CurrentAetnaPolicy 0545

Electrothermal Arthroscopy

Defines Aetna's coverage position on electrothermal arthroscopy (thermal capsular shrinkage/ETAC) for joints including shoulder, knee, wrist, ankle, TMJ and others; lists that the procedure is experimental and investigational for all indications and provides related CPT/HCPCS/ICD-10 codes and clinical background and evidence summary.

Policy Summary

PayerAetna

PolicyElectrothermal Arthroscopy

Policy CodePolicy 0545

Change TypeAdministrative revision/history

Effective DateJun 22, 2001

Next Review DateJun 8, 2023

Key ActionElectrothermal arthroscopy/ETAC is considered experimental and investigational for all indications; claims for these procedures for listed indications are not covered and should be documented accordingly.

SourceLink

POLICY UPDATE CHANGES

Policy history shows last review on 08/04/2023 and effective date 06/22/2001 with next review 06/08/2023.

1Policy position: ETAC considered experimental/investigational

2001-06-22Effective date

2023-08-04Last review date

64-69Cited References

Coverage Summary

This policy (Number: 0545) defines Aetna's coverage position on electrothermal arthroscopy (ETAC / thermal capsular shrinkage) for joints including shoulder, knee, wrist, ankle, temporomandibular joint and others. Aetna considers ETAC experimental and investigational for all indications because available evidence does not establish effectiveness or long-term health outcomes.

Status: CURRENT. Effective date: 2001-06-22. Last review: 2023-08-04. Next review: 2023-06-08.

Electrothermal arthroscopy (ETAC) policy summary

Policy positionETAC considered experimental/investigational

Effective date2001-06-22

Last review date2023-08-04

Next review date2023-06-08

Cited referencesReferences: 64-69

Medical Necessity / Not Covered Criteria

Experimental and Investigational (Not Covered)

Aetna considers electrothermal arthroscopy (also known as electrothermally-assisted capsule shift and electrothermally-assisted capsulorrhaphy (ETAC)) experimental and investigational for all indications, including any of the following:

Achilles injuries
Adhesive capsulitis
Ankle, hip, knee, or thumb instability
Bankart lesions
Bony avulsion of the capsule
Deficient or thin capsule
Frozen shoulder
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
Wrist injuries

Coding

CPT codes listed as related / not covered for indications in CPBCPTNot Covered

29804	Arthroscopy, temporomandibular joint, surgical
29806-29828	Arthroscopy, shoulder, surgical (range listed)
29843-29847	Arthroscopy, wrist, surgical (range listed)
29848	Endoscopy, wrist surgical, with release of transverse carpal ligament
29861-29863	Arthroscopy, hip, surgical (range listed)
29870-29887	Arthroscopy, knee (not covered for electrothermal arthroscopy)
29891-29899	Arthroscopy, ankle (range listed)
29905	Arthroscopy, subtalar joint, surgical; with synovectomy
29906	Arthroscopy, subtalar joint, with debridement
29907	Arthroscopy, subtalar joint, with subtalar arthrodesis

HCPCS codes not covered for indications listed in the CPBHCPCSNot Covered

S2300

Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy

ICD-10 codes listed as not covered for indications in CPB (not all-inclusive)ICD-10Not Covered

M23.000-M23.92	Internal derangement of knee (range)
M24.00-M25.9	Other specific joint derangements (range)
M26.601-M26.69	Temporomandibular joint disorders (range)
M65.871-M65.879	Other synovitis and tenosynovitis of ankle and foot (range)
M75.00-M75.02	Adhesive capsulitis of shoulder (range)
M76.60-M76.62	Achilles tendinitis (range listed but truncated in source)
S03.00x+-S03.02x+	Dislocation of jaw (range)
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 (range)
S83.200A-S83.32xS	Tear of meniscus, current injury (range)

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Provider Actions / Billing Guidance

Documentation Required

Do not perform / document ETAC as medically necessary

Electrothermal arthroscopy (ETAC) is considered experimental and investigational for all indications; claims for these procedures for the listed indications are not covered and should be documented accordingly.

S2300
29870-29887
29806-29828
29843-29847
29891-29899
29804
29905-29907

Note

Refer to full policy for coverage criteria

Consult the complete Clinical Policy Bulletin for specific medical necessity, prior authorization, and billing requirements related to electrothermal arthroscopy.

Background & Evidence Summary

Thermal capsular shrinkage (electrothermal arthroscopy / ETAC) is an arthroscopic technique that uses radiofrequency/thermal energy to heat and contract collagen in joint capsules, ligaments, or tendons with the goal of tightening tissue and increasing joint stability. Devices cited include ArthroCare system 2000, ArthroWand, ORA-50, VULCAN EAS, and VAPR TC electrodes.

Short-term, uncontrolled studies reported preserved range of motion and quicker recovery versus open procedures, but evidence is primarily case series and small prospective studies. Mid- and long-term studies have raised concerns about high failure and recurrence rates, complications, and variable outcomes; several randomized and prospective trials have not demonstrated clear long-term benefit compared with open procedures. Overall, the literature and technology assessments conclude that there is inadequate high-quality evidence to support ETAC as effective and durable for shoulder instability, ACL laxity, and other joint indications.

Study / Source	Key finding
Mohtadi 2014 randomized trial	No clinically significant differences in outcomes at 2 years between ETAC and open inferior capsular shift; ETAC had fewer complications and shorter surgical time
Smith et al. 2008 multicenter study (ACL)	Failure rate 50.8% past 2 years; concluded not appropriate treatment for lax ACLs
D'Alessandro 2004 prospective	37% unsatisfactory results at median 38 months; high unsatisfactory rate is of concern
Enad 2004 (overhand athletes)	High recurrence and failure rates; some return to sport but results do not reproduce open surgery success
Crespo Romero 2021 (partial SL tears)	Small level IV study (n=20) with improvement in Mayo wrist score; Level IV evidence, findings need validation
Referenced studies / reviews	Multiple peer-reviewed publications and a health technology assessment cited (references 64-69); evidence largely case series and limited RCTs
Additional referenced literature	Various reports note mixed short-term results but concerns about long-term failure rates and complications (multiple citations)
Policy conclusion / assessments	Technology assessments and reviews conclude inadequate evidence of long-term effectiveness; procedure considered experimental/investigational for all indications

Electrothermal arthroscopy / ETAC: Arthroscopic procedure using thermal energy (radiofrequency) to shrink joint capsule, ligaments, or tendons (aka electrothermally-assisted capsulorrhaphy, capsule shift, thermal capsulorrhaphy).