ModifiedColorado Rocky Mountain Health PlansPolicy MMP052.12

Joint Procedures

Clinical coverage guidance for various joint surgical procedures (hip, knee, shoulder, ankle, elbow, hand/wrist, foot/toes) applicable to Colorado Rocky Mountain Health Plans members and providers; references Medicare NCD/LCD status and related commercial policies where local coverage does not exist.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyJoint Procedures

Policy CodePolicy MMP052.12

Change TypeMaterial change — code removal and CMS updates

Effective DateJan 1, 2026

Next Review DateN/A

Key ActionFollow applicable LCD/LCA prior authorization requirements when they exist and comply with delegate prior authorization processes for Medicare Advantage where applicable.

SourceLink

POLICY UPDATE CHANGES

Removed CPT code 27445

Updated list of Centers for Medicare & Medicaid Services (CMS) documents in the Medicare Coverage Database

Archived previous policy version MMP052.11

10+procedure groups listed

Not supportedTenJet status

510(k)FDA status (TenJet)

Systematic reviewEvidence gap

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Determinations and Evidence Notes

Procedure group coverage summaries

General coverage guidance by procedure group.

Hip surgeries: Medicare does not have a National Coverage Determination (NCD) for surgery of the hip. Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) exist and compliance with those policies is required where applicable; where no LCD/LCA exists, refer to the UnitedHealthcare Commercial Medical Policy titled 'Surgery of the Hip'.

see chunks 1,14

Femoroacetabular impingement (FAI): For procedures such as acetabuloplasty or other FAI-related surgery, Medicare does not have an NCD; where LCDs/LCAs do not exist, refer to InterQual criteria for coverage guidance.

see chunk 2

Knee surgeries: Medicare does not have an NCD for surgery of the knee. LCDs/LCAs exist for some knee procedures and compliance with those policies is required where applicable; where no LCD/LCA exists, refer to the UnitedHealthcare Commercial Medical Policy titled 'Surgery of the Knee'.

see chunk 4

Ankle, Hand/Wrist, Elbow, Foot/Toes: Medicare does not have NCDs for many procedures in these anatomical regions. Where LCDs/LCAs exist, comply with them; where they do not, refer to UnitedHealthcare commercial policies or InterQual procedural criteria as indicated (for example endoscopic cubital tunnel release, see InterQual).

see chunks 9 and 17

TenJet tenotomy: Tenotomy utilizing the TenJet™ device for the treatment of rotator cuff tendinopathy is not reasonable and necessary due to insufficient evidence of safety and/or efficacy.

see chunk 12

TenJet evidence/regulatory summary

Supporting evidence and regulatory notes.

Evidence and regulatory summary: The TenJet system is a high‑pressure saline jet tenotomy device that delivers saline through a 2‑channel, 12‑gauge needle with a 1.5 mm cutting window to debride tendinopathic tissue (Maag, 2025). A systematic review (Maag et al., 2025) found no studies using the TenJet device that met inclusion criteria, indicating insufficient clinical evidence specific to TenJet for rotator cuff tendinopathy. The U.S. Food and Drug Administration has cleared the TenJet device via the 510(k) process.

Clinical evidence gap may affect medical necessity determinations; see FDA 510(k) clearance reference.

Tenotomy utilizing the TenJet™ device for the treatment of rotator cuff tendinopathy is considered not reasonable and necessary. Medicare has no National Coverage Determination (NCD) for this use and no Local Coverage Determinations/Articles (LCDs/LCAs) exist; the policy therefore relies on the coverage rationale that concludes the procedure lacks sufficient evidence of safety and/or efficacy for this indication.

No additional explicit exclusions are stated in the referenced material beyond the TenJet tenotomy statement. The source provides device description and evidence appraisal but does not list other specific excluded procedures or clinical scenarios.

As restated in the coverage rationale, tenotomy using the TenJet™ device for rotator cuff tendinopathy is not reasonable and necessary. This exclusion is based on the lack of adequate evidence demonstrating safety or clinical benefit for this specific application.

A focused evidence review concluded there is insufficient clinical evidence to support the safety and effectiveness of TenJet tenotomy for rotator cuff tendinopathy. The TenJet system is described as a high‑pressure saline jet delivered through a two‑channel, 12‑gauge needle with a 1.5 mm cutting window, but the cited systematic review (Maag et al., 2025) identified no studies of the TenJet device that met inclusion criteria, leaving an evidentiary gap that underpins the noncoverage determination.

