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Knee Arthroscopy - CAM 776

General Information
It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.

Purpose
This guideline addresses the following elective, non-emergent, arthroscopic knee repair procedures; diagnostic knee arthroscopy, debridement with or without chondroplasty, meniscectomy/meniscal repair/meniscal transplant, ligament reconstruction/repair, articular cartilage restoration/repair (marrow stimulating and restorative techniques) , synovectomy (major [2+ compartments], minor [1 compartment]), loose body removal, lateral release/patellar realignment, manipulation under anesthesia (MUA), and lysis of adhesions for arthrofibrosis of the knee.

Scope
Open, non-arthroplasty knee surgeries are performed instead of an arthroscopy as dictated by the type and severity of injury and/or disease.

General Requirements

  • Elective arthroscopic surgery of the knee may be considered if the following general criteria are met:
    • There is clinical correlation of the individual’s subjective complaints with objective exam findings and/or imaging (when applicable)
    • Knee pain with documented loss of function: Deviation from normal knee function which may include painful weight bearing and/or inadequate range of motion (> 10 degrees flexion contracture or < 110 degrees flexion or both) to accomplish age-appropriate activities of daily living (ADLs), occupational or athletic requirements)
    • Individual is medically stable and optimized for surgery, and any treatable comorbidities are adequately medically managed such as diabetes, nicotine addiction, or an excessively high BMI. There should also be a shared decision between the patient and physician to proceed with knee surgery when comorbidities exist as it pertains to the increased risk of complications
    • Individual does not have an active local or systemic infection
    • Individual does not have active, untreated drug dependency (including but not limited to narcotics, opioids, or muscle relaxants) unless engaged in a treatment program
    • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)
  •  Clinical notes should address:
    • Symptom onset, duration, and severity
    • Loss of function and/or limitations
    • Type and duration of non-operative management modalities (where applicable)
  •  Unless otherwise stated in the subsections below, non-operative management must include at least TWO or more of the following, unless otherwise specified (4):
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Injections: corticosteroid, NSAID, viscosupplementation

Policy
INDICATIONS
Diagnostic Knee Arthroscopy
Diagnostic knee arthroscopy should rarely be required however may be medically necessary when the following criteria are met:

  • At least 12 weeks of knee pain with documented loss of function
  • History of painful weight bearing and/or physical examination that shows joint line tenderness, effusion and/or limited motion compared to pre-symptomatic joint range
  • Indeterminate radiographs AND MRI findings. Radiographs and/or MRI should not demonstrate any of the following: Kellgren-Lawrence Grade 3-4 changes (based on weight-bearing radiographs), meniscus tears, ligament tears, loose bodies, stress fractures (including insufficiency fractures) or patellofemoral instability (lateral patellar tilt or patellar subluxation)
  • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following (4):
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Corticosteroid injection
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Chondroplasty
Non-Patellofemoral chondroplasty (Femoral Condyle and Tibial Plateau)
Non-Patellofemoral (femoral condyle and tibial plateau) chondroplasty may be medically necessary when the following criteria are met (6):

  • At least 12 weeks of knee pain with documented loss of function
  • Two or more or persistent effusion(s)
  • MRI results demonstrate evidence of an area of localized articular cartilage damage or an unstable chondral flap
  • Failure of at least 12 weeks of non-operative treatment, including at least two of the following (4):
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Corticosteroid injection
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Patellofemoral chondroplasty
Patellofemoral chondroplasty may be medically necessary when the following criteria are met (7):

  • Anterior knee pain with documented loss of function, exacerbated by activities that load the patellofemoral joint such as ascending or descending stairs or being in seated position for extended periods of time with knee flexed
  • Other extra-articular or intra-articular sources of pain or dysfunction have been excluded (referred hip pain, radicular pain, tendinitis, bursitis, neuroma)
  • Physical exam localizes tenderness to the patellofemoral joint
  • No evidence of moderate to severe osteoarthritis (Kellgren-Lawrence Grade 3-4 based on weight-bearing radiographs and patellofemoral views [see Grading Appendix])
  • Failure of at least 12 weeks of non-operative treatment, including at least two of the following (4):
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Corticosteroid injection
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Meniscectomy/Meniscal Repair
Meniscectomy and/or meniscal repair may be medically necessary when the criteria in any of the following sections are met (8,9):

