Knee Arthroplasty - West Central and North East Region

POLICY NUMBER

L.7.01.437

DESCRIPTION

Knee arthroplasty also called knee replacement is most commonly performed for knee joint failure caused by osteoarthritis (OA) and other types of inflammatory arthritis. The aims of knee arthroplasty are relief of pain and improvement in function by removing damaged cartilage at interfacing surfaces of the femur, tibia and/or patella and then resurfacing the damaged interface areas with artificial implants.

Traditionally, an inpatient hospital stay was required for all joint replacement procedures. Three primary factors made inpatient hospitalization necessary: pain control, physical therapy, and the possible need for blood transfusion. Advances in surgical technique, implants, comprehensive blood management, and multimodal pain management have strikingly reduced the hospital stay. Adjustments to anesthesia and other medications reduce pain more effectively while also minimizing side effects like nausea that could delay recovery.

Related medical policies -

• Total Knee Arthroplasty (TKA)

POLICY

Knee Arthroplasty is considered medically necessary when ALL of the following criteria are met:

1. A diagnosis of osteoarthritis (OA), osteonecrosis, or rheumatoid arthritis (RA),

2. Radiographic evidence of joint damage,

3. End-stage disease with exposed bone in ≥ 1 knee compartment,

4. Significant persistent pain and functional limitations that interfere with activities of daily living, e.g., reduced walking distance, inability to work,

5. Optimal medical management has been tried and failed, including but not limited to:

   • Weight loss efforts

   • Nonsteroidal anti-inflammatory medications (NSAIDs)

   • Disease modifying antirheumatic drugs (DMARDs)

   • Cortisone injections

   • Lubricating injections

   • Physical therapy

   • External support (e.g., brace)

Revision knee arthroplasty or replacement of the previous failed knee prosthesis with a new prosthesis may be considered medically necessary in individuals with significant increase in pain/swelling and/or decrease in knee function, in the presence of any of the following:

• Infection

• Wear and loosening

• Malalignment or malposition

• Fractures

• Instability

The Company requires care coordination for all knee arthroplasty Specialty Services, to determine 1) Whether medical necessity and medical policy guidelines have been met and 2) Most appropriate Place of Treatment.

Hospital Criteria

Knee arthroplasty (including revision arthroplasty) is considered medically necessary in the hospital setting in adults (18 and older) that meet the above medical necessity criteria AND one or more of the following additional clinical requirements:

1. American Society of Anesthesiologists (ASA) Physical Status classification of ASA PS 4 or more, or

2. Body Mass Index (BMI) 50 or more subject to physician discretion, or

3. Body Mass Index (BMI) 40 – 49 with an additional clinical criteria listed in policy, or

4. Pregnant, or

5. Known history of difficult airway/intubation, or 

6. Known history or strong family history of malignant hyperthermia, psudocholinesterase deficiency or other anesthesia complication, or 

7. Known history of recent myocardial infarction (less than 6 months), or

8. Pacemakers or Internal Automatic Defibrillators at physician discretion, or 

9. Recent sepsis (less than 3 months), or

10. History of cirrhosis (MELD Score >8), or

11. Chronic Obstructive Pulmonary Disease (COPD) with FEV1<50%, or

12. End stage renal disease (on dialysis), or

13. Expected operative time > 120 minutes, or

14. Hemoglobin <12 or other anticipated need for blood transfusion or replacement clotting factor (i.e. bleeding disorder), or

15. Uncompensated chronic heart failure (NYHA class III or IV), or

16. Poorly controlled, resistant hypertension (3 or more drugs to control blood pressure), or

17. Recent history of cerebrovascular accident (<3 months), or

18. Increased risk for cardiac ischemia (drug eluting stent placed <1 year or angioplasty <90 days), or

19. Symptomatic cardiac arrhythmia despite medication, or

20. Significant valvular heart disease, or

21. Poorly controlled asthma (FEV1 <80% despite treatment), or

22. Moderate to severe obstructive sleep apnea defined as Apnea/Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) ≥15 events/hour not compliant with CPAP or compliant with CPAP but have non-optimized comorbid conditions, or

