CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Knee Arthroscopy

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These guidelines identify the clinical information MassHealth requires to determine medical necessity for knee arthroscopy without arthroplasty, including diagnostic arthroscopy and specified knee repairs, reconstructions, and related procedures. Prior authorization is required, and requests are reviewed case by case.

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Knee Arthroscopy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2018

Next Review DateN/A

Key ActionSubmit a prior authorization request with clinical documentation supporting the medical necessity of the proposed knee arthroscopy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

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CurrentMassachusetts Executive Office of Health and Human ServicesPolicy N/A

Guidelines for Medical Necessity Determination for Knee Arthroscopy

Customize your policy alerts

Sign up for all Massachusetts Executive Office of Health and Human Services policy alerts

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Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Knee Arthroscopy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2018

Next Review DateN/A

Key ActionSubmit a prior authorization request with clinical documentation supporting the medical necessity of the proposed knee arthroscopy.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Knee arthroscopy indications addressed

12 weeksCommon minimum duration of symptoms or failed conservative care

6 monthsFailed nonoperative care for selected patellar conditions

7Examples of non-medically necessary circumstances

3Core documentation categories

Knee Arthroscopy Medical Necessity Criteria

Diagnostic knee arthroscopy

Covered when ALL criteria are met.

Diagnostic arthroscopy criteria

Symptoms and function: At least 12 weeks of knee pain with documented loss of function affecting activities of daily living, recreation, or employment due to injury or pain.>10 degrees flexion contracture or <90 degrees flexion, or both
Loss of function may include painful weight bearing, unstable articulation, or inadequate range of motion.
Failed conservative care: At least 12 weeks of nonoperative care has failed to improve symptoms.12 weeks
Clinical findings: Clinical documentation shows painful weight bearing, joint-line tenderness, effusion, and/or limited motion compared with the presymptomatic joint range of motion.
Imaging: Radiographic and MRI findings are indeterminate.

Meniscectomy or repair of torn meniscus

Covered when ALL criteria are met.

Meniscal surgery criteria

Qualifying meniscal pathology
- Vascular-zone tear: Symptomatic meniscal tear is confirmed by MRI showing a peripheral longitudinal tear in a vascular zone, with pain and mechanical symptoms on physical examination.
- Pediatric or adolescent unstable tear: A pediatric or adolescent patient has pain and mechanical symptoms on physical examination and MRI shows an unstable tear.
- Clinical meniscal findings
  - Patient-reported history of catching or locking.

Popliteal or Baker's cyst

Covered after failed conservative treatment.

Excision of a popliteal/Baker's cyst or exploration of causative pathology may be medically necessary after a failed trial of nonoperative conservative therapy.Failed conservative therapy

Lateral release or patellar realignment

Covered when ALL criteria are met.

Lateral release or patellar realignment criteria

Radiologic lateral tilt: Evidence of lateral patellar tilt is shown on a patellofemoral radiologic view: Mercer-Merchant at 45–60 degrees flexion, skyline at 60–90 degrees flexion, or sunrise at 60–90 degrees flexion.
Lateral facet changes: Associated lateral patellar facet Kellgren-Lawrence changes are Grade I, II, or III.KL I–III
Pain with tilt test: Reproducible isolated lateral patellofemoral pain is present with patellar tilt testing.
Failed conservative care:

Patellar malalignment or instability repair

Covered when ALL criteria are met.

Patellar malalignment or instability criteria

Qualifying patellar presentation
- Acute traumatic dislocation: Acute traumatic patellar dislocation is associated with an osteochondral fracture, loose body, vastus medialis obliquus/medial patellofemoral ligament muscle avulsion, or another intra-articular injury requiring urgent operative management.
- Recurrent instability: More than two patellar dislocations or subluxations have occurred despite six months of nonoperative care, with radiologic confirmation of medial patellofemoral ligament deficiency.>2 episodes and 6 months
- Abnormal articulation: Physical examination shows patellofemoral tenderness and abnormal articulation in the femoral trochlear groove, including patellar apprehension with a positive J-sign.

Collateral ligament repair or reconstruction

Reviewed case by case for medical necessity.

Collateral ligament review: Collateral ligament repair or reconstruction should rarely occur independently of additional repair or reconstruction surgery. All nontraumatic collateral ligament repair or reconstruction requests are reviewed case by case for medical necessity.

