Clinical Policy Title: Major joint replacement (hip and knee) Clinical Policy Number: 14.03.02 Effective Date: Initial Review Date: Most Recent Review Date: Next Review Date:

April 1, 2015 October 15, 2014 October 19, 2016 October 2017

Related policies: CP# 00.02.08

Policy contains:  Total hip or knee replacement/arthroplasty.  Partial hip replacement.  Joint resurfacing.  Osteoarthritis or fracture.

Intra-articular hyaluronic acid injection for osteoarthritis

ABOUT THIS POLICY: AmeriHealth Caritas Pennsylvania has developed clinical policies to assist with making coverage determinations. AmeriHealth Caritas Pennsylvania’s clinical policies are based on guidelines from established industry sources, such as the Centers for Medicare & Medicaid Services (CMS), state regulatory agencies, the American Medical Association (AMA), medical specialty professional societies, and peer-reviewed professional literature. These clinical policies along with other sources, such as plan benefits and state and federal laws and regulatory requirements, including any state- or plan-specific definition of “medically necessary,” and the specific facts of the particular situation are considered by AmeriHealth Caritas Pennsylvania when making coverage determinations. In the event of conflict between this clinical policy and plan benefits and/or state or federal laws and/or regulatory requirements, the plan benefits and/or state and federal laws and/or regulatory requirements shall control. AmeriHealth Caritas Pennsylvania’s clinical policies are for informational purposes only and not intended as medical advice or to direct treatment. Physicians and other health care providers are solely responsible for the treatment decisions for their patients. AmeriHealth Caritas Pennsylvania’s clinical policies are reflective of evidence-based medicine at the time of review. As medical science evolves, AmeriHealth Caritas Pennsylvania will update its clinical policies as necessary. AmeriHealth Caritas Pennsylvania’s clinical policies are not guarantees of payment. ____________________________________________________________________________________________________________________

Coverage policy AmeriHealth Caritas Pennsylvania considers the use of hip or knee replacement to be clinically proven and, therefore, medically necessary when one or more of the following criteria/documentation requirements are met: Primary total hip or knee arthroplasty Distal femur or tibia fracture. Malignancy of distal femur, proximal tibia, knee joint, or adjacent soft tissues. Avascular necrosis of knee or hip. Proximal fracture. Advanced joint disease demonstrated by:  Radiographs.  If conventional radiography inadequate then magnetic resonance imaging (MRI) showing subchondral cysts or sclerosis; periarticlar osteophytes; joint subluxation; joint space narrowing; avascular necrosis. 1

Pain or functional disability due to trauma or arthritis of the joint. History of unsuccessful conservative therapy (medical management consisting of anti-inflammatory or analgesic medications and/or physical therapy) ≥ three months clearly addressed in the medical record.  Diminished capacity for activities of daily living (ADLs) despite completing plan of care.  Activity restrictions as reasonable, weight reduction, assistive devices, or therapeutic joint injection. Revision/replacement hip or knee arthroplasty Failure of previous osteotomy. Failure of previous unicompartmental knee replacement. Disabling pain or functional disability. Progressive and substantial bone loss. Infection. Periprosthetic fracture or aseptic loosening. Failure and wear of prosthetic components. Dislocation of knee joint. Instability of knee joint. History of unsuccessful conservative therapy (medical management consisting of anti-inflammatory or analgesic medications and/or physical therapy) ≥ three months clearly addressed in the medical record.  Diminished capacity for ADLs despite completing plan of care.  Activity restrictions as reasonable, weight reduction, assistive devices, or therapeutic joint injection. Limitations (hip or knee replacement; primary or revision):   

Active infection. Neuropathic arthritis. Rapidly progressive neurologic disease.

Alternative covered services: None. Background Osteoarthritis (OA) is a chronic and progressive disease resulting from failure of joint cartilage repair after breakdown or wear, accompanied by changes in synovial fluid, pain, and joint movement limitations. Among the most commonly affected joints are hip and knee. Treatments include medical management with acetaminophen, NSAIDs, and COX-2 inhibitors. Other options are intra-articular injections with corticosteroids or hyaluronic acid (see policy #00.02.08 Intra-Articular Hyaluronic Acid Injection for Osteoarthritis).

