Medical Policy Bulletin

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Title:

Arthroscopic Electrothermal Joint Repair

Policy #:

11.14.11c

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The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the coverage positions for arthroscopic electrothermal joint repair.

Description with Scientific Evidence:

Connective tissue is composed primarily of type I collagen, which has been shown to contract when heat is applied. Electrothermal energy that is delivered through a radiofrequency probe that is inserted arthroscopically is used to shrink stretched or damaged connective tissue around joints. A narrow range of temperatures (65 degrees to 75 degrees centigrade) is required for the safe and effective shrinkage of tissues. Lasers have been used for thermal shrinkage, but significant drawbacks include lack of temperature control, complications, and cost. As a result, lasers are commonly replaced by radiofrequency devices that provide increased temperature control with less collateral tissue damage. In a survey of members of the American Shoulder and Elbow Surgeons, the Arthroscopy Association of North America, and the American Orthopaedic Society for Sports Medicine, only 45 percent of shoulder procedures involved laser energy, versus six percent for radiofrequency energy. Theoretically, shrinkage of joint capsules and ligaments results in tighter, more stable joints. The advantages of electrothermal repair include a short operative time, when compared with reconstruction, and minimal morbidity. The procedure is most frequently applied to tighten stretch-deficient or redundant knee ligaments and shoulder capsular tissue. The alternative to electrothermal repair is open surgical reconstruction. SHOULDER Laxity of the glenohumeral joint capsule often occurs as a result of gradual tearing and stretching and is commonly seen in overhead athletes (eg, throwing sports, racquet sports, swimming). Electrothermal repair is used on glenohumeral ligaments to tighten and reduce the volume of the shoulder capsule. A previous review found sufficient scientific evidence to support the efficacy of thermal capsulorrhaphy for symptomatic shoulder instability that had failed a course of conservative management. Some investigators suggest that in spite of electrothermal repair being widely applied, the procedure does not produce the success of open surgery. More research is needed, particularly in individuals with multiple dislocations or multidirectional instabilities. However, current studies confirm improvement in health outcomes for electrothermal stabilization of the shoulder of up to three years duration in a select group of individuals. In addition, many researchers report that electrothermal repair used as an adjunct to other stabilization procedures improves outcomes with minimal morbidity. Serious complications, including neuropathic joint arthropathy and changes in proprioception, have not been reported, and results appear comparable to other arthroscopic surgical procedures. Questions remain about the efficacy of electrothermal repair in treating multidirectional instabilities. According to Khan, et al, electrothermal repair is indicated to treat an attenuated, but otherwise intact, shoulder capsule that occurs as a result of repetitive microtrauma or to tighten a damaged shoulder when used as an adjunct procedure (eg, arthroscopic Bankart repair). In either case, the procedure should be offered only after a failed course of nonsurgical rehabilitation. Therefore, there continues to be insufficient evidence for the support of electrothermal capsulorrhaphy as an initial therapy to tighten a damaged shoulder. However, studies have shown support for the use of electrothermal capsulorrhaphy after the failure of nonsurgical rehabilitation to treat an attenuated, but otherwise intact, shoulder capsule, or to tighten a damaged shoulder when used as an adjunct procedure. KNEE Electrothermal repair of the knee is most frequently used to treat partial anterior cruciate ligament (ACL) tears and ACL reconstruction laxity. In 2001, electrothermal repair of cruciate ligament laxity was considered to be medically necessary based on documented positive outcomes in small numbers of individuals and widespread usage in the orthopedic community. The minimally invasive nature of the procedure, along with a reduced rehabilitation time, made it an attractive alternative to open reconstruction. Published reports of outcomes in a substantial number of individuals were expected to subsequently appear in the medical literature. However, up to this time, the early reports by Thabit have not been replicated, and there still are few published reports on long-term clinical outcomes of electrothermal repair of cruciate ligament laxity. Questions remain about the optimum rehabilitation protocol and whether restoration of normal tissue occurs as a result of thermal shrinkage, or if the ligament stretches over time, increasing the risk of re-injury. Failures associated with the electrothermal treatment of laxity in the posterior cruciate ligament (PCL) and ACL have been reported. Leading researchers recommend caution in the use of this modality until additional studies with longer-term follow-up are reported. There is insufficient evidence to support the use of electrothermal treatment for the repair of knee ligaments because the clinical effectiveness of electrothermal repair of cruciate ligament laxity cannot be established by review of the available published literature.