Applicable CPT / HCPCS Codes by Procedure Group

Surgery of the Hip; Femoroacetabular Impingement (FAI) syndromeCPT

27120	Acetabuloplasty; (e.g., Whitman, Colonna, Haygroves, or cup type)
27122	Acetabuloplasty; resection, femoral head (e.g., Girdlestone procedure)
27125	Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty)
27130	Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty)
27132	Conversion of previous hip surgery to total hip arthroplasty
27134	Revision of total hip arthroplasty; both components
27137	Revision of total hip arthroplasty; acetabular component only
27138	Revision of total hip arthroplasty; femoral component only
29914	Arthroscopy, hip, surgical; with femoroplasty (treatment of cam lesion)
29915	Arthroscopy, hip, surgical; with acetabuloplasty (treatment of pincer lesion)

1–10 of 12

1/2

Surgery of the Knee; Surgery of the Ankle (selected)CPT

27412	Autologous chondrocyte implantation, knee
27415	Osteochondral allograft, knee, open
27416	Osteochondral autograft(s), knee, open (includes harvesting)
27446	Arthroplasty, knee, condyle and plateau; medial or lateral compartment
27447	Arthroplasty, knee, condyle and plateau; medial and lateral compartments (total knee)
27486	Revision of total knee arthroplasty; 1 component
27487	Revision of total knee arthroplasty; femoral and entire tibial component
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (includes harvesting)
29867	Arthroscopy, knee, surgical; osteochondral allograft
29868	Arthroscopy, knee, surgical; meniscal transplantation

1–10 of 11

1/2

Surgery of the Ankle; Arthrodesis/Arthroplasty, toesCPT

28446	Open osteochondral autograft, talus (includes obtaining graft[s])
29892	Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture
29894	Arthroscopy, ankle; removal of loose body or foreign body
29895	Arthroscopy, ankle; synovectomy, partial
29897	Arthroscopy, ankle; debridement, limited
29898	Arthroscopy, ankle; debridement, extensive
29899	Arthroscopy, ankle; with ankle arthrodesis
28899	Unlisted procedure, foot or toes

Surgery of the Hand or WristCPT

25441	Arthroplasty with prosthetic replacement; distal radius
25442	Arthroplasty with prosthetic replacement; distal ulna
25444	Arthroplasty with prosthetic replacement; lunate
25446	Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)
25449	Revision of arthroplasty, including removal of implant, wrist joint
29840	Arthroscopy, wrist, diagnostic, with or without synovial biopsy
29844	Arthroscopy, wrist, surgical; synovectomy, partial
29845	Arthroscopy, wrist, surgical; synovectomy, complete
29846	Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement
29847	Arthroscopy, wrist, surgical; internal fixation for fracture or instability

Surgery of the Elbow; Endoscopic Cubital Tunnel Release (unlisted procedure code noted)CPT

24360	Arthroplasty, elbow; with membrane (e.g., fascial)
24361	Arthroplasty, elbow; with distal humeral prosthetic replacement
24362	Arthroplasty, elbow; with implant and fascia lata ligament reconstruction
24363	Arthroplasty, elbow; with distal humerus and proximal ulnar prosthetic replacement (total elbow)
24365	Arthroplasty, radial head
29834	Arthroscopy, elbow; removal of loose body or foreign body
29837	Arthroscopy, elbow; debridement, limited
29838	Arthroscopy, elbow; debridement, extensive

Surgery of the Shoulder; specific device/procedure codesCPT

23470	Arthroplasty, glenohumeral joint; hemiarthroplasty
23472	Arthroplasty, glenohumeral joint; total shoulder
29999	Unlisted procedure, arthroscopy (subacromial balloon spacers)
23929	Unlisted procedure, shoulder (TenJet tenotomy)

HCPCS codesHCPCS

J7330

Autologous cultured chondrocytes, implant

Applicable CPT/HCPCS codes mentionedmixed

23470	Arthroplasty, glenohumeral joint; hemiarthroplasty.
23472	Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement) (e.g., total shoulder).
29999	Unlisted procedure, arthroscopy.
23929	Unlisted procedure, shoulder
J7330	Autologous cultured chondrocytes, implant.

Coding: thresholds and implications

Coding thresholdsNone specified in this policy for procedure-specific thresholds.

ImplicationListing of a code does not imply coverage or guarantee payment; benefit coverage is determined by the member-specific benefit plan and applicable laws.

Reference guidanceOther policies and guidelines may apply to determine coverage and reimbursement.

Evidence inclusion for TenJet

Systematic review findingNo studies using the TenJet device met inclusion criteria in the cited systematic review (Maag et al., 2025).

Evidence gapAvailable studies in the review evaluated TENEX and PNT but not TenJet; clinical evidence specific to TenJet for rotator cuff tendinopathy is insufficient.

Impact on coverageInsufficient clinical evidence is cited as rationale for TenJet tenotomy being not reasonable and necessary for rotator cuff tendinopathy.