OA is the most common type of arthritis, particularly in the elderly, and is associated with high rates of disability. Aging populations and the risk factor of obesity contribute to increasing prevalence in developed countries. U.S. prevalence of adults with arthritis is expected to increase from 52.5 million in 2010–2012 to 78 million in 2040 (CDC, 2016). Ultimately when a patient with knee or hip OA remains in pain and functionally limited despite medical management, total knee or hip replacement or arthroplasty (TKA/THA, respectively) may be considered. These procedures relieve pain and improve function for the vast majority of patients with osteoarthritis or fracture, with failure rates of only approximately 1 percent in non-obese patients, when surgery is performed at a center handling at least 25 procedures per year and is performed before a patient’s functional status or muscle tone have substantially declined due to prolonged immobility. Other surgical options include partial or hemi replacement of one joint component rather than both (e.g., of the femoral head, the “ball” of the “ball and socket” hip joint alone, rather than head and acetabulum or “socket” together) or resurfacing of surfaces within the joint cavity. Technology developments in the late 1990s resulted in new prostheses for, and approaches to, knee arthroplasty with corresponding priorities for research in the UK’s National Health Service Research Program (Murray, 2014). The Knee Arthroplasty Trial (KAT; Murray, 2014) provided evidence to support patellar resurfacing and metal-backed tibial components even in the elderly. Hip and knee replacements have rapidly become among the most commonly performed procedures in the United States. In 2010, a total of 719,000 knee replacements and 332,000 hip replacements were performed (CDC, 2010). Of these, 47 percent were performed on persons under 65 years old. A total of 7.2 million Americans have undergone this surgery (4.7 million TKA, 2.5 million THA), of whom 4.7 million are still living (Mayo Clinic, 2014). Searches AmeriHealth Caritas Pennsylvania searched PubMed and the databases of:  UK National Health Services Centre for Reviews and Dissemination.  Agency for Healthcare Research and Quality’s National Guideline Clearinghouse and other evidence-based practice centers.  The Centers for Medicare & Medicaid Services (CMS). We conducted searches on September 13, 2016. Search terms were: “hip replacement” and “knee replacement.” We included:  Systematic reviews, which pool results from multiple studies to achieve larger sample sizes and greater precision of effect estimation than in smaller primary studies. Systematic

 

reviews use predetermined transparent methods to minimize bias, effectively treating the review as a scientific endeavor, and are thus rated highest in evidence-grading hierarchies. Guidelines based on systematic reviews. Economic analyses, such as cost-effectiveness, and benefit or utility studies (but not simple cost studies), reporting both costs and outcomes — sometimes referred to as efficiency studies — which also rank near the top of evidence hierarchies.

Findings Perhaps the most comprehensive professional guideline on knee replacement is contained in the American Academy of Orthopedic Surgeons (AAOS) guideline on osteoarthritis of the knee (AAOS, 2016). The National Institute for Health and Care Excellence (NICE) has published a detailed guideline addressing total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip (NICE, 2014a). The professional literature contains many studies of process and outcomes of hip and knee replacement, allowing for meta-analyses to be conducted. For knee replacement, postsurgical quality of life generally shows improvement in terms of total score, pain level, and functional ability (Shan, 2015). Similar results have been documented for hip replacement patients (Shan, 2014). Many of these procedures are performed on patients with osteoarthritis or fractures. Improvements in surgery and outcomes have been made, but greater improvement are possible. One systematic review found that 7 percent to 23 percent and 10 percent to 34 percent of THA and TKA patients have moderate to severe pain after surgery, and that 10 percent and 30 percent, respectively, have no significant functional improvement. Patients with poorer psychological health, physical function, or pain before surgery had poorer long-term outcomes and may benefit from presurgical interventions (Blom, 2016). Minimally invasive surgery has yet to show benefits over standard surgery in terms of outcomes. One review of 26 studies on hip replacement found the two approaches yield similar outcomes, noting that there are numerous contraindications to minimally invasive surgery, i.e., active infection, marked femoral deformity, poor hip adductor musculature, progressive neurological disease, and neuropathic arthritis causing bone destruction (Hayes, 2014a). Some reviews provide document efficacy of new technical refinements in major joint replacement. For example, the Knee Arthroplasty Trial (Murray, 2014) provided evidence to support patellar resurfacing and metal-backed tibial components even in the elderly. However, additional high-quality trials are still required to assess the stability of KAT findings over time and to inform the choice of mobile or fixed knee bearings. Other reviews show new techniques do not produce superior outcomes, as in unipolar (compared to bipolar) hip arthroplasty (Hayes, 2016).

