Arthroscopic Debridement and Lavage as Treatment of Osteoarthritis of the Knee

POLICY NUMBER

L.7.01.441

DESCRIPTION

Arthroscopic lavage and cartilage debridement are operative treatments for osteoarthritis (OA). Lavage is a procedure in which intra-articular fluid is aspirated and the joint is washed out, removing inflammatory mediators, debris, or small loose bodies from the osteoarthritic knee. Articular debridement involves removal of cartilage or meniscal fragments, but also can include cartilage abrasion, excision of osteophytes, and synovectomy. Debridement is intended to improve symptoms and joint function in patients with mechanical symptoms such as locking or catching of the knee.

Osteoarthritis (OA) affects approximately 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:

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 radiography film 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.

Although devices used during arthroscopic lavage and cartilage débridement are subject to regulation by the FDA, operative procedures are not.

POLICY

Arthroscopic debridement and/or lavage are considered not medically necessary for treatment of osteoarthritis of the knee.

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.

POLICY EXCEPTIONS

None

POLICY GUIDELINES

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member’s specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

A.  consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

B.  appropriate with regard to standards of good medical practice; and

C.  not solely for the convenience of the Member, his or her Provider; and

D.  the most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

Investigative is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized as a generally accepted standard of good medical practice for the treatment of the condition being treated and; therefore, is not considered medically necessary. For the definition of Investigative, “generally accepted standards of medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. In order for equipment, devices, drugs or supplies [i.e, technologies], to be considered not investigative, the technology must have final approval from the appropriate governmental bodies, and scientific evidence must permit conclusions concerning the effect of the technology on health outcomes, and the technology must improve the net health outcome, and the technology must be as beneficial as any established alternative and the improvement must be attainable outside the testing/investigational setting.

POLICY HISTORY

5/26/2009: Policy added

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.

03/07/2014: Policy reviewed; no changes.

01/30/2015: Policy reviewed; description updated. Policy statement unchanged.

04/30/2015: Removed ICD-9 diagnosis code 715.06 from the Code Reference section.

08/18/2015: Code Reference section updated for ICD-10 and to remove ICD-9 diagnosis codes 715.16, 715.26, 715.36, and 715.96.

05/31/2016: Policy number A.7.01.117 added. Policy Guidelines updated to add medically necessary and investigative definitions.

12/01/2016: Code Reference section updated to remove CPT code 29871.

07/27/2020: Policy reviewed. Policy statements unchanged. Sources updated.

01/18/2023: Policy reviewed. Policy statements unchanged. Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Medical policy number changed from "A.7.01.117" to "L.7.01.441."

08/21/2023: Policy reviewed; no changes.

08/20/2024: Policy reviewed; no changes.

SOURCE(S)

1. Blue Cross & Blue Shield Association policy # 7.01.117

2. Blue Cross and Blue Shield of South Carolina

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

Not Medically Necessary Codes

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