GL-172-Arthroscopy-shoulder-surgical …



HCPCS S2300 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphyLast reviewed at VbBS in September 2017. Minutes indicate that the staff recommendation was accepted without significant discussion. HERC approved the recommendations without change. Question: Should capsulorrhaphy be a covered procedure for recurrent shoulder dislocation?Question source: HSD claims reconsiderationIssue: Thermal capsulorrhaphy is a surgical technique which uses thermal energy to treat several types of shoulder instability. The procedure uses heat to shrink and tighten the shoulder capsule, which is the connective tissue around the shoulder joint that helps to keep it stable. Thermal capsular shrinkage was developed as a less invasive way to treat a shoulder that is loose or frequently dislocates. Early short-term results with thermal capsulorrhaphy were encouraging, and the procedure rapidly gained in popularity. However, more recent results with patients over a longer follow-up period have shown a much higher failure rate than was first seen. Also, more complications have been reported (American Academy of Orthopedic Surgeons, ). HSD has received multiple requests for coverage of capsulorrhaphy for recurrent shoulder dislocation. Currently, any type of capsulorhapthy is only on line 417 DISORDERS OF SHOULDER, INCLUDING SPRAINS/STRAINS GRADE 4 THROUGH 6. Recurrent shoulder dislocation (ICD-10 M24.41) is on line 359 DEFORMITY/CLOSED DISLOCATION OF MAJOR JOINT AND RECURRENT JOINT DISLOCATIONS. The only copsulorrhaphy-like procedure on line 359 is CPT 29806 (Arthroscopy, shoulder, surgical; capsulorrhaphy) which is not the coding used for thermal capsulorrhaphy. A review of the literature did not find other indications for capsulorrhaphy other than for recurrent shoulder dislocation. Consultation with Dr. Susan Williams indicates that the correct coding for thermal capsulorrhaphy is CPT 29999 (other unlisted procedure, arthroscopy), which is current Ancillary. Additional research found HCPCS S2300 (Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy) as likely a correct code, which is currently on the Services Recommended for Non-Covered Tabled but was not added to the new GN168 at the August 2017 VBBS meeting. CPT 23462-23466 involve other procedures, such as coracoid process transfer or surgery in the glenohumeral joint, and are open procedures.CPT codeCode Description23462Capsulorrhaphy, anterior, any type; with coracoid process transfer23465Capsulorrhaphy, glenohumeral joint, posterior, with or without bone block23466Capsulorrhaphy, glenohumeral joint, any type multi-directional instability29806Arthroscopy, shoulder, surgical; capsulorrhaphyHCPCS S2300Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphyEvidenceLongo 2015, systematic review of repair of shoulder instabilityN=24 articles comparing patients with open or arthroscopic repair or with conservative treatment of multidirectional instability (MDI)N=861 shoulders in 790 patientsMedian follow up 4.2 yearsThe redislocation event occurred in 17 of 226 (7.5%) shoulders with open capsular shift management, in 21 of 268 (7.8%) shoulders with arthroscopic plication management, in 12 of 49 (24.5%) shoulders undergoing arthroscopic thermal shrinkage, and in 11 of 55 (22%) shoulders undergoing arthroscopic laser-assisted capsulorrhaphy. Conclusions: Arthroscopic capsular plication and open capsular shift are the best surgical procedures for treatment of MDI after failure of rehabilitative management. Arthroscopic capsular plication shows results comparable to open capsular shift. Level of Evidence: Level IV, systematic review of Level I to IV studies.Other policies: most major insurers do not cover electrothermal or thermal capsulorrhaphy due to its experimental nature.HERC staff summary:Thermal or electrothermal capsulorrhaphy has good short-term results but worse long-term outcomes than open surgical repair for recurrent shoulder dislocation—there appears to be a 3 fold increase in redislocation with thermal capsulorrhaphy or other thermal shrinkage techniques compared to open procedures. There are also multiple case reports in the literature of complications from this procedure.HERC staff recommendations:Add open capsulorrhaphy (CPT 23462-23466) to line 359 DEFORMITY/CLOSED DISLOCATION OF MAJOR JOINT AND RECURRENT JOINT DISLOCATIONS (29806 already there)Contains recurrent shoulder dislocation diagnoses (ICD-10 M24.41)Remove CPT 23462-23466 (open capsulorrhaphy) and 29806 from line 417 DISORDERS OF SHOULDER, INCLUDING SPRAINS/STRAINS GRADE 4 THROUGH 6Only used for shoulder dislocation treatment; these diagnoses are not present on line 417Do not add thermal capsulorrhaphy (HCPCS S2300 Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy) to line 359 DEFORMITY/CLOSED DISLOCATION OF MAJOR JOINT AND RECURRENT JOINT DISLOCATIONSMore effective surgical procedures are available for treatment of recurrent shoulder dislocationAdd HCPCS S2300 (Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphy) to line 500 Conditions for which certain treatments result in marginal clinical benefit or low cost-effectiveness with an entry in GN168 as shown belowGUIDELINE NOTE 168, TREATMENTS WITH MARGINAL CLINICAL BENEFIT OR LOW COST-EFFECTIVENESS FOR CERTAIN CONDITIONSThe following treatments are prioritized on Line 500 for the conditions listed here:CONDITIONCPT/HCPCS codeTREATMENTRationaleRecurrent shoulder dislocation or any other shoulder conditionS2300Arthroscopy, shoulder, surgical; with thermally-induced capsulorrhaphyMore effective treatments are available ................
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