  • Section One
    • Symptomatic meniscal tear confirmed by MRI results that demonstrate a peripheral tear in the vascular zone, root tear, (10) or other tear that the requesting physician considers repairable and is associated with pain localized to the corresponding compartment upon physical examination
    • No Kellgren-Lawrence Grade 3-4 changes on standing X-rays
  • Section Two
    • MRI demonstrate a meniscus tear in a patient age <21 years who complains of pain or mechanical symptoms or has ANY positive meniscal findings on physical examination
  • Section Three
    • MRI demonstrates a bucket-handle tear of the meniscus and there is a history of acute injury/onset of symptoms with a locked knee and/or mechanical symptoms of locking
  • Section Four: When a symptomatic meniscus tear is suspected and meets the following criteria:
    • When at least two of the following physical examination findings are present or there is at least one of the following physical examination findings and there is a history of mechanical symptoms such as 'catching' or 'locking':
      • Knee joint line pain with forced hyperextension upon physical exam
      • Knee joint line pain with maximum flexion upon physical exam
      • Knee pain, crepitus, or an audible or palpable click with the McMurray’s test or Apley grind test
      • Joint line tenderness to palpation upon physical exam
    • Weight-bearing X-rays (standing X-rays, Rosenberg view, 45-degree flexed PA view, etc.) demonstrate no moderate or severe osteoarthritic changes defined as Kellgren-Lawrence Grade 3-4 [see Grading Appendix]; X-rays should be described as showing either no arthritis or mild/minimal arthritis only

OR

    • MRI results confirm a frank meniscal tear (not simply degenerative changes, i.e., fraying) and the MRI does not demonstrate any of the following: moderate or severe articular cartilage thinning, full-thickness articular cartilage loss or defects, extrusion of the meniscus, subchondral edema, more than mild osteophytes, subchondral cysts, or an impression of 'moderate' or 'advanced/severe' arthritis (see absolute and relative contraindications). If the MRI demonstrates any of the above-described findings of more than mild arthritis, weight-bearing X-rays are required to confirm no moderate or severe articular cartilage loss * (see background section).
    • Failure of at least 6 weeks of non-operative treatment, including at least TWO of the following:
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
    • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Absolute Contraindications Meniscectomy/Meniscal Repair

  • Arthroscopic meniscectomy or meniscal repair is never medically necessary in the presence of Kellgren-Lawrence Grade 4 osteoarthritis (8) [see Grading Appendix]
  • ANY intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Relative Contraindications Meniscectomy / Meniscal Repair

  • Meniscectomy or repair is considered NOT MEDICALLY NECESSARY in the presence of Kellgren-Lawrence Grade 3 osteoarthritis [see Grading Appendix], Unless (8):
    • There has been the acute onset of locking (does not include catching, popping, cracking, etc.); AND
    • There is MRI evidence of a bucket-handle or displaced meniscal fragment that correlates with the correct compartment (i.e., medial tenderness and locking, for a medial meniscus tear)
  • If grade 3 changes are present, only a meniscectomy may be indicated, not a repair.  If there is evidence of meniscal extrusion on coronal MRI, with/without subchondral edema, arthroscopy is relatively contraindicated, even if a tear is present
Meniscal Transplant

Meniscal Transplants may be medically necessary when the following criteria are met (9,11):

  • Individual is < 40 years of age
  • Individual has no evidence of arthritic changes
  • Symptomatic meniscal deficiency confirmed by MRI results that show a meniscal deficient compartment, OR previous arthroscopy photographs or video showing subtotal or total meniscectomy
  • Failure of at least 6 weeks of non-operative treatment, including at least two of the following:
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Corticosteroid injection
Absolute Contraindications: Meniscal Transplant  (11)
  • Uncorrected (staged or simultaneous) ligamentous insufficiency (ACL, PCL, MCL, LCL, PMC, PLC)
  • Uncorrected (staged or simultaneous) malalignment greater than 5 degrees varus or 5 degrees valgus
  • Uncorrected (staged or simultaneous) full-thickness articular cartilage isolated defects (International Cartilage Research Society Grade 3 or 4; Outerbridge Grade IV [see Grading Appendix])
  • Kellgren-Lawrence Grade 3 or 4 osteoarthritis [see Grading Appendix]
  • Intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Ligament Reconstruction or Repair
Anterior Cruciate Ligament (ACL) Repair or Reconstruction with Allograft or Autograft, With or Without Extraarticular Tenodesis (12,13,14)
ACL reconstruction or repair may be medically necessary when the criteria in any of the following sections are met and individual has no evidence of severe arthritis defined as Kellgren-Lawrence grade 3 or 4. (If the MRI results demonstrate an ACL tear and there is no mention of significant arthritis, especially in the younger individual, X-rays are not required. However, in others with significant MRI evidence of arthritis, standing X-rays are required to confirm that no Kellgren-Lawrence grade 3 or 4 changes are present).