Policy

Arthroscopic electrothermal repair of the shoulder is considered medically necessary and, therefore, covered when either one of the following criteria is met: It is performed as an adjunct procedure to tighten a damaged shoulder. A course of nonsurgical rehabilitation has failed, and the procedure is used to treat an attenuated, but otherwise intact, shoulder capsule. Arthroscopic electrothermal repair of joints other than the shoulder is considered experimental/investigational and, therefore, not covered because the safety and/or efficacy of this service cannot be established by review of the available published literature. REQUIRED DOCUMENTATION The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to: records from the health care professional's office, hospital, nursing home, home health agencies, therapies, and test reports. The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service. BILLING REQUIREMENTS To report arthroscopic electrothermal repair of the shoulder, use Healthcare Common Procedure Coding System (HCPCS) code S2300: Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy. To report arthroscopic electrothermal repair of joints other than the shoulder, use Current Procedural Terminology (CPT) code 29999. Inclusion of a code in this policy does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Guidelines

BENEFIT APPLICATION Subject to the terms and conditions of the applicable benefit contract, arthroscopic electrothermal joint repair of the shoulder is covered under the medical benefits of the Company’s products when medical necessity criteria in the medical policy are met. Subject to the terms and conditions of the applicable benefit contract, arthroscopic electrothermal repair of joints other than the shoulder is not eligible for payment under the medical benefits of the Company’s products because the service is considered experimental/investigational and, therefore, not covered. Services that are experimental/investigational are a benefit contract exclusion for all products of the Company. MEDICARE There is no Medicare coverage criteria addressing this service; therefore, the Company policy is applicable.

