Knee Arthroplasty*

Medical Policy: 07.01.50 
Original Effective Date: March 2010 
Reviewed: July 2011 
Revised: July 2010 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Total knee arthroplasty, also known as total knee replacement, is one of the most common orthopaedic procedures performed. Its intent is to alleviate pain and restore physical function in patients who have failed to respond to non-surgical interventions. According to the National Institutes of Health (NIH), in the past, patients between 60 and 75 years of age were considered to be the best candidates for total knee replacement. However, over the past couple of decades the age range has broadened to include both more elderly patients, many of whom have a higher number of comorbid conditions, and younger patients, whose implants may be exposed to greater mechanical stresses over an extended period of time. In patients younger than age 55, the NIH believes alternative surgical procedures such as osteotomy and unicompartmental knee replacement deserve consideration.

Unicompartmental knee replacement, also known as partial knee replacement, may be an alternative for patients with disease limited to a single compartment (i.e., medial, lateral, or patellofemoral) and has the advantages of less pain, quicker recovery, and reported better long-term results. The incision is smaller and less invasive and preserves the proprioceptive function of the cruciate ligaments. Studies have demonstrated that patients treated with unicompartmental knee replacement have better functionality and greater range of motion than those treated with total knee replacement. Other research has shown that a unicompartmental knee replacement can be revised with greater ease than a total knee replacement.

Revisions of failed total knee replacements are performed to alleviate pain and restore function. The goals are restoration of a mechanical and rotational alignment, restoration of joint line and space, and achievement of stable implant fixation. Revision may also be considered in an effort to avoid catastrophic prosthesis failure when progressive and substantial bone loss occurs. Identifying the cause of the original prosthesis failure is critical to improve outcomes following the revision surgery.

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Prior Approval: 

Prior approval is recommended for Iowa and South Dakota providers only.  Submit a prior approval now.

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Policy: 

Total knee replacement may be considered medically necessary in patients with knee joint failure caused by one of the following:

• Osteoarthritis
• Rheumatoid arthritis
• Juvenile rheumatoid arthritis
• Post-traumatic arthritis
• Varus, valgus, or post-traumatic deformity
• Osteonecrosis 

AND

• Radiographic or arthroscopic evidence of complete (bone-on-bone) destruction of cartilage; e.g., Kellgren-Lawrence grade IV or modified Outerbridge grade IV, respectively
• Significant functional limitations resulting in diminished quality of life and impaired, age-appropriate activities of daily living

OR

Knee joint failure caused by one of the following:

• Osteoarthritis
• Rheumatoid arthritis
• Juvenile rheumatoid arthritis
• Post-traumatic arthritis
• Varus, valgus, or post-traumatic deformity
• Osteonecrosis

AND

Meet ALL of the following criteria:

• Body mass index (BMI) < 50 kg/m²
• Radiographic or arthroscopic evidence of cartilage damage; e.g., Kellgren-Lawrence grade III, or modified Outerbridge III, respectively
• Clinically significant functional limitations resulting in diminished quality of life and impaired, age-appropriate activities of daily living
• Failure of at least one course of viscosupplementation [intra-articular hyaluronan injections] or intraarticular corticosteroids
• Moderate to severe persistent pain that is not adequately relieved by a period of non-surgical management prior to surgery. Such management must include a program of supervised physical therapy and self-management education to address activity and lifestyle modification

Unicompartmental knee replacement for the medial or lateral compartment (also known as a partial knee replacement) may be considered medically necessary when ALL of the following criteria are met:

• Body mass index (BMI) < 50 kg/m²
• Radiographic or arthroscopic evidence of osteoarthritis confined to a single compartment with evidence of cartilage damage; e.g., Kellgren-Lawrence grade III, or modified Outerbridge grade III, respectively
• Knee involved demonstrates good alignment and ligamentous stability
• Clinically significant functional limitations resulting in diminished quality of life and impaired, age-appropriate activities of daily living
• Failure of at least one course of viscosupplementation [intra-articular hyaluronan injections] or intraarticular corticosteroids
• Moderate to severe persistent pain despite a course of non-surgical management prior to surgery. Such management must include a program of supervised physical therapy and self-management education to address activity and lifestyle modification

Patellofemoral arthroplasty may be considered medically necessary when ALL of the following criteria are met:

• Body mass index (BMI) < 50 kg/m²
• Radiographic or arthroscopic evidence of osteoarthritis isolated to the patellofemoral compartment with evidence of severe articular cartilage damage
• Knee involved demonstrates good alignment and ligamentous stability
• Clinically significant functional limitations resulting in diminished quality of life and impaired, age-appropriate activities of daily living
• Moderate to severe persistent pain despite a course of non-surgical management prior to surgery. Such management must include a program of supervised physical therapy and self-management education to address activity and lifestyle modification

Revision of a total knee replacement may be considered medically necessary for ANY of the following indications:

• Recurrent disabling pain and functional limitation that has not responded to appropriate non-surgical management including lifestyle modification
• Infection
• Periprosthetic fractures
• Instability of the prosthetic components (including “worn out” components) or aseptic loosening
• Fracture or dislocation of the patella
• Progressive and substantial bone loss in advance of catastrophic prosthetic failure

The following procedures related to knee replacement are considered investigational:

• Minimally invasive approaches to knee replacement
• Unicondylar interpositional spacers
• Bicompartmental knee replacement, including bi-unicompartmental
• Gender-specific knee replacements

See related medical policy

02.01.12 Viscosupplementation for Osteoarthritis

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
• 27437 Arthroplasty, patella; without prosthesis
• 27438 Arthroplasty, patella; with prosthesis
• 27440 Arthroplasty, knee, tibial plateau
• 27441 Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy
• 27442 Arthroplasty, femoral condyles or tibial plateau(s), knee
• 27443 Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy
• 27445 Arthroplasty, knee, hinge prosthesis (e.g., Walldius type)
• 27446 Arthroplasty, knee, condyle and plateau; medial OR lateral compartment
• 27447 Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty)
• 27486 Revision of total knee arthroplasty, with or without allograft; one component
• 27487 Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component

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Selected References: 

• National Institutes of Health (NIH) Consensus Statement on Total Knee Replacement. NIH Consens State Sci Statements. 2003 Dec 8-10; 20(1) 1-32.
• Canale & Beaty: Campbell’s Operative Orthopaedics, 11^th ed.
• Newman JH, Ackroyd CE, Shah NA. Unicompartmental or total knee replacement? Five-year results of a prospective randomized trial of 102 osteoarthritic knees with unicompartmental arthritis. J Bone Joint Surg Br. 1998 Sep;80(5):862-5.
• Santaguida PL, Hawker GA, Hudak PL et al. Patient characteristics affecting the prognosis of total hip and knee joint arthroplasty: a systemic review. Can J Surg. 2008 Dec; 51(6): 248-36.
• Ethgen O, Bruyere O, Richy F et al. Health-related quality of life in total hip and total knee arthroplasty. A qualitative and systemic review of the literature. J Bone Joint Surg Am 2004; 86-A:963-74.
• Kane RL, Saleh KJ, Wilt TJ et al. The Functional Outcomes of Total Knee Arthroplasty. J Bone Joint Surg Am 2005; 87-A (8) 1719-23.
• Mont MA, Lee CW, Sheldon M et al. Total knee arthroplasty in patients </= 50 years old. J Arthroplasty. 2002 Aug; 17(5): 538-43.
• Lonner JH, Hershman S, Mont M et al. Total knee arthroplasty in patients 40 years of age and younger with osteoarthritis. Clin Orthop Relat Res. 2000 Nov;(380):85-90.
• Blue Cross Blue Shield Association. Technology Evaluation Center (TEC). Computer-Assisted Navigation for Total Knee Arthroplasty. February 2008. 22(10).
• Dutton AQ, Yeo SJ. Computer-assisted minimally invasive total knee arthroplasty compared with standard knee arthroplasty. J Bone Joint Surg Am 2009; 91 Suppl 2 (Part 1): 116-30.
• Deshmukn RG, Hayes JH, Pinder IM. Does body weight influence outcome after total knee arthroplasty? A 1-year analysis. J Arthroplasty. 2002 Apr; 17(3):315-9.
• Amin AK, Patton JT, Cook RE et al. Does obesity influence the clinical outcome at five years following total knee replacement for osteoarthritis? J Bone Joint Surg Br. 2006 Mar;88(3):335-40.
• Naal FD, Neuerburg C, Salzmann GM et al. Association of body mass index and clinical outcome 2 years after unicompartmental knee arthroplasty. Arch Orthop Trauma Surg. 2009 Apr; 129(4):463-8. Epub 2008 Apr 15.
• Foran JRH, Mont MA, Etienne G et al. The outcome of total knee arthroplasty in obese patients. J Bone Joint Surg Am 2004;86:1609-15.
• Saleh KJ, Dykes DC, Tweedie RL et al. Functional outcome after total knee arthroplasty revision: a meta-analysis. J Arthroplasty. 2002 Dec; 17(8):967-77.
• Leadbetter WB. Patellofemoral Arthroplasty in the Treatment of Patellofemoral Arthritis: Rationale and Outcomes in Younger Patients. Orthop Clin N Am 2008 Jul; 39(3):363-80.
• Christensen CP, Jacobs CA, Jennings HR. Effect of Periarticular Corticosteroid Injections During Total Knee Arthroplasty. A Double-Blind Randomized Trial. J Bone Joint Surg Am. 2009;91:2550-2555.

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Policy History: 

Date                                        Reason                              Action

July 2011                                Annual review                   Renewed

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.