  • Section One
    • Acute ACL tear confirmed by MRI in high demand occupation or competitive athlete (as quantified by Marx activity score for athletics (any score > 4) and Tegner activity score for athletics and/or occupation ((score > 2) [see Grading Appendix]
  • Section Two
    • MRI results confirm an ACL tear associated with other ligamentous instability or repairable meniscus
  • Section Three
    • When the following criteria are met
      • Patient history of instability at the time of an acute injury or history of recurrent knee instability (as defined subjectively as 'giving way', 'giving out', 'buckling', two-fist sign) 
      • Physical examination findings demonstrate a positive Lachman test, Lachman test 1A, 1B, 2A, 2B, 3A, 3B, anterior drawer, pivot shift test, or instrumented (KT-1000 or KT-2000) laxity of greater than 3 mm side-side difference
      • MRI results confirm complete ACL tear or substantial partial tear with a non-functioning ACL as demonstrated on physical examination

NOTE: Requests for ACL repair or reconstruction in individuals < age 13 will be reviewed on a case-by-case basis (15)

Posterior Cruciate Ligament (PCL) Reconstruction  (16,17)
PCL reconstruction or repair may be medically necessary when the following criteria are met:

  • Knee instability (as defined subjectively as 'giving way', 'giving out' or 'buckling') with clinical findings of any of the following signs/tests: positive posterior drawer, posterior sag, quadriceps active, dial test at 90 degrees knee flexion or reverse pivot shift test
  • MRI results confirm complete PCL tear
  • Failure of at least 12 weeks of non-operative treatment, including physical therapy emphasizing quadriceps strengthening
  • Absence of medial and patellofemoral K-L grade 3-4 changes in chronic tears [see Grading Appendix]

The following clinical scenarios will be considered and decided on a case-by-case basis (18):

  • Pediatric and adolescent tears in individuals with open physis or growth plates
  • Symptomatic partial tears with persistent instability despite non-operative treatment
  • Incidental Kellgren-Lawrence grade 2-3 osteoarthritis [see Grading Appendix] in acute/subacute tears with unstable joint
  • Acute PCL repair or reconstruction when surgery is also required for the ACL, MCL or LCL
  • Tears in individuals < age 13

Collateral Ligament Repair or Reconstruction
Collateral ligament repair or reconstruction should rarely occur independent of additional ligament repair or reconstruction surgery (ACL, MCL, LCL).

All non-traumatic collateral ligament repair/reconstruction requests will be reviewed on a case-by-case basis.

Articular Cartilage Restoration/Repair
Skeletally Immature Indications
Articular cartilage reparative or stimulation procedures may be medically necessary when the following criteria in ANY of the following Sections are met (19,20,21):

  • Section One
    • Skeletally immature patient
    • Individual is symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion)
    • Asymptomatic patients will be reviewed on a case-by-case basis
    • Radiographic findings (X-ray or MRI) of a displaced osteochondral lesion
  • Section Two
    • Skeletally immature patient
    • Individual is symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion)
    • Radiographic findings (X-ray or MRI) findings of a stable osteochondral lesion
    • Failure of at least 12 weeks of non-operative treatment, including at least two of the following:
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection

Exclusion (applies to all criteria above)

  • Exclude individuals with evidence of meniscal deficiency and/or malalignment if these are not being addressed (meniscal transplant and/or lateral release/patellar realignment procedure) at the same time as the cartilage restoration procedure

Skeletally Mature Indications
Articular cartilage reparative marrow stimulation procedures
Reparative marrow stimulation techniques such as microfracture & drilling (22,23) may be medically necessary when the following criteria are met (24,25,26):

  • Skeletally mature adult
  • Individuals are symptomatic with anterior knee pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion
  • For trochlea or patellar lesions physical examination findings should be localized to the patellofemoral joint
  • MRI confirms an isolated full-thickness chondral or osteochondral lesion of the femoral condyle, trochlea, or patella < 2.0 cm2
  • Physical exam findings and/or (imaging) results confirm no ligamentous instability
  • For femoral condyle lesions, no evidence of prior meniscectomy in same compartment unless concurrent meniscal transplant performed
  • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following:
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Corticosteroid injection
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

