mp-391
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Arthroscopic Debridement and Lavage as Treatment for Osteoarthritis of the Knee

Policy Number: MP-391

Latest Review Date: July 2021

Category: Surgical                                                                 

 

POLICY:

Arthroscopic debridement may be considered medically necessary when preoperative imaging indicates that specific anatomic lesions other than osteoarthritis, e.g., large meniscal tears, loose bodies, are the cause of the patient’s symptoms regardless of the presence of osteoarthritis.

Arthroscopic debridement and/or lavage for the treatment of osteoarthritis of the knee in the absence of any other findings is considered not medically necessary.

DESCRIPTION OF PROCEDURE OR SERVICE:

Arthroscopic lavage and cartilage debridement are operative treatments for osteoarthritis (OA).  Lavage is a procedure in which intra-articular fluid is aspirated and the joint is washed out, removing inflammatory mediators, debris, or small loose bodies from the osteoarthritic knee.  Articular debridement involves removal of cartilage or meniscal fragments, but also can include cartilage abrasion, excision of osteophytes, and synovectomy.  Debridement is intended to improve symptoms and joint function in patients with mechanical symptoms such as locking or catching of the knee.  

Osteoarthritis (OA) affects about 21 million people in the United States.  By age 65 years, the majority of the population has radiographic evidence of osteoarthritis and 11% have symptomatic OA of the knee.  The diagnosis of osteoarthritis is established using a combination of clinical information derived from history, physical examination, radiologic imaging, and laboratory evaluation.  An algorithm of diagnostic criteria for OA of the knee has been proposed by the American College of Rheumatology (ACR).  The diagnosis of OA of the knee is defined as presenting with pain and meeting at least five of the following criteria:

  • Patient older than 50 years of age
  • Less than 30 minutes of morning stiffness
  • Crepitus (noisy, grating sound) on active motion
  • Bony tenderness
  • Bony enlargement
  • No palpable warmth of synovium
  • Erythrocyte sedimentation rate (ESR) <40 mm/hr
  • Rheumatoid factor <1:40
  • Noninflammatory synovial fluid

The presence of clinical symptoms of OA does not always correlate well with the degree of abnormality seen radiographically.  It has been noted that approximately 40% of patients who have severe findings on x-rays report no symptoms; conversely, patients with clinical symptoms may show no significant radiological changes.

Treatment for OA of the knee aims to alleviate pain and improve function to mitigate reduction in activity.  However, most treatments do not modify the natural history or progression of OA, and thus are not considered curative.  Nonsurgical modalities that are used include exercise; weight loss; various supportive devices; acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen; nutritional supplements (glucosamine and chondroitin); and intra-articular visco-supplements.  Corticosteroid injection may be considered when relief from NSAIDs is insufficient or the patient is at risk from gastrointestinal adverse effects.  If symptom relief is inadequate with conservative measures, invasive treatments may be considered. Operative treatments for symptomatic OA of the knee include arthroscopic lavage and cartilage debridement, osteotomy, and ultimately total joint arthroplasty.  Surgical procedures intended to repair or restore articular cartilage in the knee, e.g., abrasion arthroplasty, microfracture techniques, and autologous chondrocyte implantation, are appropriate only for younger patients with focal cartilage defects secondary to injury and are not addressed in this policy.

KEY POINTS:

The most recent review of this policy has been was performed through July 14, 2021 using MEDLINE database. 

Summary of Evidence

Arthroscopic lavage and cartilage debridement are operative treatments for OA that may be performed separately or at the same time. The evidence base includes two large well-designed controlled trials, one comparing arthroscopic debridement with lavage and placebo, and the other comparing arthroscopy and lavage along with medical and physical therapy to medical and physical therapy alone. These studies provide sufficient evidence to conclude that arthroscopic debridement and lavage separately or together, do not improve symptoms of OA of the knee and, therefore, are considered not medically necessary.

Practice Guidelines and Position Statements

A systematic review of recommendations and guidelines for the management of OA was published in 2014 by the U.S. Bone and Joint Initiative. Sixteen guidelines from the U.S., Canada, Europe, and Asia were reviewed. Needle lavage and arthroscopy with débridement were not recommended for symptomatic knee OA by the American Academy of Orthopaedic Surgeons (AAOS, see next) or U.K.’s National Collaborating Centre for Chronic Conditions. Osteoarthritis Research Society International (OARSI) guidelines from 2008 found limited support for these procedures. Overall, arthroscopy with débridement was not recommended.

Guidelines from the American Academy of Orthopaedic Surgeons (AAOS) in 2013 provide a strong recommendation against performing arthroscopic debridement and lavage: “We cannot recommend performing arthroscopy with lavage and/or debridement in patients with a primary diagnosis of symptomatic osteoarthritis of the knee.”  A strong recommendation means that the quality of the supporting evidence is high and that practitioners should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. Based on moderate evidence, the AAOS “cannot suggest that the practitioner use needle lavage for patients with symptomatic osteoarthritis of the knee”.

The Osteoarthritis Research Society International (OARSI) convened 16 experts from primary care, rheumatology, orthopedics, and evidence-based medicine from six countries, including the United States, to develop consensus recommendations for management of hip and knee OA.  OARSI concluded that “the roles of joint lavage and arthroscopic debridement are controversial and that, although some studies have demonstrated short-term symptom relief, others suggest that improvement in symptoms could be attributable to a placebo effect.”