23. Have a presumptive diagnosis of obstructive sleep apnea determined by STOP-Bang screening questionnaire and have non-optimized comorbid conditions, or,

24. Have known moderate to severe obstructive sleep apnea or presumptive diagnosis of obstructive sleep apnea and post-operative pain cannot be managed predominantly with non-opioid analgesics, or

25. Substance use disorder (opioids, alcohol, street drugs) or,

26. Procedural considerations subject to Company approval.

Benefits are only provided for hospital knee arthroplasty Specialty Services when medical necessity and medical policy guidelines including hospital setting criteria have been met and care coordinated by the Company. BCBSMS will provide coverage for all other knee arthroplasty Specialty Services that meet medical necessity and medical policy guidelines if rendered by a Blue Specialty Network Provider in a setting coordinated and contracted with the Company.

POLICY EXCEPTIONS

This Knee Arthroplasty – West Central and North East Region Medical Policy is applicable to Network Providers in the West Central and North East Regions of Mississippi only. The West Central and North East Regions includes counties Alcorn, Attala, Benton, Bolivar, Calhoun, Carroll, Chickasaw, Choctaw, Claiborne, Clay, Copiah, Grenada, Hinds, Holmes, Humphreys, Issaquena, Itawamba, Leake, Lee, Leflore, Lowndes, Madison, Monroe, Montgomery, Oktibbeha, Pontotoc, Prentiss, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Tippah, Tishomingo, Union, Warren, Washington, Webster, Yalobusha, and Yazoo.

State Health Plan (State and School Employees): All Inpatient Hospital admissions for knee arthroplasty must be certified as medically necessary by the State Health Plan’s Utilization Review Vendor. 

BlueCard Claims: This Medical Policy does not apply to Inpatient Hospital admissions for knee arthroplasty performed and submitted under the BlueCard® Program for Members of other Plans.

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.

POLICY HISTORY

08/30/2019: New policy added.

09/13/2019: Made correction to medical policy number.

10/01/2020: Policy title changed from "Knee Arthroplasty - West Central Region" to "Knee Arthroplasty - West Central and North East Region." Policy Exceptions updated to list additional counties.

02/22/2022: Policy statement updated to change “Inpatient” criteria to “Hospital” criteria effective 01/01/2022.

09/30/2022: Policy Guidelines updated to change "Nervous/Mental Conditions" to "Mental Health Disorders" and "Medically Necessary" to "medical necessity." Code Reference section updated to add new ICD-10 procedure codes XRRG0L8, XRRG0M8, XRRH0L8, and XRRH0M8, effective 10/01/2022.

11/08/2022: Policy reviewed; no changes.

03/15/2024: Policy reviewed; no changes.

07/01/2024: Policy updated to state that care coordination is required for Specialty Services.

12/06/2024: Policy reviewed; no changes.

SOURCE(S)

1. American Academy of Orthopedic Surgeons. Total Knee Replacement. http://orthoinfo.aaos.org/topic.cfm?topic=A00389

2. American Association of Hip and Knee Surgeons (AAHKS). Surgical Options for Knee Arthritis. http://www.aahks.org/care-for-hips-and-knees/surgical-options-for-knee-arthritis/

3. American Association of Hip and Knee Surgeons (AAHKS). Total Knee Replacement. 

   http://www.aahks.org/care-for-hips-and-knees/do-i-need-a-joint-replacement/total-knee-replacement/

4. Journal of Clinical Anesthesia. The association of body mass index with same-day admission, postoperative complications, and 30-day readmission following day-case eligible joint arthroscopy

5. Medical Policy Advisory Committee

6. Premera Blue Cross Medical Policy 7.01.551

CODE REFERENCE

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

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Medically Necessary Codes

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