NOTE: Abrasion arthroplasty is included in coding but is not indicated

Articular cartilage restorative procedures – femoral condyle and trochlea
Restorative procedures for articular cartilage loss may include the following: osteochondral autograft transfer (OAT), osteochondral allograft transplantation (OCA), autologous chondrocyte implantation (ACI), or matrix autologous chondrocyte implantation (MACI). The OAT or OCA procedures are preferable if the lesion involves subchondral bone. (22,23,27)

An articular cartilage restorative procedure may be medically necessary when the following criteria are met (24,25,26):

  • Skeletally mature adult
  • Individual has been symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion) for at least 6 months
  • Individual is < 50 years of age
  • BMI < 35 (optimal outcomes if patient BMI < 30)
  • No prior meniscectomy in same compartment (unless concurrent or staged meniscal transplant performed)
  • MRI results confirm an isolated full thickness chondral or osteochondral lesion of the femoral condyles or trochlea with stable surrounding articular cartilage:
    • < 2.0 cm2 - OAT
    • > 2.0 cm2 - ACI, MACI, OCA
  • MRI and/or physical findings confirm knee has normal alignment as defined as +/- 3 degrees from neutral on full-length mechanical axis long-leg x-ray (unless concurrent or staged tibial or femoral osteotomy performed) and stability (unless concurrent ligamentous repair or reconstruction performed)
  • MRI and/or X-rays shows no evidence of osteoarthritis (no greater than Kellgren-Lawrence Grade 2 changes on weight-bearing X-rays [see Grading Appendix])
  • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following:
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Corticosteroid injection
  • No prior meniscectomy in same compartment (unless concurrent or staged meniscal transplant performed)
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Articular cartilage restorative procedures - patella
Restorative procedures for articular cartilage loss of the patella may include the following:  osteochondral autograft transfer (OAT), osteochondral allograft transplantation (OCA), autologous chondrocyte implantation (ACI), or matrix autologous chondrocyte implantation (MACI), with or without tibial tubercle osteotomy. * (22,28)

An articular cartilage restorative procedure may be medically necessary when the following criteria are met (24,25,26):

  • Anterior knee pain and loss of function
  • Individual is < 50 years of age
  • BMI < 35 (optimal outcomes if patient BMI < 30)
  • Other extra-articular or intra-articular sources of pain or dysfunction have been excluded (referred pain, radicular pain, tendinitis, bursitis, neuroma)
  • Physical exam localizes tenderness to the patellofemoral joint with pain aggravated by activities that load the joint (single leg squat, descending > ascending stairs or stair climbing, and being in seated position for extended periods of time with knee flexed)
  • MRI results confirm an isolated full thickness chondral or osteochondral lesion of the patella:
    • < 2.0 cm2 - OAT
    • > 2.0 cm2 - ACI, MACI, OCA
  • No evidence of associated osteoarthritis greater than Kellgren-Lawrence 2 of the patellofemoral joint or medial/lateral compartments on weight bearing X-rays [see Grading Appendix]
  • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following:
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Corticosteroid injection
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

*Patellofemoral Chondrosis

For isolated tibial tubercle osteotomy for patellofemoral chondrosis without articular cartilage restoration procedures, the same criteria above apply except patellofemoral X-rays should document Kellgren-Lawrence grade 3 or 4 changes with no more than K-L 2 changes of the medial and lateral compartments on weight-bearing X-rays.

Articular Cartilage Restoration and Repair Exclusions

  • These requests are excluded from consideration under this guideline:
    • Micronized cartilage extracellular matrix (BioCartilage)
    • Autologous Matrix-Induced Chondrogenesis (AMIC)
    • Bone marrow aspirate concentrate (BMAC) implantation
    • Hybrid ACI/OAT procedure
    • Particulated juvenile allograft cartilage (PJAC, DeNovo)
    • Particulated autologous cartilage implantation (PACI)
    • Viable cartilage allograft putty (CartiMax)
    • Decellularized Osteochondral Allograft Plugs (e.g., Chondrofix)
    • Cryopreserved viable osteochondral allograft (CVOCA; Cartiform and ProChondrix)
    • Aragonite biphasic osteochondral scaffolds (Agili-C™)
    • Human umbilical cord blood-derived mesenchymal stem cells (CARTISEM)

Synovectomy (Major [2+ compartments], Minor [1 compartment])
Synovectomy may be medically necessary when the criteria in any of the following sections are met (29,30):