Anterior cruciate ligament reconstruction or repair

Covered when ALL criteria are met.

ACL criteria

Qualifying ACL pathway
- Complete tear with instability: Knee instability is documented by symptoms such as giving way, giving out, buckling, or two-fist sign, with clinical findings of instability; MRI confirms a complete ACL tear; and there is no severe arthritis.KT-1000 or KT-2000 laxity >3 mm side-to-side; no KL III–IV
- Alternative ACL indications
  - MRI confirms an ACL tear associated with other ligamentous instability or a repairable meniscus.
  - MRI confirms a partial or complete ACL tear and symptoms persist despite at least 12 weeks of nonoperative care.

Loose body or foreign object removal

Medical necessity may be determined case by case.

Functional impairment from loose body: A loose body or foreign object causes documented loss of function affecting activities of daily living, recreation, or employment due to injury or pain.>10 degrees flexion contracture or <90 degrees flexion, or both, may establish inadequate range of motion

Loss of function may include painful weight bearing or unstable articulation.

Synovectomy

Covered when ONE qualifying pathway is met.

Synovectomy indications

Proliferative rheumatoid synovium: Established rheumatoid arthritis with proliferative rheumatoid synovium is not responsive to DMARD therapy for at least six months, at least six weeks of nonoperative care has failed to improve symptoms, and there has been at least one aspiration of joint effusion plus cortisone injection when there is no evidence of infection.DMARD 6 months; conservative care 6 weeks
Hemarthrosis
- Qualifying hemarthrosis pathway
  - At least six weeks of nonoperative care has failed to improve symptoms and there has been at least one aspiration of joint effusion with cortisone injection when there is no evidence of infection.6 weeks

Arthroscopically assisted lysis of adhesions for knee arthrofibrosis

Covered when ONE pathway is met.

Lysis of adhesions pathways

Post-reconstruction or resolved-infection pathway: Physical examination demonstrates knee flexion less than 105 degrees; range of motion has failed to improve despite six weeks and 12 visits of documented physical therapy; and the member is more than 12 weeks after ligamentous or joint reconstruction or resolved infection.Flexion <105 degrees; PT 6 weeks/12 visits; >12 weeks after surgery or resolved infection
Native-knee trauma pathway: The member is more than 12 weeks after trauma or resolved infection, has a native knee, and manipulation under anesthesia is also performed.>12 weeks

Debridement with or without chondroplasty for mild-to-moderate cartilage wear

Covered when ONE pathway is met.

Cartilage debridement pathways

Unstable chondral flap pathway: At least 12 weeks of knee pain with documented loss of function; at least 12 weeks of nonoperative care has failed to improve symptoms; MRI shows an unstable chondral flap; and effusions are recurrent, more than two, or persistent.12 weeks; >2 or persistent effusions
Loss of function may include painful weight bearing, unstable articulation, flexion contracture >10 degrees, or flexion <90 degrees.
Arthrofibrosis pathway: Arthrofibrosis is evidenced by painful stiffness and loss of motion due to proliferation of scar tissue in or around the joint, and at least six weeks of supervised or self-directed physical therapy has failed to improve symptoms.PT 6 weeks
Imaging may assist diagnosis but is not necessary.

Debridement chondroplasty for patellofemoral chondrosis

Covered when ALL criteria are met.

Patellofemoral chondrosis criteria

Symptoms and function: At least 12 weeks of knee pain with documented loss of function affecting activities of daily living, recreation, or employment.>10 degrees flexion contracture or <90 degrees flexion, or both, may establish inadequate range of motion
Alternative causes excluded: Other extra-articular or intra-articular sources of pain or dysfunction, including referred pain, radicular pain, tendinitis, bursitis, or neuroma, have been excluded.
Patellofemoral examination findings: Tenderness is localized to the patellofemoral joint and pain is aggravated by joint-loading activities, including a single-leg squat, ascending stairs, or prolonged seated knee flexion.
Ascending stairs is more difficult than descending stairs.

Manipulation under anesthesia after total knee replacement

Covered when ALL criteria are met.