Decisions such as whether to perform total or partial hip replacement, or cemented vs. cement-less replacement, remain difficult ones, underlining the need for more precise future guidelines. Physical therapy benefits postsurgery have been shown consistently, regardless of setting or timing relative to surgery (Coulter, 2013). Potential overutilization and nonadherence to professional guidelines for major joint replacement procedures have also been addressed. A 2014 multi-institutional study of 175 patients undergoing TKA judged only 44.0 percent to be appropriate. The remainder were classified as inappropriate (34.3 percent) or inconclusive (21.7 percent). The authors state that these findings be considered in light of the rapid increase, and potential overutilization, of TKA surgery (Riddle, 2014). Introduction of decision aids at a large health system in Washington state was linked with 26 percent and 38 percent fewer hip and knee replacement surgeries, respectively (Arterburn, 2012). Analyses by the Dartmouth Atlas Project found Medicare rates of THA and TKA to vary among metropolitan areas by as much as four times, even within the same state (Dartmouth, 2010). Policy updates: The findings section has been rewritten to cite specific relevant guidelines and peer-reviewed references. Seven clinical guidelines/other and two peer-reviewed references have been cited. New information on potential overutilization and medical necessity of THA and TKA has been included. Summary of clinical evidence: Citation

Content, Methods, Recommendations

Blom (2016)

Key points:

Improving patient outcomes after THA or TKA

Shan (2015)

  

Systematic review of longitudinal studies. 7-23% of THA and 10–34% of TKA patients have moderate to severe pain after surgery. 10% of THA and 30% of TKA patients have no significant functional improvement after surgery. Patients with poorer psychological health, physical function, or pain before surgery had poorer longterm outcomes and may benefit from presurgical interventions. Key points:  

19 studies of persons undergoing the procedure since 2000. Total score, pain, function, and satisfaction all showed improvement postsurgery.

Meta-analysis of quality of life after knee replacement Shan (2014)

Key points:

Meta-analysis of quality of life after hip replacement

 

Bedair (2014) Economic analysis of TKA in younger patients

Twenty studies of persons undergoing the procedure since 2000. Improvements in Harris Health Score, combined pain, physical function (Short Form 36), role physical, role emotional, social functioning, patient satisfaction after seven years. Key points: 

Replacement less costly than nonoperative management in younger patients with severe arthritis.

Citation

Content, Methods, Recommendations

Hayes (2014a)

Key points:

Minimally invasive total hip arthroplasty

Riddle (2014) Appropriateness of TKA surgery Canadian Agency for Drugs and Technologies in Health (CADTH) (2013) Components and materials for total hip replacement

Nieuwwenhuijse (2014) New implant devices

Coulter (2013) Home or outpatient physical therapy after elective THA Hayes (2013)

 

RCTs and CCTs, 2000 – 2014, of 26 trials (2,578 hips in 2,653 patients). Minimally invasive; may be comparable to standard surgical replacement, although additional research (other indications and/or surgical approaches and contraindications) is needed.  Contraindications: active infection, marked femoral deformity, poor hip adductor musculature, progressive neurological disease, neuropathic arthritis conditions causing bone destruction. Key points:  Multi-institutional study of 175 patients undergoing TKA.  44.0% judged appropriate; 34.3% judged inappropriate; 21.7% judged inconclusive. Key points:   

English-language clinical studies, 2008 – 2013. No strong evidence for superiority of polyethylene vs. polyethylene on metal. Some evidence for lower revision rate of ceramic on ceramic vs. metal on polyethylene ≤5 years.  Modular stems may have lower early survival but equivalent in longer term.  No high-quality evidence for adverse events of any component type.  More and higher-quality research is needed. Key points:  RCTs — February 2013.  Five trials (712 subjects).  Nonsignificant (NS) differences at four weeks and 12 weeks.  No safety concerns from review but limited by short follow-up. Key points:  

Five RCTs (234 subjects). Physical-therapist-directed exercise in these settings is effective.

Key points:   

Burgers (2012)

Human clinical studies, 2003 – 2013; Five studies (n=437). Follow-up reported in only three studies; five weeks–six months. No studies reported clinically important outcomes: survival, revision rate, quality of life, or pain.  Overall: low-quality evidence. Key points:

Total vs. hemiarthroplasty for displaced femoral neck fractures in healthy elderly Okoro (2012)

 Eight RCTs (986 subjects).  NS differences: revision, mortality, dislocation, major or minor complications.  Further research needed. Key points:

Computer-aided total hip arthroplasty

Rehabilitation after total hip replacement Parker (Cochrane, 2010) Arthroplasties (with and



Progressive resistance training improves muscle strength and function regardless of timing. Key points: 

No significant differences.

Citation

Content, Methods, Recommendations

without cement) for proximal femoral fractures Smith (2010)

Key points:

Hip resurfacing vs. arthroplasty

Hayes (2008) Total hip replacement with hard-on-hard prostheses

  

Published studies, January 2010. Forty-six studies; designs and sample sizes not reported. Resurfacing may have better functional outcomes but increased risk of heterotopic ossification, aseptic loosening, and revision.  THA is superior for implant survival. Key points:  

Comparable clinical outcomes to conventional metal-on-polyethylene prostheses. But differences in safety: – Metal-on-metal bearings have higher revision risk and potential cancer risk. – Ceramic-on-ceramic, fewer revisions but higher rates of chipping or fracture. – Limitations of available studies include inadequate sample size/statistical power, incomplete representation of all diagnoses likely to require THA and potentially biased patient selection.

