Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee

Arthroscopy is a surgical procedure that allows the direct visualization of the interior joint space. In addition to providing visualization, arthroscopy enables the process of joint cleansing through the use of lavage or irrigation. Lavage alone may involve either large or small volume saline irrigation of the knee by arthroscopy. Although generally performed to reduce pain and improve function, current practice does not recognize the benefit of lavage alone for the reduction of mechanical symptoms. Arthroscopy also permits the removal of any loose bodies from the interior joint space, a procedure termed debridement. Debridement, when used alone or not otherwise specified, may include low volume lavage or washout. Osteoarthritis is a chronic and painful joint disease caused by degeneration. The American College of Rheumatology defines a patient diagnosis of osteoarthritis of the knee as presenting with pain, and meeting at least 5 of the following criteria:

• Over 50 years of age;
• Less than 30 minutes of morning stiffness;
• Crepitus (noisy, grating sound) on active motion;
• Bony tenderness;
• Bony enlargement;
• No palpable warmth of synovium;
• ESR <40mm/hr;
• Rheumatoid Factor <1:40; or,
• Synovial fluid signs.

A. Nationally Covered Indications

Not applicable.

B. Nationally Noncovered Indications

The clinical effectiveness of arthroscopic lavage and arthroscopic debridement for the severe osteoarthritic knee has not been verified by scientifically controlled studies. After thorough discussions with clinical investigators, the orthopedic community, and other interested parties, CMS determines that the following procedures are not considered reasonable or necessary in treatment of the osteoarthritic knee and are not covered by the Medicare program:

• Arthroscopic lavage used alone for the osteoarthritic knee;
• Arthroscopic debridement for osteoarthritic patients presenting with knee pain only; or,
• Arthroscopic debridement and lavage with or without debridement for patients presenting with severe osteoarthritis (Severe osteoarthritis is defined in the Outerbridge classification scale, grades III and IV. Outerbridge is the most commonly used clinical scale that classifies the severity of joint degeneration of the knee by compartments and grades. Grade I is defined as softening or blistering of joint cartilage. Grade II is defined as fragmentation or fissuring in an area <1 cm. Grade III presents clinically with cartilage fragmentation or fissuring in an area >1 cm. Grade IV refers to cartilage erosion down to the bone. Grades III and IV are characteristic of severe osteoarthritis.)

C. Other

Apart from the noncovered indications above for arthroscopic lavage and/or arthroscopic debridement of the osteoarthritic knee, all other indications of debridement for the subpopulation of patients without severe osteoarthritis of the knee who present with symptoms other than pain alone; i.e., (1) mechanical symptoms that include, but are not limited to, locking, snapping, or popping (2) limb and knee joint alignment, and (3) less severe and/or early degenerative arthritis, remain at local contractor discretion. Medicare contractors may require submission of one or all of the following documents to define the patient’s knee condition:

• Operative notes,
• Reports of standing x-rays, or,
• Arthroscopy results.

(This NCD last reviewed June 2004.)

6/2004 - Arthroscopic lavage alone for treatment of osteoarthritis of knee, and arthroscopic debridement for presentation of knee pain only or arthroscopic debridement and lavage with or without debridement for patients with severe osteoarthritis of knee are noncovered. All other indications of debridement for subpopulation of patients without severe osteoarthritis of knee who present with symptoms other than pain alone remain at contractor discretion. Effective date 6/11/04. Implementation date 7/11/04. (TN 14) (CR 3281)