision (craterization, saucerization, or diaphysectomy) bone (eg, 23184 osteomyelitis), proximal humerus Ostectomy of scapula, partial (eg, superior medial angle) 23190 Resection, humeral head 23195 Radical resection of tumor; clavicle 23200 Radical resection of tumor; scapula 23210 Radical resection of tumor, proximal humerus 23220 Removal of prosthesis, includes debridement and synovectomy when performed; 23334 humeral or glenoid component Removal of prosthesis, includes debridement and synovectomy when performed; 23335 humeral and glenoid components (eg, total shoulder) Scapulopexy (eg, Sprengels deformity or for paralysis) 23400 Tenotomy, shoulder area; single tendon 23405 Tenotomy, shoulder area; multiple tendons through same incision 23406 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; acute 23410 Repair of ruptured musculotendinous cuff (eg, rotator cuff) open; chronic 23412

Coracoacromial ligament release, with or without acromioplasty 23415 Reconstruction of complete shoulder (rotator) cuff avulsion, chronic (includes 23420 acromioplasty) Tenodesis of long tendon of biceps 23430 Resection or transplantation of long tendon of biceps 23440 Capsulorrhaphy, anterior; Putti-Platt procedure or Magnuson type operation 23450 Capsulorrhaphy, anterior; with labral repair (eg, Bankart procedure) 23455 Capsulorrhaphy, anterior, any type; with bone block 23460 Capsulorrhaphy, anterior, any type; with coracoid process transfer 23462 Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block 23465 Capsulorrhaphy, glenohumeral joint, any type multi-directional instability 23466 Prophylactic treatment (nailing, pinning, plating or wiring) with or without 23490 methylmethacrylate; clavicle Prophylactic treatment (nailing, pinning, plating or wiring) with or without 23491 methylmethacrylate; proximal humerus Manipulation under anesthesia, shoulder joint, including application of fixation 23700 apparatus (dislocation excluded) Arthrodesis, glenohumeral joint; 23800 Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft) 23802

Definition:

1. Shoulder instability occurs when the head of the upper arm bone is forced out of the shoulder socket. This can happen as a result of a sudden injury or from overuse. Once a shoulder has dislocated, it is vulnerable to repeat episodes. When the shoulder is loose and slips out of place repeatedly, it is called chronic shoulder instability. Surgery is often necessary to repair torn or stretched ligaments so that they are better able to hold the shoulder joint in place. An open surgical repair involves making a large incision over the shoulder and performing the repair under direct visualization.

Guideline: . Open surgery of the shoulder for chronic shoulder instability may be reasonable and appropriate when the patient’s medical record specifies a contraindication to arthroscopic approach is present and ALL of the following: (1- 5,7) o Shoulder pain and associated functional disability which interferes with ADLs; o Limited range of motion, swelling/effusion present on physical exam; o Previous imaging of the shoulder correlates with symptoms and physical presentation;; o At least twelve (12) weeks of treatment with analgesic or anti-inflammatory medication without relief;

o Patient has a contraindication to anti-inflammatory or analgesic medication; o At least twelve (12) weeks of treatment with supervised physical therapy without relief.

References 1. Kim SH, Wise BL, Zhang Y, Szabo RM. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011;93:2249–54. 2. Trofa D, Rajaee SS, Smith EL. Nationwide trends in total shoulder arthroplasty and hemiarthroplasty for osteoarthritis. Am J Orthop (Belle Mead NJ). 2014;43:166–72. 3. Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elb Surg. 2015;24:91–7. Highlights the substantial increase in the use of reverse total shoulder arthroplastry over the past decade. 4. Schairer WW, Nwachukwu BU, Lyman S, Craig EV, Gulotta LV. National utilization of reverse total shoulder arthroplasty in the United States. J Shoulder Elbow Surg. 2015 Jan;24(1):91-7. doi: 10.1016/j.jse.2014.08.026. Pub 2014 Oct 29. 5. Nitin B. Jain, MD, MSPH1,2 and Ken Yamaguchi, MD, MBA3, The Contribution of Reverse Shoulder Arthroplasty to Utilization of Primary Shoulder Arthroplasty. J Shoulder Elbow Surg. 2014 December; 23(12): 1905–1912. 6. Jaicharan J. Iyengar, M.D., Sanjum P. Samagh, M.D., M.S., William Schairer, B.S., Gaurav Singh, M.D., M.P.H., Frank H. Valone III, M.D., and Brian T. Feeley, M.D. Current Trends in Rotator Cuff Repair: Surgical Technique, Setting, and Cost. Arthroscopy: The Journal of Arthroscopic and Related Surgery, 2014-03-01, Volume 30, Issue 3, Pages 284-288 7. Chillemi C, Franceschini V. Shoulder Osteoarthritis. Arthritis. 2013;2013:370231. doi:10.1155/2013/370231 8. HCPUnet, Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality. http://hcupnet.ahrq.gov (Accessed on December 20, 2012). 9. https://orthoinfo.aaos.org/en/diseases--conditions/chronic-shoulder-instability/