Glossary Acetabulum — The “socket” part (in the pelvis) of the “ball and socket” hip joint; the “ball” is the head of the femur. Hard-on-hard hip prostheses — Prosthetic joints in which articular surfaces are made of metal or ceramic, presumably lasting longer and reducing need for revision or replacement, as opposed to articular surfaces made of less wear-resistant materials, such as polyethylene. Minimally invasive arthroplasty — A procedure using small incisions and/or less soft tissue dissection to reduce blood loss, reducing healing and rehabilitation times vs. standard surgical arthroplasties. Neuropathic arthritis —Joint destruction secondary to loss of the trophic and protective effects of its nerve supply. Resurfacing — An alternative to total hip replacement, in which concave or convex metal caps are placed over acetabular and femoral head surfaces, rather than replacing those components of the joint. Subluxation — Dislocation of a bone from its ligaments or other correct positioning within a joint. Trochanter/trochanteric — An anatomical term referring to one of several (greater, lesser, or third) protuberances from the proximal femur, near the head/neck and providing muscle attachments. References Professional society guidelines/other:

AHRQ. Inpatient quality indicators. #14: hip replacement mortality rate provider-level indicator technical specifications. Version 4.2. 2010. http://www.qualityindicators.ahrq.gov/. Accessed October 12, 2015. American Academy of Orthopedic Surgeons (AAOS). American Academy of Orthopedic Surgeons clinical practice guideline on treatment of osteoarthritis of knee. 2nd ed. Rosemont, IL: American Academy of Orthopedic Surgeons. 2013. www.aaos.org/cc_files/aaosorg/research/guidelines/treatmentofosteoarthritisofthekneeguideline.pdf. Accessed September 14, 2016. American Academy of Orthopedic Surgeons (AAOS). Surgical management of osteoarthritis of the knee: Evidence-based clinical practice guideline. Rosemont IL: American Academy of Orthopedic Surgeons. 2016. http://www.aaos.org/uploadedFiles/PreProduction/Quality/Guidelines_and_Reviews/guidelines/SMOA K%20CPG_4.22.2016.pdf. Accessed September 14, 2016. Brener S. Anesthesia among patients undergoing knee arthroplasty: a rapid review. Toronto: Health Quality Ontario. 2013. http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?LinkFrom=OAI&ID=32014001058. Accessed September 14, 2016. Dartmouth Institute for Health Policy and Clinical Practice. Dartmouth Atlas Project Finds Substantial Variation in Joint Replacement Surgery. April 15, 2010. http://www.dartmouthatlas.org/downloads/press/joint_replacement_release.pdf. Accessed September 14, 2016. Hayes Inc. Aquamantys system with transcollation technology (Medtronic Inc.) for hip arthroplasty. Health technology brief. Published May 17, 2012. Accessed September 14, 2016. Hayes Inc. Minimally invasive total hip arthroplasty. Health technology directory pocket summary. Published April 23, 2014. Accessed September 14, 2016. Hayes Inc. Computer-aided total hip arthroplasty. Medical technology directory pocket summary. Published December 7, 2012. Accessed September 14, 2016. Hayes Inc. Ganz trochanteric flip osteotomy approach to hip resurfacing for treatment of osteoarthritis. Health technology brief. Published June 12, 2012. Accessed September 14, 2016. Hayes Inc. Total hip replacement with hard-on-hard prostheses. Medical Technology Directory pocket summary. Published June 26, 2014. Accessed September 14, 2016. Hayes Inc. Unipolar versus bipolar hip arthroplasty. Clinical Research Response. Published May 12, 2016. Accessed on September 16, 2016. Mayo Clinic. First nationwide prevalence study of hip and knee arthroplasty shows 7.2 million Americans living with implants. http://www.mayoclinic.org/medical-professionals/clinical-updates/orthopedicsurgery/study-hip-knee-arthroplasty-shows-7-2-million-americans-living-with-implants. Presented at March 2014 meeting of the American Academy of Orthopedic Surgeons. Accessed September 13, 2016.