What Providers Must Do / Billing and Documentation

Prior Authorization

Follow LCD/LCA Requirements When Present

Medicare does not have a National Coverage Determination (NCD) for these procedures in all anatomic sites. Follow any applicable Local Coverage Determinations (LCDs) and Local Coverage Articles (LCAs) where present — compliance with LCD/LCA requirements is required. After checking the Medicare Coverage Database, if no NCD/LCD/LCA is found, refer to the coverage criteria in this policy's Coverage Rationale.

Check the Medicare Coverage Database for NCD/LCD/LCA before applying this policy.
When an LCD/LCA exists, the LCD/LCA requirements must be followed and take precedence for Medicare-related determinations.

Documentation Required

Documentation Retention and Availability

Providers are responsible for submission of accurate claims and for retaining documentation to support coverage. UnitedHealthcare Medicare Advantage Policies are intended to support coverage decisions; they do not guarantee payment. Providers must retain or have access to appropriate documentation and produce it upon request.

Retain medical records, operative reports, imaging, and other supporting documentation.
Be prepared to provide documentation upon request for claim adjudication or medical review.

Prior Authorization

Prior Authorization May Be Required by Delegate

For UnitedHealthcare Medicare Advantage members where a delegate manages utilization management and prior authorization, providers must follow the delegate's prior authorization requirements in addition to this policy. Prior authorization may be required by the delegate.

Verify if the member's plan delegates prior authorization to a vendor or delegated entity before scheduling procedures.
Obtain and document any required prior authorizations from the delegate as applicable.

Billing Rule

Coverage Not Guaranteed by Code Listing

Listing of codes in this policy is for reference only and does not imply benefit coverage or guarantee payment. Benefit determination is made by the member's specific benefit plan document and applicable law.

Do not assume coverage solely because a procedure or diagnosis code appears in this policy.
Confirm member-specific benefits and plan limitations prior to performing services.

Note

Medicare Coverage Check

After checking the Medicare Coverage Database and the applicable LCDs/LCAs, if no NCD/LCD/LCA is identified for the procedure, apply the coverage criteria set forth in this policy's Coverage Rationale section.

Search the Medicare Coverage Database (MCD) for NCDs, LCDs, and LCAs relevant to the procedure and contractor.
If none are found, use this policy's Coverage Rationale to determine medical necessity for Medicare-related claims.

Documentation Required

Claims and Documentation Responsibility

Providers must retain documentation to support claims and be able to produce it upon request for medical review or audit. Accurate claims submission is the provider's responsibility; following coding guidelines does not guarantee payment.

Keep documentation for the time period required by payer or regulatory authorities.
Ensure records include rationale for procedures, operative notes, imaging results, and any prior authorization approvals.

Policy Background and Scope

This policy groups coverage guidance across multiple joint surgery categories (hip, knee, shoulder, ankle, elbow, hand/wrist, foot/toes) and identifies when Medicare documents (NCDs, LCDs/LCAs) apply. Where a Medicare NCD or an applicable LCD/LCA exists, compliance with those local coverage policies is required and providers should follow their prior authorization and documentation processes; where no Medicare coverage determination exists, the policy refers providers to the referenced UnitedHealthcare commercial policies or InterQual criteria for clinical coverage guidance.

For the TenJet system specifically, the document provides a device description and a summary of regulatory status but notes an evidence gap: although the TenJet device has been described (high‑pressure saline jet via a 2‑channel, 12‑gauge needle with a 1.5 mm cutting window), a recent systematic review found no TenJet studies that met inclusion criteria. That insufficiency of clinical data is presented as the rationale for deeming TenJet tenotomy not reasonable and necessary for rotator cuff tendinopathy under this policy.

Definitions and Reference Criteria

InterQual

InterQual referencedInterQual criteria are cited as the clinical guidance source for selected procedures (e.g., acetabuloplasty, endoscopic cubital tunnel release).

Where to find InterQualProviders are directed to view InterQual clinical criteria via the UnitedHealthcare InterQual link referenced in the policy.

Use caseWhen Medicare NCD/LCD/LCA do not apply, InterQual may be used for coverage guidance as noted in the policy.

LCD / LCA

DefinitionLocal Coverage Determination (LCD) / Local Coverage Article (LCA): Medicare contractor–specific coverage policies that, where applicable, must be followed for the indicated procedures.

When applicablePolicy notes that LCDs/LCAs exist for some hip, knee, and shoulder procedures and compliance with those policies is required where applicable.

Action for providersRefer to the policy tables for specific LCDs/LCAs and follow their prior authorization and coverage requirements when present.

TenJet system (definition)

Device descriptionThe TenJet system utilizes high-pressure saline delivered through a 2-channel, 12-gauge needle with a 1.5 mm cutting window to debride tendinopathic tissue.

Intended useDescribed for use in tenotomy procedures to debride tendinopathic tissue (example: rotator cuff tendinopathy).

Regulatory noteThe policy notes FDA 510(k) clearance for the TenJet device elsewhere in document context (regulatory summary).