Manipulation under anesthesia criteria

Limited flexion: Physical examination demonstrates inadequate knee range of motion.<105 degrees flexion
Failed physical therapy: Six weeks, with a minimum of 12 visits, of physical therapy fails to improve knee range of motion.6 weeks/12 visits
Timing after reconstruction: The patient is less than 12 weeks after ligamentous or joint reconstruction.<12 weeks

Noncoverage

Not medically necessary under the following circumstances.

Noncovered circumstances

Osteoarthritis alone: Osteoarthritis of the knee is the sole diagnosis.
Degenerative meniscal disease without qualifying findings: A meniscal tear occurs in chronic degenerative knee joint disease without mechanical symptoms such as locking or catching, without a loose body, or without the specified qualifying meniscal tear.
Meniscal tear with severe OA: A meniscal tear is present with Kellgren-Lawrence Grade IV osteoarthritis.KL IV
Isolated ligament tear:

Knee arthroscopy is not medically necessary when osteoarthritis of the knee is the sole diagnosis.

Arthroscopy for a meniscal tear in chronic degenerative knee joint disease is not medically necessary when mechanical symptoms, such as locking or catching, are absent and there is no loose body or other specified qualifying meniscal tear.

A meniscal tear in the presence of Kellgren-Lawrence Grade IV osteoarthritis is not medically necessary for knee arthroscopy.

Repair or reconstruction of an isolated medial or collateral ligament tear is not medically necessary under these guidelines.

Procedures utilizing computer-navigated, patient-specific, or gender-specific instrumentation are not medically necessary.

Investigational bicompartmental arthroplasty and robot-assisted total knee arthroplasty, including Makoplasty, are not medically necessary under these guidelines.

MassHealth does not consider knee arthroscopy medically necessary in the following circumstances: osteoarthritis as the sole diagnosis; chronic degenerative meniscal tear without mechanical symptoms such as locking or catching, a loose body, or a specified qualifying meniscal tear; meniscal tear with Kellgren-Lawrence Grade IV osteoarthritis; isolated medial or collateral ligament tears; use of computer-navigated, patient-specific, or gender-specific instrumentation; investigational bicompartmental arthroplasty; or robot-assisted total knee arthroplasty, including Makoplasty.

Clinical Thresholds and Examination Findings

Documented loss-of-function range of motion

Flexion contracture>10 degrees

Knee flexion<90 degrees

Functional impactAffects activities of daily living, recreation, or employment due to injury or pain

Meniscal examination findings

Minimum findingsAt least 3 of 5 specified findings

Specified findingsCatching or locking; joint-line pain with forced hyperextension; joint-line pain with maximum flexion; pain or audible click with McMurray's maneuver; or joint-line tenderness

Examination basis

Prior Authorization and Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for knee arthroscopy. MassHealth reviews each request for medical necessity before determining whether the service may be covered.

Documentation Required

Document Failed Conservative Treatment

Document the required period of unsuccessful conservative treatment when applicable. Clinical documentation should show at least 12 weeks of nonoperative care that failed to improve symptoms, including the specific treatments tried.

Activity modification, rest or limitation, bracing or orthosis, walking aids, protected weight bearing, or weight optimization
Physical therapy, including ice or heat, formal strengthening and mobility exercises, or a supervised home exercise program
Medication or other symptom management, including oral or topical NSAIDs, other analgesics, or injections such as cortisone

Knee Arthroscopy Overview

Knee arthroscopy uses a fiber-optic camera and surgical instruments placed into the knee joint to visualize structures and to diagnose, repair, remove, or reconstruct cartilage and other knee structures. The guideline addresses arthroscopy without arthroplasty for diagnostic procedures, meniscal surgery, cysts, patellar disorders, ligament reconstruction, loose bodies, synovectomy, arthrofibrosis, cartilage wear, patellofemoral chondrosis, and manipulation after total knee replacement.

Clinical Definitions and Grading

Knee arthroscopy

Procedure typeSurgical procedure

VisualizationA fiber-optic camera is placed into the knee joint to view joint structures

Permitted treatmentInstruments can repair, remove, or reconstruct knee cartilage and other structures

Documented loss of function

DefinitionA deviation from normal knee function

ExamplesPainful weight bearing, unstable articulation, or inadequate range of motion

Range-of-motion definition

Policy Summary

PayerMassachusetts Executive Office of Health and Human Services

PolicyGuidelines for Medical Necessity Determination for Knee Arthroscopy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJun 1, 2018

Next Review DateN/A

Key ActionSubmit a prior authorization request with clinical documentation supporting the medical necessity of the proposed knee arthroscopy.