National Clinical Guideline Centre. Osteoarthritis. The care and management of osteoarthritis in adults. London, UK: National Institute for Health and Clinical Excellence (NICE). 2014 (clinical guideline no. 59). http://www.ncbi.nlm.nih.gov/pubmed/21290638. Accessed September 14, 2016. National Institute for Health and Care Excellence (NICE). Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip. (Review of technology appraisal guidance 2 and 44). London, UK: National Institute for Health and Care Excellence. 2014a (technology appraisal guidance no. 304). https://www.guideline.gov/summaries/summary/47870#. Accessed September 14, 2016. Ontario Health Technology Advisory Committee (OHTAC). Update on physiotherapy rehabilitation after total knee or hip replacement: OHTAC recommendation. Toronto: Queen’s Printer for Ontario. March 2014. http://www.hqontario.ca/Portals/0/Documents/evidence/reports/recommendation-knee-hipreplacement-140310-en.pdf. Accessed September 14, 2016. Riddle DL, Kiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol. 66(8):2134-43. U.S. Centers for Disease Control and Prevention. Arthritis-Related Statistics. Last updated July 26, 2016. http://www.cdc.gov/arthritis/data_statistics/arthritis-related-stats.htm. Accessed September 13, 2016. U.S. Centers for Medicare and Medicaid Services (CMS). Documenting Medical Necessity for Major Joint Replacement (Hip and Knee). Medicare Learning Network: MLN Matters® Number SE1236. https://www.cms.gov/outreach-and-education/medicare-learning-networkmln/mlnmattersarticles/downloads/se1236.pdf. Last revised August 19, 2015. Accessed September 14, 2016. Work Loss Data Institute. Hip & pelvis (acute and chronic). Encinitas, CA: Work Loss Data Institute. 2013. https://ca.grandroundtable.com/guidelines/hip-pelvis-acute-chronic/ Accessed September 14, 2016. Peer-reviewed references: Abdulkarim A, Ellanti P, Fahey T, O’Byrne JM. Cemented versus uncemented fixation in total hip replacement: a systematic review and meta-analysis. Orthop Rev. 2013;5(1):34 – 44. Arterburn D, Wellman R, Westbrook E, et al. Introducing decision aids at Group Health was linked to sharply lower hip and knee surgery rates and costs. H Affairs. 2012;31(9):2094 – 104. Bedair H, Cha TD, Hansen VJ. Economic benefit to society at large of total knee arthroplasty in younger patients. J Bone Joint Surg Am. 2014;96(2):119 – 26. Blackman AJ, Smith MV, Flanigan DC, Matava MJ, Wright RW, Brophy RH. Correlation between magnetic resonance imaging and clinical outcomes after cartilage repair surgery in the knee: a systematic review and meta-analysis. Am Journ Sports Med. 2013;4(6):1426 – 34.

Blom AW, Artz N, Beswick AD, et al. Improving patients’ experience and outcome of total joint replacement: the RESTORE programme. Southampton (UK): NIHR Journals Library; 2016 Aug. Bo Z-D, Liao L, Zhao J-M, Wei Q-J, Ding X-F, Yang B. Mobile bearing or fixed bearing? A meta-analysis of outcomes comparing mobile bearing and fixed bearing bilateral total knee replacements. Knee. 2014;21(2):374 – 81. Burgers PTPW, van Geene AR, van den Bekerom MPJ, et al. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials. Int Orthop. 2012;36:1549 – 60. Coulter CL, Scarvell JM, Neeman TM, Smith PN. Physiotherapist-directed rehabilitation exercises in the outpatient or home setting improve strength, gait cadence, and speed after elective total hip replacement: a systematic review. J Physiother. 2013;59(4):219 – 26. De Bellis UG, Legnani C, Calori GM. Acute total hip replacement for acetabular fractures. Injury. 2014;45(2):356 – 61. Fennema P, Heyse TJ, Uyl-de Groot C. Cost-effectiveness and clinical implications of advanced bearings in total knee arthroplasty: a long-term modelling analysis. Int Journ Tech Assessment H Care. 2014;30(2):218 – 25. Gøthesen Ø, Slover J, Havelin L, Askildsen JE, Malchau H, Furnes O. An economic model to evaluate costeffectiveness of computer assisted knee replacement surgery in Norway. BMC Muskuloskelet Disord. 2013;14:202. Jämsen E, Stogiannidus I, Malmivaara A, Pajamäki T, Konttinen YT. Outcome of prosthesis exchange for infected knee arthroplasty: the effect of treatment approach. Acta Orthop. 2009;80(1):67 – 77. Jonas SC, Shah R, Mitra A, Deo SD. 5-year cost-benefit analysis of revision of failed unicompartmental knee replacements (UKRs): not “just” a primary total knee replacement (TKR). Knee. 2014;21(4):840 – 42. Li C, Zeng Y, Shen B, et al. A meta-analysis of minimally invasive and conventional medial parapatellar approaches for primary total knee arthroplasty. Knee Sur Sports Traumatol Arthrosc. 2015; 23(7):1971— 85. Liu Y, Tao X, Wang P, Zhang Z, Qi Q. Meta-analysis of randomized controlled trials comparing unipolar with bipolar hemiarthroplasty for displaced femoral neck fractures. Int Orthop. 2014;38(8):1691 – 6. Mather RC, Hug TK, Orlando LA, et al. Economic evaluation of access to musculoskeletal care: the case of waiting for total knee arthroplasty. BMC Muskuloskelet Disord. 2014;5:22.

