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Medical Policy: 07.01.22
Original Effective Date: September 2003
Reviewed: November 2011
Revised: October 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:
Thermal capsulorrhaphy, also known as thermal coagulation of joints, radiofrequency thermal shrinkage, electrothermal assisted capsulorrhaphy and laser-assisted capsular shrinkage has been investigated as a way to repair instability or laxity in shoulders, knees and other joints.
The theoretical mechanism of action for this treatment is the application of heat, which causes the proteins making up the ligament to denature and shorten. The bonds between the collagen molecules are presumably transformed by the heat and recoil from their normal straight configuration. The desired result is a reduction in the laxity of the joint. The treatment, however, also results in a weakening of the mechanical properties of the tissue.
Thermal capsulorraphy has been performed in the outpatient setting and is accomplished by percutaneous or arthroscopic placement of a radiofrequency probe or the arthroscopic use of a laser device to shrink the tissues in the joint. The long term (>2 years) safety and efficacy of this treatment has not been documented in the peer reviewed medical literature.
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Prior Approval:
Not applicable
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Policy:
Thermal capsulorrhaphy is considered not medically necessary as a treatment of joint instability, including, but not limited to the shoulder, knee, ankle and elbow.
The literature does not support the use of thermal capsulorrhaphy alone, or in combination with other arthroscopic procedures.
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Procedure Codes and Billing Guidelines:
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To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9-CM diagnostic codes.
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29999 unlisted arthroscopy procedure
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S2300 arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy.
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
- Carter TR. Anterior cruciate ligament thermal shrinkage. Clin Sports Med. 2002 Oct; 21(4): 693-700.
- Carter TR, Bailie DS, Edinger S. Radiofrequency electrothermal shrinkage of the anterior cruciate ligament. Am J Sports Med. 2002 Mar-Apr; 30(2):221-6.
- Indelli PF, et al. Monopolar thermal treatment of symptomatic anterior cruciate ligament instability. Clin Orthop. 2003 Feb;(407):139-47.
- Thermal shrinkage for cruciate ligament injury. Hayes Report, April 2003
- Shabi Khan A, Sherman O, DeLay B Thermal treatment of anterior cruciate ligament injury and laxity with its imaging characteristics. Clin Sports Med2002 Oct;21(4):701-11.
- Merter Ozenci A, Panjabi MM Radiofrequency treatment weakens the fatigue characteristics of rabbit anterior cruciate ligament. Clin Biomech (Bristol, Avon). 2003 Feb;18(2):150-6.
- Lopez MJ, Markel MD Anterior cruciate ligament rupture after thermal treatment in a canine model. Am J Sports Med. 2003 Mar-Apr;31(2):164-7.
- Perry JJ, Higgins LD Anterior and posterior cruciate ligament rupture after thermal treatment. Arthroscopy. 2000 Oct;16(7):732-6.
- Savoie FH 3rd, Field LD. Thermal versus suture treatment of symptomatic capsular laxity. Clin Sports med 2000; 19(1):63-75.
- Gieringer RE. Arthroscopic monopolar radiofrequency thermal capsulorrhaphy for the treatment of shoulder instability: a prospective outcome study with mean 2-year follow-up. Alaska Med 2003; 45(1):3-8.
- D'Alessandro DF, Bradley JP et al. Prospective evaluation of thermal capsulorrhaphy for shoulder instability: Indications and results, two-and five-year follow up. Am J Sports Med 2004; 32:21-33.
- Levine WN, Bigliani LU, Ahmad CS. Thermal Capsulorrhaphy Orthopedics 2004; 27:823-26.
- Chen S, Haen PS, et al. The effects of thermal capsular shrinkage on the outcomes of arthroscopic stabilization for primary anterior shoulder instability. Am J Sports Med. 2005; 33(5):705-11.
- Mohtadi NG, Hollinshead RM, Ceponis PJ, Chan DS, Fick GH. Multi-centre randomized controlled trial comparing electrothermal arthroscopic capsulorrhaphy versus open inferior capsular shift for patients with shoulder instability: protocol implementation and interim performance: lessons learned from conducting a multi-centre RCT. Trials. 2006 Feb 2;7:4.
- ECRI. Thermal Shrinkage of the Anterior Cruciate Ligament for Knee Instability. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 March 13. 7 p. Also available: http://www.ecri.org.
- ECRI. Thermal Capsulorrhaphy (Shrinkage) for Shoulder Instability. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 March 24. 8p. Also available: http://www.ecri.org.
- Engelsma Y, Willems WJ, Arthroscopic stabilization of posterior shoulder instability. Knee Surg Sports Traumatol Artrosc 2010 [Epub ahead of print].
- Johnson SM, Robinson CM. Shoulder instability in patients with joint hyperlaxity. J. Bone Joint Surg Am 2010; 92(6):1545-57.
- Virk, SS & Kocher, MS. Adoption of new technology in sports medicine: case studies of the Gore-Tex prosthetic ligament and of thermal capsulorrhaphy. Arthroscopy. 2011 Jan;27(1):113-21.
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Policy History:
Date Reason Action
October 2010 Annual review Policy revised
November 2011 Annual review Policy 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.
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