CurrentAetnaPolicy 0545

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.

Policy Summary

PayerAetna

PolicyElectrothermal Arthroscopy

Policy CodePolicy 0545

Change TypeNo material change

Effective DateJun 22, 2001

Last ReviewJun 10, 2027

Next Review DateJun 10, 2027

Key ActionDo not submit claims for electrothermal arthroscopy as a covered procedure; listed arthroscopy CPT/HCPCS codes (including S2300) are referenced as not covered for the indications in this bulletin.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15+listed indications experimental

S2300+procedure codes not covered

2randomized trials cited

2001policy effective

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CurrentAetnaPolicy 0545

Electrothermal Arthroscopy

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Policy Summary

PayerAetna

PolicyElectrothermal Arthroscopy

Policy CodePolicy 0545

Change TypeNo material change

Effective DateJun 22, 2001

Last ReviewJun 10, 2027

Next Review DateJun 10, 2027

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

15+listed indications experimental

S2300+procedure codes not covered

2randomized trials cited

2001policy effective

06/10/2027next review

Coverage Determinations

Not established / Experimental or Investigational

Covered when ALL of the following are met:

Primary coverage stance: Aetna considers electrothermal arthroscopy of the joint capsule, ligaments, or tendons experimental, investigational, or unproven for all indications

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

Procedure codes referencedCPT|HCPCSNot Covered

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

1–10 of 11

1/2

ICD-10 diagnosis codes referencedICD-10Not Covered

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

1–10 of 12

1/2

Billing, Authorization, and Provider Guidance

Billing Rule

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.

CPT/HCPCS codes listed include: 29804; 29806–29828; 29843–29847; 29848; 29861–29863; 29870–29887; 29891–29899; 29905–29907; and HCPCS S2300.

Prior Authorization

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.

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

Electrothermal arthroscopy / electrothermally-assisted capsulorrhaphy (ETAC)

TermElectrothermal arthroscopy / electrothermally-assisted capsulorrhaphy (ETAC)

DefinitionAn arthroscopic procedure that uses controlled thermal energy (high-energy radiofrequency) applied to joint capsule, ligaments, or tendons to heat collagen fibers and induce contraction and shortening with the goal of tightening soft tissue and increasing joint stability.

MechanismThermal energy causes molecular changes in collagen resulting in shrinkage and firming of connective tissue; devices cited include ArthroCare system 2000, CAPS X ArthroWand, ORA-50, VULCAN EAS, and VAPR TC electrode.

Synonyms / Alternate namesElectrothermally-assisted capsulorrhaphy; thermal capsular shrinkage; electrothermal capsule shift; ETAC.

Bankart lesion

Term

Policy History and Review Dates

2001-06-22effective_date

Policy became effective.

2026-07-31last_review

Policy most recently reviewed.

2027-06-10next_reviewLatest

Policy scheduled next review date.

Policy Summary

PayerAetna

PolicyElectrothermal Arthroscopy

Policy CodePolicy 0545

Change TypeNo material change

Effective DateJun 22, 2001

Last ReviewJun 10, 2027

Next Review DateJun 10, 2027

SourceLink

On This Page

Prior Authorization

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.

Step Therapy

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

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

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.

Billing Rule

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.

Example procedure codes listed: 29804; 29806–29828; 29843–29847; 29848; 29861–29863; 29870–29887; 29891–29899; 29905–29907; S2300.
ICD‑10 diagnosis ranges referenced include M23.000–M23.92; M24.00–M25.9; M26.601–M26.69; M75.00–M75.02; M76.60–M76.62.

Documentation Required

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 Required

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.

Denial Risk

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.

Note

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 Risk

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.

DefinitionAn injury to the glenoid labrum (the fibro-cartilage rim attached to the glenoid cavity) of the shoulder that contributes to glenohumeral instability.

Clinical relevanceBankart lesions undermine stabilization of the humeral head within the glenoid and may be addressed with anatomic re-attachment of the capsulo-labral complex; ETAC has been proposed as an adjunct to tighten a stretched capsule when repairing the labrum.

TFCC (Triangular fibro-cartilage complex)

TermTriangular fibro-cartilage complex (TFCC)

ComponentsTriangular fibro-cartilage discus, radio‑ulnar ligaments, and ulno‑carpal ligaments.

Clinical contextTFCC tears present with ulnar‑sided wrist pain and have been treated with arthroscopic electrothermal collagen shrinkage in observational series; studies excluded cases with distal radioulnar joint instability.

Policy history and definitions references

Policy number and statusAetna Policy 0545 — Electrothermal Arthroscopy; Effective 06/22/2001; Last review 07/31/2026; Next review 06/10/2027.

History accessReview history and prior versions are available via the policy 'Review History' link referenced in the policy document.

Definitions referenceDefinitions for terms used in this policy (for example, ETAC, Bankart lesion, TFCC) are provided in the policy 'Definitions' section and linked from the Policy History area.