Moskal JT, Capps SG. Rotating platform TKA no different from fixed-bearing TKA regarding survivorship or performance: a meta-analysis. Clin Orthop Relat Res. 2014;472(7):2185 – 93. Murray DW, MacLennan GS, Breeman S, et al., on behalf of the KAT Group. A randomized controlled trial of the clinical and cost-effectiveness of different knee prostheses: the Knee Arthroplasty Trial (KAT). Health Technol Assess. 2014;18(9). Nieuwenhuijse MJ, Nelissen RGHH, Schoones JW, Sedrakyan A. Appraisal of evidence base for introduction of new implants in hip and knee replacement: a systematic review of five widely used device technologies. BMJ. 2014;349:g5133. Okoro T, Lemmey AB, Maddison P, Andrew JG. An appraisal of rehabilitation regimens for improving functional outcomes after total hip replacement surgery. Sports Med Arthrosc Rehabil Ther Technol. 2012;4(1):5. Parker MJ, Guruswamy KS, Shin A. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database of Syst Rev. 2010;6. Pennington M, Grieve R, Sekhon JS, Gregg P, Black N. van der Meulen JM. Cemented, cement-less and hybrid prostheses for total hip replacement: cost-effectiveness analysis. BMJ. 2013;346:fl026. Schindler OS. The controversy of patellar resurfacing in total knee arthroplasty: Ibisne in medio tutissimus? Knee Surg Sports Traumatol Arthrosc. 2012; 20:1227 – 44. Shan L, Shan B, Graham D, Saxena A. Total hip replacement: a systematic review and meta-analysis on mid-term quality of life. Osteo Cartilage. 2014;22(3):389 – 406. Shan L, Shan B, Suzuki A. Intermediate and long-term quality of life after total knee replacement: a systematic review and meta-analysis. J Bone Joint Surg Am. 2015;97(2):156 – 68. Smith TO, Nichols R, Donell ST, Hing CB. The clinical and radiological outcomes of hip resurfacing versus total hip arthroplasty: a meta-analysis and systematic review. Acta Orthop. 2010;81(6):684 – 95. Tilbury C, Schaasberg W, Plevier JWM, Fiocco M, Nelissen RGHH, Vlieland TPMV. Return to work after total hip and knee arthroplasty: a systematic review. Rheumatology. 2014;53(3):512 – 25. Tsang ST, Gaston P. Adverse perioperative outcomes following elective total hip replacement in diabetes mellitus: a systematic review and meta-analysis of cohort studies. Bone Joint J. 2013;95B (11):1474 – 79. U.S. Centers for Disease Control and Prevention. National Hospital Discharge Survey: 2010 table. Procedures by selected patient characteristics – number by procedure category and age. http://ww.cdc.gov/nchs/data/nhds/4procedures/2010pro4_numberprocedureage.pdf.

