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Medical Necessity Guidelines Knee Arthroscopy: Surgical

Document ID#: Subject: Effective Date:

2116419 Knee Arthroscopy, Surgical May 1, 2011

Clinical Documentation and Prior Authorization Required Not Covered

Type of Review - Case Management Type of Review ­ Precertification Department Administrative Process (Internal Use Only)


Please Note: While you may not be the provider responsible for obtaining prior authorization, as a condition of payment you will need to make sure that prior authorization has been obtained. Effective January 1, 2008, Tufts Health Plan will be requiring prior authorization for certain elective upper knee arthroscopies for Members 18 years of age and older. In order to obtain prior authorization ® for certain elective knee arthroscopies, an InterQual SmartSheetTM for Arthroscopy, Surgical, Knee must be completed and faxed to the Tufts Health Plan Precertification Department at 617-972-9409. InterQual SmartSheetsTM for this procedure are available by logging on to our web site and accessing ® the Prior Authorization InterQual Criteria Link under the Clinical Resources section. If you are not a Tufts Health Plan Registered Provider, please click on the Provider Log-in and follow instructions. ORGANIZATIONAL POLICY NOTES: ® Tufts Health Plan has added Organization Policy Notes (OPN) to the InterQual SmartSheetTM listed above. These are noted in addition to the standard notes on the InterQual® SmartSheetTM with the designation (OP1, OP2, etc). The complete note is available at the end of the `Notes' section of the Interqual® SmartSheetTM under the heading `Organizational Policy Notes'. These OPN's provide additional information about the way the InterQual® SmartSheetTM is used by Tufts Health Plan to determine coverage of the requested procedure. INDICATIONS REQUIRING PRIOR AUTHORIZATION: Please Note: For Members with a diagnosis of osteoarthritis, please utilize the Tufts Health Plan Medical Necessity Guidelines: Knee Arthroscopy, Surgical, for Meniscal tear with osteoarthritis. Tufts Health Plan will be using the above InterQual SmartSheetTM for the following diagnoses and associated CPT codes only:

Associated CPT 1 Code


® ®

Tufts Health Plan Organization Policy Note

29875 29876 29877

Synovectomy (limited) Synovectomy (major) Chondroplasty

No No Yes

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Associated CPT 1 Code


Tufts Health Plan Organization Policy Note


Resection/repair of unstable meniscal tear Resection/repair of stable meniscal tear by Sx/findings Resection/repair of stable meniscal tear by imaging Lateral release Tufts Health Plan requires review all unlisted procedure codes






29873 29999

No No


A complete description of the associated CPT codes is included within this Medical Necessity Guideline.


The following CPT and HCPCS codes require prior authorization: Code 29873 29875 Description Arthroscopy, knee, surgical; with lateral release Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure) Arthroscopy, knee, surgical; synovectomy, major, two or more compartments (eg, medial or lateral) Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty) Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral) Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral) Unlisted procedure, arthroscopy


29877 29880


29882 29883 29999

Related Medical Necessity Guidelines

Autologous Chondrocyte Implant of the Knee Meniscal Transplantation of the Knee

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Approval History

Reviewed by the Medical Affairs Medical Policy Committee on October 24, 2007 for January 1, 2008 effective date. Subsequent Endorsement Date(s) and Changes Made: · · · · January 8, 2008: Additional Organizational Policy Note (OPN) added to InterQual® SmartSheetTM at criteria point 722. March 28, 2008: Additional Organizational Policy Note (OPN) added to InterQual® SmartSheetTM at criteria points 720 and 830. March 31, 2009 Reviewed by Medical Affairs Medical Policy, no changes March 2010 Reviewed Medical Policy-Medical Affairs. New criteria created for Surgical Arthroscopy, Knee for members with osteoarthritis. Document ID # 2160034. No other changes to this MNG. Effective April 2010. April 2010: Reviewed at MSPAC, OPNs at criteria points 720, and 830 change age from 50 years old to 60 years old; at criteria point 620 add OPN that eliminates positive McMurray's Test. April 2011: Reviewed by MSPAC. No changes.

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Background, Product and Disclaimer Information

Medical Necessity Guidelines are developed to determine coverage for Tufts Health Plan benefits, and are published to provide a better understanding of the basis upon which coverage decisions are made. Tufts Health Plan makes coverage decisions using these guidelines, along with the Member's benefit document, and in coordination with the Member's physician(s) on a case-by-case basis considering the individual Member's health care needs. Medical Necessity Guidelines are developed for selected therapeutic or diagnostic services found to be safe, but proven effective in a limited, defined population of patients or clinical circumstances. They include concise clinical coverage criteria based on current literature review, consultation with practicing physicians in the Tufts Health Plan service area who are medical experts in the particular field, FDA and other government agency policies, and standards adopted by national accreditation organizations. Tufts Health Plan revises and updates Medical Necessity Guidelines annually, or more frequently if new evidence becomes available that suggests needed revisions. Medical Necessity Guidelines apply to all fully insured Tufts Health Plan products unless otherwise noted in this guideline or the Member's benefit document. This guideline does not apply to Tufts Health Plan Medicare Preferred or to certain delegated service arrangements. For self-insured plans, coverage may vary depending on the terms of the benefit document. If a discrepancy exists between a Medical Necessity Guideline and a self-insured Member's benefit document, the provisions of the benefit document will govern. Applicable state or federal mandates will take precedence. Providers in the New SM Hampshire service area are subject to Cigna's provider agreements with respect to CareLink members. Treating providers are solely responsible for the medical advice and treatment of Members. The use of this guideline is not a guarantee of payment or a final prediction of how specific claim(s) will be adjudicated. Claims payment is subject to eligibility and benefits on the date of service, coordination of benefits, referral/authorization, utilization management guidelines when applicable, and adherence to plan policies, plan procedures, and claims editing logic.

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