  • Section One
    • Proliferative rheumatoid synovium (in individuals with established rheumatoid arthritis)
    • Non-responsive to disease modifying drug (DMARD) therapy for at least 6 months
    • At least one instance of aspiration of joint effusion and corticosteroid injection (if no evidence of infection)
    • Failure of at least 6 weeks of non-operative treatment, including at least two of the following:
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
  • Section Two
    • Hemarthrosis from injury, coagulopathy or bleeding disorder confirmed by physical exam, joint aspiration, and/or MRI
  • Section Three
    • Proliferative pigmented villonodular synovitis, synovial chondromatosis, sarcoid synovitis, or similar proliferative synovial disease, traumatic hypertrophic synovitis, cyclops lesion, or fat pad syndrome confirmed by history, MRI, or biopsy (31,32)
    • At least one instance of aspiration of joint effusion and injection of corticosteroid (if no evidence of infection)
    • Failure of at least 6 weeks of non-operative treatment, including at least two of the following:
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
  • Section Four
    • Patient is symptomatic and there is detection of a painful plica confirmed by physical exam
    • MRI confirms the presence of a plica
    • Failure of at least 12 weeks of non-operative treatment, including at least two of the following:
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
    • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Loose Body Removal
Loose body removal may be medically necessary when the following criteria are met:

  • Documentation of mechanical symptoms that cause limitation or loss of function
  • X-ray, CT, or MRI documentation of a loose body
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Lateral Release/Patellar Realignment
This guideline describes indications for surgical procedures to address patellofemoral pain disorders and abnormal alignment of the extensor mechanism of the knee by arthroscopic and/or open surgical techniques.

Lateral Patellar Compression Syndrome
Surgical intervention for the treatment of lateral patellar compression syndrome is indicated when the following criteria are met (33,34,35):

  • No evidence of patellar dislocation
  • Reproducible isolated lateral patellofemoral pain with patellar tilt test
  • Evidence of lateral patellar tilt from radiologic images (patellofemoral view: Merchant (45 degrees flexion; and/or skyline (60-90 degrees flexion); and/or sunrise (60-90 degrees flexion)
  • Associated lateral patella facet Kellgren-Lawrence changes grade 1, 2, or 3 [see Grading Appendix]
  • No evidence of medial patellofemoral changes (Kellgren-Lawrence Grade 2 osteoarthritis or higher [see Grading Appendix])
  • Failure of at least 6 months of non-operative treatment, including quadriceps strengthening and appropriate hamstring/IT band stretching and patellar mobilization techniques, and at least one of the following:
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Corticosteroid injection
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

Patellar Malalignment and/or Patellar Instability
Surgical intervention for the treatment of patellar malalignment and/or patellar instability is indicated when the following criteria in any of the following sections are met (36,37,38,39):

  • Section One
    • Acute traumatic patellar dislocation is associated with an osteochondral fracture, loose body, vastus medialis obliquus/medial patellofemoral ligament muscle avulsion, or other intra-articular injury that requires urgent operative management
  • Section Two
    • First time patellar dislocation (not subluxation)
    • Age < 25
    • Any of the following:
      • Imaging demonstrates a TT-TG distance of 15 mm or greater
      • Trochlear dysplasia
      • Patella alta
  • Section Three
  • History of 2 or more patellar dislocations
    • Radiologic confirmation of MPFL (medial patellofemoral ligament) deficiency (including evidence of acute or remote injury, scarring, incomplete healing, etc.) and there is a TT-TG distance of 15 mm or greater, trochlear dysplasia, or patella alta
    • Physical examination demonstrates evidence of patellar instability (positive apprehension test, increased lateral patellar translation, etc.)
  • Section Four
    • When ALL of the following criteria have been met:
      • Patient complains of patellar subluxation or has a history of only one patellar dislocation (see Section Two above)
      • Physical exam has patellofemoral tenderness and abnormal articulation of the patella in the femoral trochlear groove (patellar apprehension or positive J sign)
      • Radiologic and/or advanced images (CT or MRI) rule out fracture or loose body, and show abnormal articulation, trochlear dysplasia, abnormal TT-TG distance (tibial tubercle-trochlear groove) * or other abnormality related to malalignment
      • Failure of at least 6 months of non-operative treatment, including at least 3 months of physical therapy, and ONE of the following:
        • Rest or activity modifications/limitations
        • Ice/heat
        • Protected weight bearing
        • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
        • Brace/orthosis
        • Supervised home exercise
        • Weight optimization
        • Corticosteroid injection
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

 *The tibial tubercle-trochlear groove (TT-TG) distance is normally @5-10 mm. Some authors use 13 mm as a cut-off and most agree that a TT-TG of 15 mm or over is abnormal. (40) TT-TG values over 17 mm indicate other possible bony abnormalities such as increased femoral anteversion that may cause patellar instability. (38,41)

