<<

Musculoskeletal Surgical Services: Open Surgical Procedures; Knee : Open

POLICY INITIATED: 06/30/2019 MOST RECENT REVIEW: 06/30/2019 POLICY # HH-5588

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, deep abscess, bursa, or hematoma, thigh or knee region 27301 Incision, deep, with opening of cortex, femur or knee (eg, osteomyelitis or bone 27303 abscess) , knee, with exploration, drainage, or removal of foreign body (eg, 27310 infection) Arthrotomy, knee; including joint exploration, biopsy, or removal of loose or foreign 27331 bodies Arthrotomy, with excision of semilunar (meniscectomy) knee; medial OR 27332 lateral

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

Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial AND 27333 lateral Arthrotomy, with synovectomy, knee; anterior OR posterior 27334 Arthrotomy, with synovectomy, knee; anterior AND posterior including popliteal area 27335 Excision, prepatellar bursa 27340 Excision of lesion of meniscus or capsule (eg, cyst, ganglion), knee 27347 Excision or curettage of bone cyst or benign tumor of femur; 27355 Excision or curettage of bone cyst or benign tumor of femur; with allograft 27356 Excision or curettage of bone cyst or benign tumor of femur; with autograft (includes 27357 obtaining graft) Partial excision (craterization, saucerization, or diaphysectomy) bone, femur, 27360 proximal tibia and/or fibula (eg, osteomyelitis or bone abscess) Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; less than 27329 5 cm Radical resection of tumor (eg, sarcoma), soft tissue of thigh or knee area; 5 cm or 27364 greater Radical resection of tumor, femur or knee 27365 Removal of foreign body, deep, thigh region or knee area 27372 Arthrotomy with meniscus repair, knee 27403 Repair, primary, torn ligament and/or capsule, knee; collateral 27405 Repair, primary, torn ligament and/or capsule, knee; cruciate 27407 Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments 27409 Autologous chondrocyte implantation, knee 27412 Osteochondral allograft, knee, open 27415 Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of 27416 autograft[s]) Anterior tibial tubercleplasty (eg, Maquet type procedure) 27418 Reconstruction of dislocating patella; (eg, Hauser type procedure) 27420 Reconstruction of dislocating patella; with extensor realignment and/or muscle 27422 advancement or release (eg, Campbell, Goldwaite type procedure) Reconstruction of dislocating patella; with patellectomy 27424 Lateral retinacular release, open 27425 Ligamentous reconstruction (augmentation), knee; extra-articular 27427 Ligamentous reconstruction (augmentation), knee; intra-articular (open) 27428 Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra- 27429 articular Manipulation of knee joint under general anesthesia (includes application of traction 27570 or other fixation devices) , knee, any technique 27580

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

Definition:

1. Synovectomy refers to the destruction or surgical removal of the membrane (synovium) that lines a joint. As the largest articulation and the one most frequently affected by chronic inflammation, the knee is the joint most often selected for synovectomy. Open surgical, chemical, radiation, and arthroscopic are all options for removing potentially damaging synovium of the knee.

Guideline: Requests for Open synovectomy will require review by the HealthHelp Medical Director for medical necessity.

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

References 1. Cram P, Lu X, Kates SL, et al. Total knee volume, utilization, and outcomes among Medicare beneficiaries, 1991-2010. JAMA 2012; 308:1227. 2. Kurtz S, Ong K, Lau E, et al. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89:780. 3. Mahomed NN, Barrett J, Katz JN, et al. Epidemiology of total in the United States Medicare population. J Bone Joint Surg Am 2005; 87:1222. 4. Skou ST, Rasmussen S, Laursen MB, et al. The efficacy of 12 weeks non-surgical treatment for patients not eligible for total knee replacement: a randomized controlled trial with 1-year follow-up. Osteoarthritis Cartilage 2015; 23:1465. 5. Skou ST, Roos EM, Laursen MB, et al. A Randomized, Controlled Trial of Total Knee Replacement. N Engl J Med 2015; 373:1597. 6. Arthroscopic Surgery doesn’t help with Arthritis Knee Pain. Carmen Rodriguez - https://www.npr.org/sections/health- shots/2017/05/11/527915056/arthroscopic-surgery-doesnt-help-with-arthritis-knee-pain 7. Knee versus conservative management in patients with degenerative knee disease: a systematic review. Romina Brignardello- Petersen-Gordon Guyatt-Rachelle Buchbinder-Rudolf Poolman-Stefan Schandelmaier-Yaping Chang-Behnam Sadeghirad-Nathan Evaniew- Per Vandvik - BMJ Open – 2017 8. Arthroscopic surgery not recommended for almost all cases of knee osteoarthritis. Susan Perry, 2017, https://www.minnpost.com/second- opinion/2017/05/arthroscopic-surgery-not-recommended-almost-all-cases-knee-osteoarthritis 9. Total Knee Arthroplasty Volume, Utilization, and Outcomes Among Medicare Beneficiaries, 1991-2010 Peter Cram-Xin Lu-Stephen Kates- Jasvinder Singh-Yue Li-Brian Wolf - Jama – 2012 10. Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, Berry DJ., The epidemiology of revision total knee arthroplasty in the United States. J Bone Joint Surg Am. 2009 Jan;91(1):128-33 11. Azad, Abul Kalam, et al. “Role of Muscle Strengthening Exercise on Osteoarthritis of the Knee Joint.” Journal of Medicine, vol. 12, no. 2, 2011, doi:10.3329/jom.v12i2.8418. 12. Alexandra Kirkley, M.D.,* Trevor B. Birmingham, Ph.D., Robert B. Litchfield, M.D., J. Robert Giffin, M.D.,Kevin R. Willits, M.D., Cindy J. Wong, M.Sc., Brian G. Feagan, M.D., Allan Donner, Ph.D., Sharon H. Griffin, C.S.S., Linda M. D’Ascanio, B.Sc.N., Janet E. Pope, M.D., and Peter J. Fowler, M.D. “A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee.” NEJM, vol 359 no. 11, 2008 13. https://www.uptodate.com/contents/synovectomy-for-inflammatory-arthritis-of-the-knee

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