CurrentColorado Rocky Mountain Health PlansPolicy MMP052.12

Joint Procedures

Medicare Advantage policy summarizing coverage guidance, references to applicable Medicare LCDs/LCAs and external commercial policies (UnitedHealthcare/InterQual) for various joint surgeries; includes specific statement that tenotomy using the TenJet device for rotator cuff tendinopathy is not reasonable and necessary due to insufficient evidence. Applicable CPT/HCPCS procedure codes are listed for reference.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyJoint Procedures

Policy CodePolicy MMP052.12

Change TypeCodes removed / CMS docs updated / Archived prior version

Effective DateJan 1, 2026

Next Review Date

Key ActionProviders are expected to retain or have access to appropriate documentation to support coverage and supply documentation when requested; benefit coverage is determined by the member's benefit plan document.

SourceLink

POLICY UPDATE CHANGES

Removed CPT code 27445 from Applicable Codes.

Updated list of CMS documents available in the Medicare Coverage Database to reflect current information.

Archived previous policy version MMP052.11.

1Procedures explicitly listed as not medically necessary

~30Procedure codes listed for reference

1Policy versions archived

Coverage Summary

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Policy Number: MMP052.12; Status: CURRENT; Subject: Joint Procedures (surgical procedures of hip, knee, ankle, shoulder, elbow, hand, foot; TenJet tenotomy). Effective Date: 2026-01-01; Last Review: 2025-12-10. Overview: This Medicare Advantage coverage criteria document summarizes coverage guidance for a range of joint surgical procedures and references applicable Medicare LCDs/LCAs and UnitedHealthcare external criteria (Commercial policies, InterQual) for specific joints. The overall coverage stance is mixed — most procedures are addressed via existing Medicare determinations or UnitedHealthcare/InterQual criteria, while one procedure is explicitly categorized as not medically necessary: Tenotomy utilizing the TenJet™ device for rotator cuff tendinopathy (not reasonable and necessary) due to insufficient evidence.

Medical-Necessity Criteria

General Coverage Guidance / References

Coverage follows applicable Medicare LCDs/LCAs where they exist; otherwise refer to UnitedHealthcare Commercial Medical Policy or InterQual criteria as noted.

General references

NCD/LCD/LCA precedence: If an applicable NCD/LCD/LCA exists for a procedure, compliance with that policy is required.
No LCD/LCA — commercial policy: For states/territories with no LCDs/LCAs for a procedure, refer to the UnitedHealthcare Commercial Medical Policy titled for that joint (e.g., Surgery of the Hip, Knee, Shoulder, Ankle, Hand/Wrist, Foot).
InterQual reference: For certain procedures (e.g., acetabuloplasty resection of femoral head) where LCDs/LCAs do not exist, refer to InterQual criteria as indicated.

Not Medically Necessary / Experimental

Not Medically Necessary: Tenotomy utilizing the TenJet™ device for the treatment of rotator cuff tendinopathy is stated as not reasonable and necessary because there is insufficient evidence of safety and/or efficacy. The policy notes that although the device has FDA 510(k) clearance, clinical literature does not provide adequate evidence to support coverage. The systematic review by Maag et al. (2025) found that no studies using the TenJet device met inclusion criteria, supporting the determination of insufficient evidence.

TenJet: High-pressure saline jet tenotomy device using a 2-channel, 12-gauge needle with a 1.5 mm cutting window (used to debride tendinopathic tissue).

Evidence summary: A systematic review (Maag et al., 2025) evaluated ultrasound-guided percutaneous needle tenotomy techniques including PNT, TENEX, and TENJET. The review reported studies using TENEX and PNT but indicated that no studies using the TenJet device met inclusion criteria, leading to a conclusion that evidence is insufficient to support TenJet for tendinopathy.