Manipulation Under Anesthesia (MUA)
Manipulation under anesthesia (MUA) may be indicated when the following criteria are met (42,43):

  • Individual is less than 20 weeks after ligamentous or joint reconstruction
  • Physical exam findings demonstrate inadequate range of motion of the knee defined as less than 110 degrees of flexion or lack of full extension
  • Failure to improve range of motion of the knee despite 6 weeks (12 visits) of documented physical therapy

Lysis of Adhesions for Arthrofibrosis of the Knee
Surgical indications are based on relevant clinical symptoms, physical exam, radiologic findings, time from primary surgery, and response to conservative management when medically appropriate. Improved range of motion may be accomplished through arthroscopically assisted or open lysis of adhesions with general anesthesia, regional anesthesia, or sedation. (43,44)

Lysis of adhesions for arthrofibrosis of the knee may be indicated when all the following criteria are met:

  • Individual is > 12 weeks post-surgery fracture or resolved infection
  • Physical exam findings demonstrate inadequate range of motion of the knee, defined as < 110 degrees of flexion or lack of full extension
  • Failure to improve range of motion of the knee despite 6 weeks (12 visits) of documented physical therapy
  • No intra-articular cortisone injections within 4 weeks of surgery (1,2,3)

BACKGROUND
Meniscectomy and Arthritis of the Knee
There is a high incidence of incidental meniscal findings on knee MRI in middle-aged and elderly individuals and several studies have indicated that there is no difference in outcome between operative and non-operative treatment of individuals with degenerative meniscus tears, especially when associated with an arthritic knee. (8,47) Arthroscopic debridement of degenerative meniscus tears in those with visible arthritis is generally not recommended and, in some cases, may worsen the symptoms and progression of the arthritis. (8,48) Studies have also demonstrated an increased incidence of revision arthroplasty, infection, loosening and stiffness in individuals who underwent a knee arthroscopy prior to a total knee arthroplasty.

The imaging evaluation of the knee for individuals with meniscus tears should be individualized, the goal of which is to recommend treatment for only those with no or minimal associated arthritis.

Although most individuals that have a request for arthroscopic meniscectomy will have had BOTH an MRI AND X-rays of the knee, only one of these tests is required for approval, provided all other criteria for meniscectomy have been met. For example, if there has been a failure to improve with 6 weeks of non-operative treatment and there are physical examination findings of a meniscus tear, an MRI is not required, only weight-bearing X-rays that demonstrate no more than mild arthritis. Likewise, if an MRI describes a frank meniscus tear and does not describe any significant associated arthritis, weight-bearing X-rays are not required. However, as noted above, if an MRI demonstrates findings of more than mild arthritis, weight-bearing X-rays are required to confirm no moderate or severe articular cartilage loss.

Grading Appendix
Kellgren-Lawrence Grading System (Standing/weight-bearing X-rays)  (49)

Grade

Description

0

No radiographic features of osteoarthritis

1

Possible joint space narrowing and osteophyte formation

2

Definite osteophyte formation with possible joint space narrowing

3

Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour

4

Large osteophytes, marked narrowing of joint space, severe sclerosis, and definite deformity of bone contour
Outerbridge Arthroscopic Grading System (50)

Grade

Description

0

Normal cartilage

I

Softening and swelling/blistering

II

Partial thickness defect, fissures < 1.5cm diameter/wide

III

Fissures /defects down to subchondral bone with intact calcified cartilage layer, diameter > 1.5cm

IV

Exposed subchondral bone

Marx Scale (51)

For determination of activity level in acute ACL tears. Indicate how often you performed each activity in your healthiest and most active state, in the past year.

Activity/Movement

Less than one time in a month

One time in a month

One time in a week

2 or 3 times in a week

4 or more times in a week

Running: running while playing a sport or jogging

0

1

2

3

4

Cutting: changing directions while running

0

1

2

3

4

Deceleration: coming to a quick stop while running

0

1

2

3

4

Pivoting: turning your body with your foot planted while playing sport; For example: skiing, skating, kicking, throwing, hitting a ball (golf, tennis, squash), etc.

0

1

2

3

4

Tegner Scores  (52)
For determination of activity level in acute ACL tears. Indicate in the spaces below the HIGHEST level of activity that you participated in BEFORE YOUR INJURY and the highest level you are able to participate in CURRENTLY.