Xu K, Li Y-M, Zhang H-F, Wang C-Q, Xu Y-Q, Li Z-J. Computer navigation in total hip arthroplasty: a metaanalysis of randomized controlled trials. Int Journ Surg. 2014a;12(5):528 – 33. Xu S-Z, Lin X-J, Tong X, Wang X-W. Minimally invasive mid-vastus versus standard parapatellar approach in total knee arthroplasty: a meta-analysis of randomized controlled trials. PlosOne. 2014;9(5):e95311. Zhao Y, Fu D, Chen K, et al. Outcome of hemiarthroplasty and total hip replacement for active elderly patients with displaced femoral neck fractures: a meta-analysis of 8 randomized controlled trials. PlosOne. 2014;9(5):e98071. Zheng H, Barnett AG, Merolini K, et al. Control strategies to prevent total hip replacement-related infections: a systematic review and mixed treatment comparison. BMJ Open. 2014;4:e003978. Clinical trials: Searched clinicaltrials.gov on September 15, 2016, using terms “hip replacement” and “knee replacement.” | 404 Open Studies for knee replacement, 137 Open Studies for hip replacement. CMS National Coverage Determinations (NCDs): No NCDs identified as of the writing of this policy. Local Coverage Determinations (LCDs): L33618 Major Joint Replacement (Hip and Knee). CMS website. First Coast Service Options, Inc. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=33618&ver=7&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&K eyWord=%22hip+replacement%22&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAA AAAAA%3d%3d&. Florida, Puerto Rico, Virgin Islands. Accessed September 15, 2016. L34294 Major Joint Replacement (Hip and Knee). CMS website. Cabaha Government Benefit Administrators® LLC. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=34294&ver=3&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All&K eyWord=%22hip+replacement%22&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAAA AAAAA%3d%3d&. Alabama, Georgia, and Tennessee. Accessed September 15, 2016. L36007 Lower Extremity Major Joint Replacement (Hip and Knee). CMS website. Novitas Solutions Inc. https://www.cms.gov/medicare-coverage-database/details/lcddetails.aspx?LCDId=36007&ver=32&CoverageSelection=Both&ArticleType=All&PolicyType=Final&s=All& KeyWord=%22hip+replacement%22&KeyWordLookUp=Title&KeyWordSearchType=And&bc=gAAAACAA AAAAAA%3d%3d&. 11 states plus the District of Columbia. Accessed September 15, 2016. Commonly submitted codes

Below are the most commonly submitted codes for the service(s)/item(s) subject to this policy. This is not an exhaustive list of codes. Providers are expected to consult the appropriate coding manuals and bill accordingly. CPT Code

Description

27090

Removal of hip prosthesis. Removal of hip prosthesis, complicated, including hip prosthesis, methylmethacrylate with or without insertion of spacer. Acetabuloplasty; (e.g., Whitman, Colonna, Haygroves or cup type). Acetabuloplasty; femoral head (e.g., Girdlestone procedure). Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty). Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or autograft. Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft. Revision of total hip arthroplasty; both components, with or without autograft or allograft. Revision of total hip arthroplasty; with or without autograft or allograft. Revision of total hip arthroplasty; femoral component only, with or without allograft. Arthroplasty, knee, condyle and plateau; medial or lateral compartment. Arthroplasty, knee, condyle and plateau; medial and lateral compartments with or without patella resurfacing (total knee arthroplasty). Revision of total knee arthroplasty, with or without allograft; one component. Revision of total knee arthroplasty, with or without allograft, femoral and entire tibial component. Removal of prosthesis, including total knee prosthesis, methylmethacrylate with or without insertion of a spacer, knee.

27091 27120 27122 27125 27130 27132 27134 27137 27138 27446 27447 27486 27487 27488 ICD-10 Code C40.20 C40.21 C40.22 C76.50 C76.51 C76.52 M16.9 M17.9 M87.050 M87.051 M87.052 M87.059 M87.061 M87.062 M87.063 M87.151 M87.152 M87.159 M87.161 M87.162

Description Malignant neoplasm of long bones of unspecified lower limb Malignant neoplasm of long bones of right lower limb Malignant neoplasm of long bones of left lower limb Malignant neoplasm of unspecified lower limb Malignant neoplasm of right lower limb Malignant neoplasm of left lower limb Osteoarthritis of hip, unspecified Osteoarthritis of knee, unspecified Idiopathic aseptic necrosis of pelvis Idiopathic aseptic necrosis of right femur Idiopathic aseptic necrosis of left femur Idiopathic aseptic necrosis of unspecified femur Idiopathic aseptic necrosis of right tibia Idiopathic aseptic necrosis of left tibia Idiopathic aseptic necrosis of unspecified tibia Osteonecrosis due to drugs, right femur Osteonecrosis due to drugs, left femur Osteonecrosis due to drugs, unspecified femur Osteonecrosis due to drugs, right tibia Osteonecrosis due to drugs, left tibia

Comments

Comments

M87.163 M87.251 M87.252 M87.256 M87.351 M87.352 M87.353 M87.361 M87.362 M87.363 M87.851 M87.852 M87.859 M87.861 M87.862 M87.863 M96.0 M96.65 M96.661 M96.662 M96.669 M96.671 M96.672 M96.679 M96.69 S72.001A S72.001B S72.001C S72.002A S72.002B S72.002C S72.009A S72.009B S72.009C S72.011A S72.011B