U.S. Preventive Services Task Force Recommendations

Not applicable

KEY WORDS:

Arthroscopic debridement, lavage, osteoarthritis, knee, arthroscopic lavage

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. FEP does not consider investigational if FDA approved and will be reviewed for medical necessity.

CODING: 

CPT Codes:

29871

Arthroscopy, knee, surgical; for infection, lavage and drainage

29874

; for removal of loose body or foreign body (e.g., osteochondritis dissecans fragmentation, chondral fragmentation)

29877

; debridement/shaving of articular cartilage (chondroplasty)

 

REFERENCES:

  1. American Academy of Orthopaedic Surgeons. Treatment of osteoarthritis of the knee - 2nd edition. 2013. www.aaos.org/research/guidelines/GuidelineOAKnee.asp.
  2. Avouac J, Vicaut E, Bardin T, Richette P. Efficacy of joint lavage in knee osteoarthritis: meta-analysis of randomized controlled studies. Rheumatology (Oxford). 2010 Feb;49(2):334-40. doi: 10.1093/rheumatology/kep382. Epub 2009 Dec 2.
  3. Chang RW, Falconer J, Stulberd SD, et al.  A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee.  Arthritis Rheum 1993; 36(3):289-96.
  4. Hubbard MJ.  Articular debridement versus washout for degeneration of the medial femoral condyle.  A five-year study.  J Bone Joint Surg Br 1996; 78(2):217-9.
  5. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013 May 2;368(18):1675-84.
  6. Khan M, Evaniew N, Bedi A, Ayeni OR, Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ. 2014 Oct 7;186(14):1057-64.
  7. Kirkley A, Birmingham TB, Litchfield RB, et al.  A randomized trial of arthroscopic surgery for osteoarthritis of the knee.  N Engl J Med 2008; 359(11):1097-107.
  8. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, et al.  Arthroscopic debridement for knee osteoarthritis.  Cochrane Database Syst Rev 2008; (1):CDD005118.
  9. Marx RG.  Arthroscopic surgery for osteoarthritis of the knee?  N Engl J Med 2008; 359(11):1169-70.
  10. Moseley JB, O’Malley K, Petersen NJ, et al.  A controlled trial of arthroscopic surgery for osteoarthritis of the knee.  N Engl J Med 2002; 347(2):81-8.
  11. Nelson AE, Allen KD, Golightly YM, et al. A systematic review of recommendations and guidelines for the management of osteoarthritis: The Chronic Osteoarthritis Management Initiative of the U.S. Bone and Joint Initiative. Semin Arthritis Rheum. Jun 2014; 43 (6):701-712.
  12. Reichenbach S, Rutjes AS, Nuesch E et al. Joint lavage for osteoarthritis of the knee. Cochrane Database Syst Rev 2010; (5):CD007320.
  13. Richmond J, Hunter D, Irrgang J et al. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg 2009; 17(9):591-600.
  14. Samson DJ, Grant MD, Ratko TA, et al.  Treatment of Primary and Secondary Osteoarthritis of the Knee.  Evidence Report/Technology Assessment No. 157 (Prepared by Blue Cross and Blue Shield Association Technology Evaluation Center Evidence-Based Practice Center under Contract No. 290-02-0026). AHRQ Publication No. 07-E012. Rockville, MD:  Agency for Healthcare Research and Quality. September 2007.  www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1b.chapter.92496. 
  15. Spahn G, Hofmann GO, Klinger HM. The effects of arthroscopic joint debridement in the knee osteoarthritis: results of a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2012. [Epub ahead of print]
  16. Thorlund JB, Juhl CB, Roos EM, Lohmander LS. Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ. 2015 Jun 16;350:h2747.
  17. Zhang W, Moskowitz RW, Nuki G, et al.  OARSI recommendations for the management of hip and knee osteoarthritis.  Part KK: OARSI evidence-based, expert consensus guidelines.  Osteoarthritis Cartilage 2008; 16(2):137-62.
  18. www.aaos.org/Research/guidelines/OAKguideline.pdf. 

POLICY HISTORY:

Medical Policy Group, September 2009 (3)

Medical Policy Administration Committee, September 2009

Available for comment September 18-November 2, 2009

Medical Policy Group, December 2010 (1): Key Points and references updated

Medical Policy Group, March 2012 (3): Updated References

Medical Policy Panel, December 2012

Medical Policy Group, December 2012 (3): Updated Key Points and References; added Summary and Practice Guidelines and Position Statements sections.  Removed CMS section and vetting.  Policy statement remains unchanged

Medical Policy Panel, December 2013

Medical Policy Group, January 2014 (3):  Updated Key Points and References; no change in policy statement

Medical Policy Panel, December 2014

Medical Policy Group, December 2014 (3): Updates to Key Points and References.  No change to policy statement.

Medical Policy Panel, July 2016

Medical Policy Group, July 2016 (7): Updates to Key Points. No change to policy statement. Retiring policy.

Medical Policy Group, October 2019 (7): Reviewed by consensus. Updates to Key Points and References. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, July 2021 (7): Reviewed by consensus. Updates to Key Points and References. No new published peer-reviewed literature available that would alter the coverage statement in this policy.

Medical Policy Group, February 2022 (7):  Clarification to Policy Statement- reworded investigational statement for clarity. No change in intent.

 

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.