SourceLink

On This Page

Joint-line pain with forced hyperextension.

Joint-line pain with maximum flexion.

Knee pain or an audible click with McMurray's maneuver.

Joint-line tenderness to palpation.

Failed conservative care: At least six weeks of nonoperative care has failed to improve symptoms.6 weeks

Qualifying imaging or radiographic finding

Radiographs show no moderate or severe osteoarthritic changes.
MRI confirms a meniscal tear in a patient younger than 30 years.<30 years
MRI confirms a displaced tear at any age.

At least six months of nonoperative care, including appropriate hamstring/IT-band stretching and patellar mobilization techniques, has failed to improve symptoms.

No unsupported dislocation: There is no evidence of patellar dislocation without documented patellar tilt.

No advanced medial patellofemoral OA: There is no medial patellofemoral Kellgren-Lawrence Grade II, III, or IV osteoarthritis.No KL II–IV

Imaging excludes fracture or loose body: Radiologic images rule out fracture or loose body and show abnormal articulation, trochlear dysplasia, or another abnormality related to malalignment.

Alignment imaging: CT or MRI rules out another cause of malalignment and assesses the tibial tubercle–trochlear groove distance.TT-TG distance >20 mm is specified in the guideline

Failed conservative care: At least six months of nonoperative care has failed to improve symptoms.6 months

Acute ACL tear is confirmed by MRI in a high-demand occupation or competitive athlete.Marx athletics score >4 and Tegner athletics and/or occupation score >2

No severe arthritis: The patient has no evidence of severe arthritis.No KL III–IV

Painful plica is confirmed by physical examination and MRI, at least 12 weeks of nonoperative care has failed to improve symptoms, and there has been at least one aspiration of joint effusion or a single cortisone injection.12 weeks

Effusion may be absent with symptomatic plica.

Proliferative or traumatic synovial disease: Proliferative pigmented villonodular synovitis, synovial chondromatosis, sarcoid synovitis, similar proliferative synovial disease, or traumatic hypertrophic synovitis is confirmed by history, MRI, or biopsy; at least six weeks of nonoperative care has failed; and there has been at least one aspiration of joint effusion plus cortisone injection when there is no evidence of infection.6 weeks

Effusion may be absent with symptomatic plica.

TT-TG imaging: Imaging measures tibial tubercle–trochlear groove distance using radiographs, MRI, or CT.

Failed conservative care: At least 12 weeks of nonoperative care has failed to improve symptoms.12 weeks

No advanced OA: Standing or weight-bearing radiographs and patellofemoral views show no Kellgren-Lawrence Grade III–IV osteoarthritis.No KL III–IV

An isolated medial or collateral ligament tear is present.

Specialized instrumentation: The procedure uses computer-navigated, patient-specific, or gender-specific instrumentation.

Investigational bicompartmental arthroplasty: Bicompartmental arthroplasty is considered investigational.

Robot-assisted TKA: Robot-assisted total knee arthroplasty, including Makoplasty, is requested.

Findings must be documented on patient history or physical examination

Failed nonoperative care for patellar procedures

Minimum durationAt least 6 months

Treatment typeNonoperative care

Required resultTreatment has failed to improve symptoms

Instrumented ACL laxity

InstrumentKT-1000 or KT-2000

Side-to-side difference>3 mm

Finding assessedInstrumented ACL laxity

High-demand activity score

Marx athletics score>4

Tegner athletics score>2

Tegner occupation score>2 when applicable

Patellar alignment measurement

MeasurementTibial tubercle-trochlear groove (TT-TG) distance

Threshold>20 mm

Measurement methodsCT or MRI

Restricted knee flexion

Knee flexion threshold<105 degrees

Clinical assessmentPhysical examination demonstrates inadequate range of motion

Applicable proceduresArthroscopically assisted lysis of adhesions or manipulation under anesthesia

Physical therapy before lysis or manipulation under anesthesia

Duration6 weeks

Minimum visits12 visits

DocumentationDocumented physical therapy fails to improve knee range of motion

Documentation Required

Required Clinical Documentation

The PA request must include complete clinical documentation supporting the proposed arthroscopy and the condition being treated.