Level

Activity Description

Level 10

Competitive sports- soccer, football, rugby (national elite)

Level 9

Competitive sports- soccer, football, rugby (lower divisions), ice hockey, wrestling, gymnastics, basketball

Level 8

Competitive sports- racquetball or bandy, squash or badminton, track and field athletics (jumping, etc.), down-hill skiing

Level 7

Competitive sports- tennis, running, motorcars speedway, handball

Recreational sports- soccer, football, rugby, bandy, ice hockey, basketball, squash, racquetball, running

Level 6

Recreational sports- tennis and badminton, handball, racquetball, down-hill skiing, jogging at least 5 times per week

Level 5

Work- heavy labor (construction, etc.)

Competitive sports- cycling, cross-country skiing; Recreational sports- jogging on uneven ground at least twice weekly

Level 4

Work- moderately heavy labor (e.g., truck driving, etc.)

Level 3

Work- light labor (nursing, etc.)

Level 2

Work- light labor

Walking on uneven ground possible, but impossible to backpack or hike

Level 1

Work- sedentary (secretarial, etc.)

Level 0

Sick leave or disability pension because of knee problems

References

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2. Forsythe B, Forlenza E M, Agarwalla A, Cohn M R, Lavoie-Gagne O et al. Corticosteroid Injections 1 Month Before Arthroscopic Meniscectomy Increase the Risk of Surgical-Site Infection. Arthroscopy. 2021; 37: 2885-2890.e2. 10.1016/j.arthro.2021.02.047.

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10. Krych A J, Lamba A, Wang A S, Boos A M, Camp C L et al. Nonoperative Management of Degenerative Medial Meniscus Posterior Root Tears: Poor Outcomes at a Minimum 10-Year Follow-up. American Journal of Sports Medicine. 2023; 51: 2603-2607. 10.1177/03635465231185132.

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16. Bedi A, Musahl V, Cowan J B. Management of Posterior Cruciate Ligament Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2016; 24: 277-289. 10.5435/JAAOS-D-14-00326.

17. Raj M A, Mabrouk A, Varacallo M. Posterior Cruciate Ligament Knee Injuries [Updated 2023 Aug 8]. Stat Pearls Publishing. 2023; Accessed: 09/24/2024. https://www.ncbi.nlm.nih.gov/books/NBK430726/.

18. Scarcella M J, Yalcin S, Scarcella N R, Saluan P, Farrow L D. Outcomes of Pediatric Posterior Cruciate Ligament Reconstruction: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2021; 9: 232596712110325. 10.1177/23259671211032539.

19. Chau M, Klimstra M, Wise K, Ellermann J, Tóth F et al. Osteochondritis Dissecans. Journal of Bone and Joint Surgery. 2021; 103: 1132-1151. 10.2106/JBJS.20.01399.

20. Salzmann G, Niemeyer P, Hochrein A, Stoddart M, Angele P. Articular Cartilage Repair of the Knee in Children and Adolescents. Orthopaedic Journal of Sports Medicine. 2018; 6: 232596711876019. 10.1177/2325967118760190.

21. Valtanen R, Arshi A, Kelley B, Fabricant P, Jones K. Articular Cartilage Repair of the Pediatric and Adolescent Knee with Regard to Minimal Clinically Important Difference: A Systematic Review. CARTILAGE. 2020; 11: 9-18. 10.1177/1947603518783503.

22. Cong B, Sun T, Zhao Y, Chen M. Current and Novel Therapeutics for Articular Cartilage Repair and Regeneration. Therapeutics and Clinical Risk Management. 2023; 19: 485-502. 10.2147/TCRM.S410277.

23. Niemeyer P, Laute V, Zinser W, Becher C, Kolombe T et al. A Prospective, Randomized, Open-Label, Multicenter, Phase III Noninferiority Trial to Compare the Clinical Efficacy of Matrix-Associated Autologous Chondrocyte Implantation With Spheroid Technology Versus Arthroscopic Microfracture for Cartilage Defects of the Knee. Orthopaedic Journal of Sports Medicine. 2019; 7: 10.1177/2325967119854442.

24. Filho J, Sousa E. Treatment of Chondral Lesions in the Knee. Rev Bras Ortop. 2023; 58: e551-e556. 10.1055/s-0043-1772196.

25. Hinckel B, Thomas D, Vellios E, Hancock K, Calcei J et al. Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures. CARTILAGE. 2021; 13: 473S-495S. 10.1177/1947603521993219.

26. Mall N, Harris J, Cole B. Clinical Evaluation and Preoperative Planning of Articular Cartilage Lesions of the Knee. Journal of the American Academy of Orthopaedic Surgeons. 2015; 23: 633-640. 10.5435/JAAOS-D-14-00241.