Coding — Applicable Procedure Codes

Applicable CPT codes - Surgery of the HipCPT

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
29915	Arthroscopy, hip, surgical; with acetabuloplasty

1–10 of 12

1/2

Applicable CPT codes - Surgery of the KneeCPT

27412	Autologous chondrocyte implantation, knee
27415	Osteochondral allograft, knee, open
27416	Osteochondral autograft(s), knee, open (includes harvesting of autograft[s])
27446	Arthroplasty, knee, condyle and plateau; medial or lateral compartment
27447	Arthroplasty, knee, condyle and plateau; medial and lateral compartments (total knee arthroplasty)
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)
29867	Arthroscopy, knee, surgical; osteochondral allograft
29868	Arthroscopy, knee, surgical; meniscal transplantation

Applicable CPT codes - Surgery of the AnkleCPT

28446	Open osteochondral autograft, talus (includes obtaining graft[s])
29891	Arthroscopy, ankle, surgical, excision of osteochondral defect of talus and/or tibia
29892	Arthroscopically aided repair of large OCD lesion, talar dome fracture, or tibial plafond fracture
29894	Arthroscopy, ankle; removal of loose body
29895	Arthroscopy, ankle; synovectomy, partial
29897	Arthroscopy, ankle; debridement, limited
29898	Arthroscopy, ankle; debridement, extensive
29899	Arthroscopy, ankle; with ankle arthrodesis

Applicable CPT codes - Arthrodesis/Arthroplasty, Interphalangeal Joint, Second-Fifth ToesCPT

28899

Unlisted procedure, foot or toes

Applicable CPT codes - 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; synovectomy, partial
29845	Arthroscopy, wrist; synovectomy, complete
29846	Arthroscopy, wrist; excision and/or repair of triangular fibrocartilage and/or joint debridement
29847	Arthroscopy, wrist; internal fixation for fracture or instability

Applicable CPT codes - Endoscopic Cubital Tunnel Release / Surgery of the ElbowCPT

29999	Unlisted procedure, arthroscopy
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

Applicable CPT codes - Surgery of the ShoulderCPT

23470	Arthroplasty, glenohumeral joint; hemiarthroplasty
23472	Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement)
29999	Unlisted procedure, arthroscopy
23929	Unlisted procedure, shoulder

Applicable HCPCS codesHCPCS

J7330

Autologous cultured chondrocytes, implant

Provider Actions

Documentation Required

Retain supporting documentation

Providers are expected to retain or have access to appropriate documentation to support coverage and to supply documentation when requested. Benefit coverage is determined by the member's benefit plan document; in the event of a conflict, the member-specific benefit plan document supersedes this policy.

Prior Authorization

Follow applicable LCD/LCA/Delegate prior authorization requirements

When a delegate manages utilization management and prior authorization requirements for a Medicare Advantage plan, follow the delegate's requirements. Where LCDs/LCAs exist for a procedure, compliance with those Medicare policies is required and takes precedence for coverage determinations.

Billing Rule

Accurate claims submission

Providers are responsible for submission of accurate claims using CPT/CMS coding guidelines. The listing of procedure and/or diagnosis codes in this policy is provided for reference only and does not guarantee reimbursement or claim payment; other policies and the member's benefit plan may apply.

Medicare Determinations / External LCDs/LCAs

Number	Name (Type)
L33618	Major Joint Replacement (Hip and Knee) (LCD)
L36039	Total Joint Arthroplasty (LCD)
L34163	Total Hip Arthroplasty (LCD)
L36007	Lower Extremity Major Joint Replacement (Hip and Knee) (LCD)
L33456	Total Joint Arthroplasty (LCD)
L39911	Total Joint Arthroplasty (LCD)
L39956	Total Shoulder Arthroplasty (LCD)
A57765	Billing and Coding: Major Joint Replacement (Hip and Knee) (LCA)
A57428	Billing and Coding: Total Joint Arthroplasty (LCA)
A57683	Billing and Coding: Total Hip Arthroplasty (LCA)

Background: Medicare Advantage policy documents are used to support UnitedHealthcare coverage decisions and are intended as guidance for medical necessity, coding, and documentation. Where applicable CMS NCDs, LCDs, or LCAs exist, compliance with those Medicare determinations takes precedence. This policy lists applicable procedure codes for reference and also references UnitedHealthcare Commercial Medical Policies and InterQual criteria for specific joint surgeries.

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