Primary and secondary diagnoses, including applicable ICD-CM codes and pertinent comorbid conditions
Specific arthroscopic procedure and appropriate CPT code(s)
Most recent medical evaluation, medical history, orthopedic knee examination, and condition-specific testing
Relevant radiology and other test results, plus risk factors and any other pertinent information MassHealth requests

Billing Rule

Submit Through MassHealth Channels

Clinical information must be submitted by an orthopedic surgeon through a designated MassHealth channel. Providers are strongly encouraged to use the Provider Online Service Center (POSC); alternatively, submit the MassHealth PA-1 form with pertinent documentation to the address on the back of the form.

The submitting orthopedic surgeon must be a MassHealth provider
Direct POSC access questions to the MassHealth Customer Service Center at 1-800-841-2900

Documentation Required

Support Medical Necessity

Submit documentation that supports the medical necessity of the proposed treatment, products, or services. Include all information pertinent to the diagnosis, requested arthroscopic procedure, examination and testing, imaging, prior treatment, and relevant risk factors or comorbidities.

Ensure the record explains why the requested knee arthroscopy is medically necessary for the member's condition
Include any other pertinent information requested by MassHealth

Denial Risk

Noncoverage and Denial Risks

MassHealth may deny coverage when medical-necessity criteria are not met or when the procedure falls within a noncoverage circumstance. Examples include osteoarthritis as the sole diagnosis, degenerative meniscal disease without mechanical symptoms or a loose body, meniscal tear with Kellgren-Lawrence Grade IV osteoarthritis, isolated medial or collateral ligament tears, and specified investigational or technology-dependent procedures.

Do not assume a diagnosis alone establishes medical necessity; submit the required clinical findings, imaging, and failed conservative treatment
Noncovered examples also include computer-navigated, patient-specific, or gender-specific instrumentation; investigational bicompartmental arthroplasty; and robot-assisted TKA (Makoplasty)

Billing Rule

PA Submission and Payment Conditions

The orthopedic surgeon is responsible for submitting the PA request and supporting clinical documentation. Approval does not guarantee payment: payment remains subject to MassHealth's general conditions, including member eligibility, other insurance, program restrictions, and applicable coverage and billing requirements.

Submit the request as a MassHealth provider and identify the requested procedure with appropriate CPT code(s)
Attach documentation demonstrating medical necessity and all applicable clinical criteria

>10 degrees flexion contracture or <90 degrees flexion, or both

Functional effectImpacts activities of daily living, recreation, or employment due to injury or pain

Kellgren-Lawrence grading system

Grade 0No radiographic features of osteoarthritis

Grade IPossible joint-space narrowing and osteophyte formation

Grade IIDefinite osteophyte formation with possible joint-space narrowing

Grade IIIModerate multiple osteophytes, definite joint-space narrowing, some sclerosis, and possible bone-contour deformity

Grade IVLarge osteophytes, marked joint-space narrowing, severe sclerosis, and definite bone-contour deformity

Synovectomy compartments

Major synovectomyInvolves 2 or more compartments

Minor synovectomyInvolves 1 compartment

Medial compartmentInside the knee joint

Lateral compartmentOutside the knee joint

Patellofemoral compartmentFront of the knee joint between the patella and femur

Kellgren-Lawrence Grade 0

Radiographic osteoarthritisNone

OsteophytesNo radiographic osteoarthritis features identified

Joint spaceNo radiographic osteoarthritis features identified

Kellgren-Lawrence Grade I

Joint-space narrowingPossible

Osteophyte formationPossible

Overall classificationPossible early radiographic osteoarthritis features

Kellgren-Lawrence Grade II

Osteophyte formationDefinite

Joint-space narrowingPossible

Overall classificationDefinite osteophytes with possible joint-space narrowing

Kellgren-Lawrence Grade III

OsteophytesModerate multiple osteophytes

Joint-space narrowingDefinite

SclerosisSome sclerosis

Bone contourPossible deformity

Kellgren-Lawrence Grade IV

OsteophytesLarge osteophytes

Joint-space narrowingMarked

SclerosisSevere sclerosis

Bone contourDefinite deformity