I'm a member

Osteoarthritis (OA) affects about 21 million people in the United States. By age 65 years, the majority of the population has radiographic evidence of osteoarthritis and 11% have symptomatic OA of the knee. The diagnosis of osteoarthritis is established using a combination of clinical information derived from history, physical examination, radiologic imaging, and laboratory evaluation. An algorithm of diagnostic criteria for OA of the knee has been proposed by the American College of Rheumatology (ACR). The diagnosis of OA of the knee is defined as presenting with pain and meeting at least five of the following criteria:

• Patient older than 50 years of age
• Less than 30 minutes of morning stiffness
• Crepitus (noisy, grating sound) on active motion
• Bony tenderness
• Bony enlargement
• No palpable warmth of synovium
• Erythrocyte sedimentation rate (ESR) <40 mm/hr
• Rheumatoid factor <1:40
• Noninflammatory synovial fluid

The presence of clinical symptoms of OA does not always correlate well with the degree of abnormality seen radiographically. It has been noted that approximately 40% of patients who have severe findings on x-rays report no symptoms; conversely, patients with clinical symptoms may show no significant radiological changes.

Treatment for OA of the knee aims to alleviate pain and improve function to mitigate reduction in activity. However, most treatments do not modify the natural history or progression of OA, and thus are not considered curative. Nonsurgical modalities that are used include exercise; weight loss; various supportive devices; acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen; nutritional supplements (glucosamine and chondroitin); and intra-articular viscosupplements. Corticosteroid injection may be considered when relief from NSAIDs is insufficient or the patient is at risk from gastrointestinal adverse effects. If symptom relief is inadequate with conservative measures, invasive treatments may be considered. Operative treatments for symptomatic OA of the knee include arthroscopic lavage and cartilage debridement, osteotomy, and ultimately total joint arthroplasty. Surgical procedures intended to repair or restore articular cartilage in the knee, e.g., abrasion arthroplasty, microfracture techniques, and autologous chondrocyte implantation, are appropriate only for younger patients with focal cartilage defects secondary to injury and are not addressed in this policy.

Note: Arthroscopic debridement may be considered medically necessary when preoperative imaging indicates that specific anatomic lesions other than osteoarthritis, e.g., large meniscal tears, loose bodies, are the cause of the patient’s symptoms regardless of the presence of osteoarthritis.

7/16/2009: Approved by Medical Policy Advisory Committee (MPAC)

02/23/2011: Policy reviewed; no changes.

01/19/2012: Policy reviewed; no changes.

04/02/2013: Policy reviewed; no changes.

All codes billed for this procedure are considered non-covered and not eligible for coverage.

Non-Covered Codes        

Top