Electrothermal Arthroscopy
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This policy governs the coverage stance for electrothermal arthroscopy (also called electrothermally-assisted capsule shift or capsulorrhaphy) of joint capsules, ligaments, or tendons and applies to Aetna's medical policy determinations for members and providers.
No material clinical or coverage changes in this revision.
Coverage Determinations
Not established / Experimental or Investigational
Covered when ALL of the following are met:
Policy explicitly lists multiple example indications considered experimental/investigational
Examples of indications considered experimental/investigational (not an all-inclusive list)
- 1: Achilles injuries
- 2: Adhesive capsulitis (frozen shoulder)
- 3: Ankle, hip, knee, or thumb instability
- 4: Bankart lesions
- 5: Bony avulsion of the capsule
- 6: Deficient or thin capsule
- 7: Glenohumeral joint (shoulder) instability
- 8: Hill-Sachs lesions
- 9: Humeral-side avulsion of the capsule
- 10: Ligament tear and meniscal injury of the knee
- 11: Multi-directional instability
- 12: Partial scapholunate ligament tears
- 13: Temporomandibular joint dislocation
- 14: Wrist injuries
Aetna considers electrothermal arthroscopy (also called electrothermally-assisted capsule shift or electrothermally-assisted capsulorrhaphy) of the joint capsule, ligaments, or tendons experimental, investigational, or unproven for all indications. Example indications specifically listed in the policy as considered experimental/investigational include: Achilles injuries; adhesive capsulitis (frozen shoulder); ankle, hip, knee, or thumb instability; Bankart lesions; bony avulsion of the capsule; deficient or thin capsule; glenohumeral joint (shoulder) instability; Hill-Sachs lesions; humeral-side avulsion of the capsule; ligament tear and meniscal injury of the knee; multi-directional instability; partial scapholunate ligament tears; temporomandibular joint dislocation; and wrist injuries.
In the retrospective series of arthroscopic electrothermal shrinkage for TFCC tears by Garcia-Lopez et al (n=162), the study's reported exclusion criteria included distal radioulnar joint instability and the presence or association of other wrist lesions.
The multi-center randomized trial by Mohtadi et al. excluded patients intra-operatively if they had bone lesions or labral, biceps anchor, or full-thickness rotator cuff tears.
Sections of the policy that summarize exclusions and procedural guidance do not present additional explicit coverage exclusions beyond those already stated in the policy text.
The policy specifies that electrothermal arthroscopy is not assigned a unique CPT code and lists arthroscopy CPT/HCPCS codes (including S2300 and range codes such as 29804, 29806–29828, 29870–29887, etc.) that are referenced as not covered when used for electrothermal arthroscopy for the indications in this bulletin.
Within the coverage criteria and related sections there is no explicit phrasing that uses the term "not medically necessary"; the policy frames the procedures as experimental, investigational, or unproven for the listed indications.
Procedure and Diagnosis Coding
| 29804 | Arthroscopy, temporomandibular joint, surgical |
| 29806-29828 | Arthroscopy, shoulder, surgical |
| 29843-29847 | Arthroscopy, wrist, surgical |
| 29848 | Endoscopy, wrist surgical, with release of transverse carpal ligament |
| 29861-29863 | Arthroscopy, hip, surgical |
| 29870-29887 | Arthroscopy, knee [not covered for electrothermal arthroscopy] |
| 29891-29899 | Arthroscopy, ankle |
| 29905 | Arthroscopy, subtalar joint, surgical; with synovectomy |
| 29906 | Arthroscopy, subtalar joint, surgical; with debridement |
| 29907 | Arthroscopy, subtalar joint, surgical; with subtalar arthrodesis |
| M23.000 - M23.92 | Internal derangement of knee |
| M24.00 - M25.9 | Other specific joint derangements |
| M26.601 - M26.69 | Temporomandibular joint disorders |
| M65.871 - M65.879 | Other synovitis and tenosynovitis of ankle and foot |
| M75.00 - M75.02 | Adhesive capsulitis of shoulder |
| M76.60 - M76.62 | Achilles tendinitis |
| S03.00x+ - S03.02x+ | Dislocation of jaw |
| S63.511A - S63.519S | Sprain of carpal (joint) of wrist (partial scapholunate ligament tears) |
| S76.111A - S76.119S | Strain of quadriceps muscle, fascia and tendon |
| S83.200A - S83.32xS | Tear of meniscus, current injury |
Billing, Authorization, and Provider Guidance
Procedure coding referenced — ETAC not specifically coded; listed arthroscopy codes referenced as not covered
Electrothermal arthroscopy (ETAC) is not assigned a unique CPT code in this policy; Aetna lists multiple arthroscopy CPT/HCPCS codes (including S2300) as referenced in the bulletin and indicates these codes are not covered when used for the ETAC indications described.