References

American Academy of Orthopaedic Surgeons (AAOS). Thermal capsulorrhaphy. [AAOS Web site]. October 2007. Available at: http://orthoinfo.aaos.org/fact/thr_report.cfm?Thread_ID=228&topcategory=Shoulder. Accessed February 3, 2008. Anderson K, Warren RF, Altchek DW, Craig EV, O'Brien SJ. Risk factors for early failure after thermal capsulorrhaphy. Am J Sports Med. 2002;30(1):103-107. Carter TR. Anterior cruciate ligament thermal shrinkage. Clin Sports Med. 2002;21(4):693-700, ix. Carter TR, Bailie DS, Edinger S. Radiofrequency electrothermal shrinkage of the anterior cruciate ligament. Am J Sports Med. 2002;30(2):221-226. Chloros GD, Wiesler ER, Poehling GG. Current concepts in wrist arthroscopy. Arthroscopy. 2008;24(3):343-354. D’Alessandro DF, Bradley JP, Fleischli JE, Connor PM. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: indications and results, two- to five-year follow-up. Am J Sports Med. 2004;32(1):21-33. Dugas JR, Andrews JR. Thermal capsular shrinkage in the throwing athlete. Clin Sports Med. 2002;21(4):771-776. Enad JG, ElAttrache NS, Tibone JE, Yocum LA. Isolated electrothermal capsulorrhaphy in overhand athletes. J Shoulder Elbow Surg. 2004;13(2):133-137. Fitzgerald BT, Watson BT, Lapoint JM. The use of thermal capsulorrhaphy in the treatment of multidirectional instability. J Shoulder Elbow Surg. 2002;11(2):108-113. Fu FH, Kaplan LD. Future trends in thermal energy. Clin Sports Med. 2002;21(4):765-770, xi. Gerber A, Warner JJ. Thermal capsulorrhaphy to treat shoulder instability. Clin Orthop Relat Res. 2002;(400):105-116. Good CR, Shindle MK, Kelly BT, Wanich T, Warren RF. Glenohumeral chondrolysis after shoulder arthroscopy with thermal capsulorrhaphy. Arthroscopy. 2007;23(7):797. Halbrecht J. Long-term failure of thermal shrinkage for laxity of the anterior cruciate ligament. Am J Sports Med. 2005;33(7):990-995. Hawkins RJ, Karas SG. Arthroscopic stabilization plus thermal capsulorrhaphy for anterior instability with and without Bankart lesions: the role of rehabilitation and immobilization. Instr Course Lect. 2001;50:13-15. Hawkins RJ, Krishnan SG, Karas SG, Noonan TJ, Horan MP. Electrothermal arthroscopic shoulder capsulorrhaphy: a minimum 2-year follow-up. Am J Sports Med. 2007;35(9):1484-1488. Hovis WD, Dean MT, Mallon WJ, Hawkins RJ. Posterior instability of the shoulder with secondary impingement in elite golfers. Am J Sports Med. 2002;30(6):886-890. Khan AM, Fanton GS. Electrothermal assisted shoulder capsulorrhaphy--monopolar. Clin Sports Med. 2002;21(4):599-618. Khan AS, Sherman OH, DeLay B. Thermal treatment of anterior cruciate ligament injury and laxity with its imaging characteristics. Clin Sports Med. 2002;21(4):701-711, ix. Lee EW, Paulos LE, Warren RF. Complications of thermal energy in knee surgery--Part II. Clin Sports Med. 2002;21(4):753-763. Levitz CL, Dugas J, Andrews JR. The use of arthroscopic thermal capsulorrhaphy to treat internal impingement in baseball players. Arthroscopy. 2001;17(6):573-577. Lino W Jr, Belangero WD. Labrum repair combined with arthroscopic reduction of capsular volume in shoulder instability. Int Orthop. 2006;30(4):219-223. Lu Y, Markel MD, Kalsc heur V, Ciullo JR, Ciullo JV. Histologic evaluation of thermal capsulorrhaphy of human shoulder joint capsule with monopolar radiofrequency energy during short- to long-term follow-up. Arthroscopy. 2008;24(2):203-209. Mason WT, Hargreaves DG. Arthroscopic thermal capsulorrhaphy for palmer midcarpal instability. J Hand Surg Eur Vol. 2007;32(4):411-416. Massoud SN, Levy O, Copeland SA. Radiofrequency capsular shrinkage for voluntary shoulder instability. J Shoulder Elbow Surg. 2007;16(1):43-48. Miniaci A, Codsi MJ. Thermal capsulorrhaphy for the treatment of shoulder instability. Am J Sports Med. 2006;34(8):1356-1363. Mishra DK, Fanton GS. Two-year outcome of arthroscopic bankart repair and electrothermal-assisted capsulorrhaphy for recurrent traumatic anterior shoulder instability. Arthroscopy. 2001;17(8):844-849. Mohtadi NG, Hollinshead RM, Ceponis PJ, Chan DS, Fick GH. A multi-centre randomized controlled trial comparing electrothermal arthroscopic capsulorrhaphy versus open inferior capsular shift for patients with shoulder instability: protocol implementation and interim performance: lessons learned from conducting a multi-centre RCT [ISRCTN68224911; NCT00251160]. Trials. 2006;7:4. Oakes DA, McAllister DR. Failure of heat shrinkage for treatment of a posterior cruciate ligament tear. Arthroscopy. 2003;19(6):E1-E4. Perry JJ, Higgins LD. Anterior and posterior cruciate ligament rupture after thermal treatment. Arthroscopy. 2000;16(7):732-736. Seip JD, Johnson DH. Electrothermal shrinkage for the ACL deficient knee (abstract). [Carleton Sports Medicine Web site]. Available at: http://www.carletonsportsmed.com/Electrothermal%20Shrinkage%20ACL.pdf. Accessed February 3, 2008. Sekiya JK, Ong BC, Bradley JP. Thermal capsulorrhaphy for shoulder instability. Instr Course Lect. 2003;52:65-80. Shih JT, Lee HM. Monopolar radiofrequency electrothermal shrinkage of the scapholunate ligament. Arthroscopy. 2006;22(5):553-557. Smith DB, Carter TR, Johnson DH. High failure rate for electrothermal shrinkage of the lax anterior cruciate ligament: a multicenter follow-up past 2 years. Arthroscopy. 2008;24(6):637-641. Wong KL, Getz CL, Yeh GL, Ramsey M, Iannotti JP, et al. Treatment of glenohumeral subluxation using electrothermal capsulorrhaphy. Arthroscopy. 2005;21(8):985-991. Wong KL, Williams GR. Complications of thermal capsulorrhaphy of the shoulder. J Bone Joint Surg Am. 2001; 83-A Suppl 2 Pt 2:151-155.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply. The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates. In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	TO REPORT ARTHROSCOPIC ELECTROTHERMAL REPAIR OF JOINTS OTHER THAN THE SHOULDER, USE THE FOLLOWING CODE: 29999
ICD Procedure	N/A
ICD Diagnosis	718.21: Pathological dislocation of shoulder joint 718.31: Recurrent dislocation of shoulder joint 718.71: Developmental dislocation of joint, shoulder region 718.81: Other joint derangement, not elsewhere classified, shoulder region 728.4: Laxity of ligament 831.00: Closed dislocation of shoulder, unspecified site 831.01: Closed anterior dislocation of humerus 831.02: Closed posterior dislocation of humerus 831.03: Closed inferior dislocation of humerus 831.04: Closed dislocation of acromioclavicular (joint) 831.09: Closed dislocation of other site of shoulder 840.2: Coracohumeral (ligament) sprain and strain 840.4: Rotator cuff (capsule) sprain and strain 840.5: Subscapularis (muscle) sprain and strain 840.7: Superior glenoid labrum lesions (SLAP) 840.8: Sprain and strain of other specified sites of shoulder and upper arm 840.9: Sprain and strain of unspecified site of shoulder and upper arm
HCPCS Level II	S2300: Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy
Revenue Codes	N/A

Version Effective Date: 10/09/2007