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The thermal shrinkage procedure involves the application of heat to a stretched but intact anterior cruciate ligament (ACL) using a specialized thermal probe. The goal of this procedure is to induce shrinkage of the collagen fibers comprising the ACL, causing the ACL to shorten and thereby stabilize the knee joint and reduce joint laxity.
This procedure is carried out by percutaneous or arthroscopic placement of a thermal catheter into the joint. A thermal coagulation generator is utilized to provide the required temperature for collagen shrinkage (between 65°C and 90°C). The probe is moved along the anterior aspect of the ligament in a distal to proximal fashion and to its medial and lateral margins. Following surgery, the leg is immobilized and kept non-weight-bearing for a period of 3 weeks. At 3 weeks, patients undergo a repeat KT 1000 measurement before being placed into a custom-made ACL derotation brace. They begin rehabilitation exercises consisting of progressive weight-bearing and closed chain exercises. At 3 months, patients can usually begin running on a flat surface and are released to full unrestricted exercise at 6 months (Naseef et al., 1997; Vangsness et al., 1997; Thabit, 1998; Fanton and Khan, 2001).
Thermal Shrinkage for Cruciate Ligament Injury is considered investigational.
Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.
The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.
POLICY HISTORY11/2002: Approved by Medical Policy Advisory Committee (MPAC)
3/10/2004: Code Reference section completed
11/10/2006: Policy reviewed, no changes
08/14/2015: Code Reference section updated for ICD-10. Removed ICD-9 diagnosis codes 718.86 and 724.86
Hayes Medical Technology Directory
CODE REFERENCEThis may not be a comprehensive list of procedure codes applicable to this policy.