Prior authorization — no explicit prior authorization requirement stated
The policy text does not specify any required prior authorization process or explicit prior authorization criteria for electrothermal arthroscopy in the provided sections.
Prior authorization — no explicit prior authorization described
Reinforcement: within the sections provided there are no described prior authorization steps or explicit authorization criteria for ETAC procedures.
Prior conservative therapy noted in cited literature — minimum 3 months nonoperative rehab in some studies
Some studies cited in the background required prior nonoperative rehabilitation before thermal capsulorrhaphy; for example, D’Alessandro et al. reported subjects underwent thermal capsulorrhaphy after failure of a minimum of 3 months of nonoperative rehabilitation.
- D’Alessandro et al. (2004): minimum of 3 months of non-operative rehabilitation required prior to thermal capsulorrhaphy in that study protocol.
Step therapy — no formal step therapy requirements specified
No step therapy program or formal stepwise authorization requirements for ETAC are specified in the policy sections provided.
Step therapy — no step therapy requirements described
Reinforcement: these sections do not describe any step therapy or mandated sequences of conservative care as policy requirements for ETAC.
Coding and documentation note — submitters should reference listed CPT/HCPCS and ICD-10 codes; ETAC has no specific CPT code
When submitting claims, use the CPT/HCPCS and ICD-10 codes listed in the policy text for arthroscopy procedures; the policy notes ETAC has no specific CPT code and lists example procedure codes and HCPCS (including S2300) and ICD‑10 diagnosis ranges to reference.
Documentation — no specific documentation or prior authorization steps detailed here
The provided sections do not specify detailed documentation requirements or particular records to include for ETAC procedures or authorizations.
Documentation/history — policy history present but no provider documentation requirements specified
These sections include policy history and review dates but do not define provider documentation requirements or required clinical documentation elements for ETAC.
- Policy history: Last review 07/31/2026; Effective 06/22/2001; Next review 06/10/2027.
Noncoverage/denial risk — ETAC for listed indications considered experimental/investigational and may be denied
Procedures identified as electrothermal arthroscopy for the indications listed in this bulletin are considered experimental, investigational, or unproven and therefore are subject to noncoverage/denial when billed for those indications.
- Policy statement: Aetna considers electrothermal arthroscopy of the joint capsule, ligaments, or tendons experimental, investigational, or unproven for all indications listed.
- Use of listed arthroscopy CPT/HCPCS codes (including S2300) for ETAC indications is listed as not covered.
Provider actions — no further provider actions specified in these sections
No additional provider actions (beyond coding, awareness of noncoverage, and literature background) are specified in the provided portions of the document.
Denial triggers — no explicit denial triggers or authorization requirements stated here
The provided policy sections do not list specific denial triggers or explicit authorization requirements that would prompt automatic denial beyond the policy’s noncoverage stance for ETAC.
Background and Evidence Summary
Thermal capsular shrinkage or electrothermal arthroscopy uses controlled thermal or radiofrequency energy applied arthroscopically to collagen-rich soft tissues (joint capsule, ligaments, or tendons) to induce collagen contraction and tissue shrinkage with the goal of tightening soft tissues and improving joint stability. Devices and trade names cited in the policy background include examples of radiofrequency/thermal systems used to deliver this energy; short-term uncontrolled studies have reported some symptomatic improvements, but overall the evidence is limited and long-term effects on joint biology and clinical outcomes remain uncertain.
Key Definitions
Policy History and Review Dates
Policy became effective.
Policy most recently reviewed.
Policy scheduled next review date.
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