Osteonecrosis due to drugs, unspecified tibia Osteonecrosis due to previous trauma, right femur Osteonecrosis due to previous trauma, left femur Osteonecrosis due to previous trauma, unspecified femur Other secondary osteonecrosis, right femur Other secondary osteonecrosis, left femur Other secondary osteonecrosis, unspecified femur Other secondary osteonecrosis, right tibia Other secondary osteonecrosis, left tibia Other secondary osteonecrosis, unspecified tibia Other osteonecrosis, right femur Other osteonecrosis, left femur Other osteonecrosis, unspecified femur Other osteonecrosis, right tibia Other osteonecrosis, left tibia Other osteonecrosis, unspecified tibia Pseudarthrosis after fusion or arthrodesis Fracture of pelvis following insertion of orthopedic implant, joint prosthesis, or bone plate Fracture of femur following insertion of orthopedic implant, joint prosthesis, or bone plate, right leg Fracture of femur following insertion of orthopedic implant, joint prosthesis, or bone plate, left leg Fracture of femur following insertion of orthopedic implant, joint prosthesis, or bone plate, unspecified leg Fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate, right leg Fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate, left leg Fracture of tibia or fibula following insertion of orthopedic implant, joint prosthesis, or bone plate, unspecified leg Fracture of other bone following insertion of orthopedic implant, joint prosthesis, or bone plate Fracture of unspecified part of neck of right femur, initial encounter for closed fracture Fracture of unspecified part of neck of right femur, initial encounter for open fracture type I or II Fracture of unspecified part of neck of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Fracture of unspecified part of neck of left femur, initial encounter for closed fracture Fracture of unspecified part of neck of left femur, initial encounter for open fracture type I or II Fracture of unspecified part of neck of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Fracture of unspecified part of neck of unspecified femur, initial encounter for closed fracture Fracture of unspecified part of neck of unspecified femur, initial encounter for open fracture type I or II Fracture of unspecified part of neck of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Unspecified intracapsular fracture of right femur, initial encounter for closed fracture Unspecified intracapsular fracture of right femur, initial encounter for open

S72.011C S72.012A S72.012B S72.012C S72.019A S72.019B S72.019C S72.021A S72.021B S72.021C S72.022A S72.022B S72.022C S72.023A S72.023B S72.023C S72.024A S72.024B S72.024C S72.025A S72.025B S72.025C S72.026A S72.026B S72.026C S72.031A S72.031B

fracture type I or II Unspecified intracapsular fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Unspecified intracapsular fracture of left femur, initial encounter for closed fracture Unspecified intracapsular fracture of left femur, initial encounter for open fracture type I or II Unspecified intracapsular fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Unspecified intracapsular fracture of unspecified femur, initial encounter for closed fracture Unspecified intracapsular fracture of unspecified femur, initial encounter for open fracture type I or II Unspecified intracapsular fracture of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Displaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for closed fracture Displaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for open fracture type I or II Displaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Displaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for closed fracture Displaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open fracture type I or II Displaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Displaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for closed fracture Displaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for open fracture type I or II Displaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Nondisplaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for closed fracture Nondisplaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for open fracture type I or II Nondisplaced fracture of epiphysis (separation) (upper) of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Nondisplaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for closed fracture Nondisplaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open fracture type I or II Nondisplaced fracture of epiphysis (separation) (upper) of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Nondisplaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for closed fracture Nondisplaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for open fracture type I or II Nondisplaced fracture of epiphysis (separation) (upper) of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Displaced midcervical fracture of right femur, initial encounter for closed fracture Displaced midcervical fracture of right femur, initial encounter for open fracture type I or II

S72.031C S72.032A S72.032B S72.032C S72.033A S72.033B S72.033C S72.034A S72.034B S72.034C S72.035A S72.035B S72.035C S72.036A S72.036B S72.036C S72.041A S72.041B HCPCS Level II N/A

Displaced midcervical fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Displaced midcervical fracture of left femur, initial encounter for closed fracture Displaced midcervical fracture of left femur, initial encounter for open fracture type I or II Displaced midcervical fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Displaced midcervical fracture of unspecified femur, initial encounter for closed fracture Displaced midcervical fracture of unspecified femur, initial encounter for open fracture type I or II Displaced midcervical fracture of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Nondisplaced midcervical fracture of right femur, initial encounter for closed fracture Nondisplaced midcervical fracture of right femur, initial encounter for open fracture type I or II Nondisplaced midcervical fracture of right femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Nondisplaced midcervical fracture of left femur, initial encounter for closed fracture Nondisplaced midcervical fracture of left femur, initial encounter for open fracture type I or II Nondisplaced midcervical fracture of left femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Nondisplaced midcervical fracture of unspecified femur, initial encounter for closed fracture Nondisplaced midcervical fracture of unspecified femur, initial encounter for open fracture type I or II Nondisplaced midcervical fracture of unspecified femur, initial encounter for open fracture type IIIA, IIIB, or IIIC Displaced fracture of base of neck of right femur, initial encounter for closed fracture Displaced fracture of base of neck of right femur, initial encounter for open fracture type I or II Description

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