27. Weishorn J, Wiegand J, Zietzschmann S, Koch K, Rehnitz C et al. Factors Influencing Long-term Outcomes After Matrix-Induced Autologous Chondrocyte Implantation: Long-term Results at 10 Years. American Journal of Sports Medicine. 2024; 10.1177/03635465241270152.

28. Ginesin E, Chari N, Barnhart J, Wojnowski N, Patel R. Cartilage Restoration for Isolated Patellar Chondral Defects: An Updated Systematic Review. Orthopaedic Journal of Sports Medicine. 2023; 11: 10.1177/23259671231153422.

29. Badin D, Leland C R, Bronheim R S, Balmuri N, Lee R J. Synovectomy in juvenile idiopathic arthritis: A protocol for systematic review and meta-analysis. Medicine (United States). 2022; 101: E32278. 10.1097/MD.0000000000032278.

30. Chalmers P, Sherman S, Raphael B, Su E. Rheumatoid synovectomy: Does the surgical approach matter? Clinical Orthopaedics and Related Research. 2011; 469: 2062-2071. 10.1007/s11999-010-1744-3.

31. Chandra A, Agarwal S, Donahue A, Handorf E, Abraham J. Arthroscopic Versus Open Management of Diffuse-Type Tenosynovial Giant Cell Tumor of the Knee: A Meta-analysis of Retrospective Cohort Studies. Journal of the American Academy of Orthopaedic Surgeons Global Research and Reviews. 2021; 4: 10.5435/JAAOSGlobal-D-21-00217.

32. Fecek C, Carter K R. Pigmented Villonodular Synovitis [Updated 2023 Aug 7]. Stat Pearls Publishing. 2023; Accessed: 09/25/2024. https://www.ncbi.nlm.nih.gov/books/NBK549850

33. Bump J M, Lewis L. Patellofemoral Syndrome [Updated 2023 Feb 13]. Stat Pearls Publishing. 2023; Accessed: 09/25/2024. https://www.ncbi.nlm.nih.gov/books/NBK557657/.

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43. Fackler N, Chin G, Karasavvidis T, Bohlen H, Smith E et al. Outcomes of Arthroscopic Lysis of Adhesions for the Treatment of Postoperative Knee Arthrofibrosis: A Systematic Review. Orthopaedic Journal of Sports Medicine. 2022; 10: 10.1177/23259671221124911.

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Coding Section

Code Number Description

CPT

27332

Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial or lateral

 

27333

Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial and lateral

 

27403

Arthrotomy with meniscus repair, knee

 

27405

Repair, primary, torn ligament and/or capsule, knee; collateral

 

27407

Repair, primary, torn ligament and/or capsule, knee; cruciate

 

27409

Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments

 

27412

Autologous chondrocyte implantation, knee

 

27415

Osteochondral allograft, knee, open

 

27416

Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])

 

27418

Anterior tibial tubercleplasty (eg, maguet type procedure)

 

27420

Reconstruction of dislocating patella; (eg, hauser type procedure)

 

27422

Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, campbell, goldwaite type procedure)

 

27424

Reconstruction of dislocating patella; with patellectomy

 

27425

Lateral retinacular release, open

 

27427

Ligamentous reconstruction (augmentation), knee; extra-articular

 

27428

Ligamentous reconstruction (augmentation), knee; intra-articular (OPEN)

 

27429

Ligamentous reconstruction (augmentation), knee; intra-articular (OPEN) and extra-articular

 

27570

Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)

 

29866

Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])

 

29867

Arthroscopy, knee, surgical; osteochondral autograft (eg, mosaicplasty)

 

29868

Arthroscopy, knee, surgical; meniscal transplantation (include arthrotomy for meniscal insertion), medial or lateral

 

29870

Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)

 

29873

Arthroscopy, knee, surgical; with lateral release

 

29874

Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)

 

29875

Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)

 

29876

Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)

 

29877

Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)

 

29879

Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture

 

29880

Arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

 

29881

Arthroscopy, knee, surgical; with meniscectomy (medial or lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

 

29882

Arthroscopy, knee, surgical; with meniscus repair (medial or lateral)

 

29883

Arthroscopy, knee, surgical; with meniscus repair (medial and lateral)

 

29884

Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)

 

29885

Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion)

 

29886

Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion

 

29887

Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation

 

29888

Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

 

29889

Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction

HCPCS

G0289

Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2026 Forward

04/01/2026 New Policy


 

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