Latest Review Date: June 2024

Category: Surgery                                                                  

POLICY

Disposable arthroscopy and/or needle arthroscopy (in-office arthroscopy) used as a procedure to evaluate intra-articular joint pathology is considered investigational.

DESCRIPTION OF PROCEDURE OR SERVICE

Arthroscopy is an invasive procedure that is performed to substantiate a diagnosis of intra-articular joint pathology, and to surgically treat such pathology. Disposable arthroscopy is usually performed in an office setting and uses a small, flexible, disposable arthroscope that is 1.6-1.7 mm in diameter.  It operates with a fiber optic system.  The articular contents are viewed via video equipment and a television monitor. This device is intended to permit arthroscopy, mostly for the knee, in an office setting under local anesthesia. 

The Inner Vue™ Diagnostic Scope System uses a small disposable diagnostic scope (outside diameter = 1.2 mm) with a single puncture wound.  It provides digital images and can be used in place of or in conjunction with MRI.

The Micronix™ Surgical Corporation has a disposable micro-endoscope that is used by orthopedic surgeons who perform minimally invasive arthroscopy of the knee and other small joints.

KEY POINTS

The most recent literature review was updated through June 6, 2024.

Summary of Evidence

No new peer-reviewed published literature was located that would alter the coverage statement of this policy.

There are a few published studies that have compared the use of the smaller arthroscope to conventional arthroscopy in an office setting to evaluate the knee joint or other joints. The studies were small groups and the authors noted limitations of the smaller scopes. The study results also showed an overall underestimation and under-recognition of intra-articular knee pathologic changes by the optical catheter system. The authors concluded that using the optical system to evaluate the knee in the office setting may result in a significant compromise in visual acuity, resulting in missed and incorrect diagnoses. The conventional arthroscopy is still the more reliable diagnostic method to evaluate intra-articular joint pathology.

KEY WORDS

Arthroscopy, disposable arthroscopy, needle arthroscopy, InnerVue™, optical catheter system, Mi-eye 2, in-office diagnostic arthroscopy, VisionScope

APPROVED BY GOVERNING BODIES

Not applicable

BENEFIT APPLICATION

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

FEP: Special benefit consideration may apply. Refer to member’s benefit plan.

CODING 

CPT Codes:

REFERENCES

1. Daggett MC, Stepanovich B, Geraghty B, Meyers A, Whetstone J, Saithna A. Office-Based Needle Arthroscopy: A Standardized Diagnostic Approach to the Shoulder. Arthrosc Tech. 2020 Apr 23;9(4):e521-e525.
2. Denti M, et al.  Comparison of catheter and conventional arthroscopy in the diagnosis of knee derangements.  Arthroscopy:  The Journal of Arthroscopic and Related Surgery 1994, Vol. 10, No. 6.
3. Ike R, et al.  Detection of intra-articular abnormalities in osteoarthritis of the knee.  Arthritis and Rheumatism, October 1993, No. 10, pp. 1353-1363.
4. IOM (Institute of Medicine). 2011. Clinical Practice Guidelines We Can Trust. Washington, DC: The National Academies Press.
5. McMillan S, Saini S, Alyea E, Ford E. Office-Based Needle Arthroscopy: A Standardized Diagnostic Approach to the Knee. Arthrosc Tech. 2017 Jul 24;6(4):e1119-e1124.
6. Meister K, et al.  Comparison of an optical catheter office arthroscope with a standard rigid rod-lens arthroscope in the evaluation of the knee.  The American Journal of Sports Medicine 1996, Vol. 24, No. 6, pp. 819-823.
7. Patel K, Makovicka JK, Dulle DL, et al. Diagnostic evaluation of the knee in the office setting using small-bore needle arthroscopy. Arthroscopy Techniques. 2018;7(1):17-21.
8. Zhang K, Crum RJ, Samuelsson K, Cadet E, Ayeni OR, de Sa D. In-Office Needle Arthroscopy: A Systematic Review of Indications and Clinical Utility. Arthroscopy. 2019 Sep;35(9):2709-2721.

POLICY HISTORY

Medical Policy Group, August 2006 (3)

Medical Policy Administration Committee, August 2006

Available for comment August 30-October 13, 2006

Medical Policy Group, March 2009 (4)

Medical Policy Group, October 2009 (4): Active Policy but no longer scheduled for regular literature reviews and updates.

Medical Policy Group, September 2019 (7): Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Clarification to Policy Statement verbiage: included “in-office arthroscopy.” Added Key Words: Mi-eye 2, in-office diagnostic arthroscopy, VisionScope.

Medical Policy Group, June  2021 (7): Reviewed by consensus. References added. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Removed “not medically necessary” verbiage from Policy Statement.

Medical Policy Group, June 2022 (7): Reviewed by consensus. No new published peer-reviewed literature available that would alter the coverage statement in this policy. Added Key Words: “NanoScope, in-office needle arthroscopy (IONA).”

Medical Policy Group, June 2023 (7): Reviewed by consensus. Update to Benefit Application and References. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, June 2024 (7): Reviewed by consensus. References added. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member’s plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member’s contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1.  The technology must have final approval from the appropriate government regulatory bodies;
2.  The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3.  The technology must improve the net health outcome;
4.  The technology must be as beneficial as any established alternatives;
5.  The improvement must be attainable outside the investigational setting.

Medical Necessity means that health care services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1.  In accordance with generally accepted standards of medical practice; and
2.  Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3.  Not primarily for the convenience of the patient, physician or other health care provider; and
4.  Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.