Thermal Shrinkage for Cruciate Ligament Injury

POLICY NUMBER

L.7.01.414

DESCRIPTION

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).

POLICY

Thermal Shrinkage for Cruciate Ligament Injury is considered investigational.

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.

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

11/2002: 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.

06/01/2016: Policy number L.7.01.414 added. Investigative definition updated in Policy Guidelines section.

01/24/2023: Policy reviewed; no changes.

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

03/27/2025: Policy reviewed; no changes.

04/23/2025: Sources updated.

SOURCE(S)

1. American Academy of Orthopaedic Surgeons Management of Anterior Cruciate Ligament Injuries Evidence-Based Clinical Practice Guideline www.aaos.org/aclcpg Published August 22, 2022. Accessed April 2025.

2. Halbrecht J. Long-term failure of thermal shrinkage for laxity of the anterior cruciate ligament. Am J Sports Med. 2005 Jul;33(7):990-5. doi: 10.1177/0363546504271975. Epub 2005 May 11. PMID: 15888717. Accessed April 2025.

3. Hayes Medical Technology Directory

CODE REFERENCE

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

Investigational Codes

CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.