Wrist Arthroplasty - Medical Clinical Policy Bulletins (2022)

Number:0853

Policy

Aetna considers total wrist arthroplasty medically necessary for rheumatoid arthritis affecting the wrist in persons who have radiographic evidence of wrist joint destruction with demonstrated resistance or failure to conservative medical treatment (3 or more months of non-steroidal antiinflammatory drugs (NSAIDS), disease modifying anti-rheumatic drugs (DMARDs), and/or glucocorticoids, as appropriate).

Aetna considers total wrist arthroplasty experimental and investigationalfor all other diagnoses including the following (not an all-inclusive list) because there is inadequate evidence in the peer-reviewed published clinical literature regarding itseffectiveness for these indications:

  • Comminuted distal radius fracture
  • Kienbock's disease
  • Osteoarthritis (incluidng osteoarthritis following distal radius fracture)
  • Post-traumatic arthritis
  • Scaphoid non-union
  • Scapholunate dissociation.

Aetna considers the following devices / procedures experimental and investigational because their effectiveness has not been established (not an all-inclusive list):

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  • Pyrocarbon interposition arthroplasty for the treatment of pisotriquetral arthritis and scaphotrapeziotrapezoid osteoarthritis
  • The Prosthelast (an iso-elastic wrist implant)
  • The Universal 2 total wrist system
  • Wrist hemiarthroplasty for rheumatoid arthritis affecting the wrist and other indications (e.g., capitolunate arthritis, giant cell tumors of the distal radius, scaphoid nonunion advanced collapse, and scapholunate advanced collapse).

Background

Total wrist arthroplasty (TWA)involves the implantation of a prosthetic joint, with the goals of reducing pain and preserving or increasing wrist mobility. The procedure is almost always performed to relieve the symptoms of severe arthritis. These components come in extra-small, small, medium, and large sizes to match patient anatomy. To enable movement and prevent dislocation, the polyethylene spacer has a convex end that slides on the surface of a concave plate on the radial component.

Several wrist implants have been developed since the early 1970s. First-generation were silicone implants, such as those designed by Swanson in the 1980s. Second-generation implants typically included 2 metal components that articulated by means of a ball-and-socket or a hemispheric design. Many of these early implants were taken off the market because of problems with joint imbalance and dislocation. The third generation of wrist prostheses were developed in an effort to better approximate the center of motion to prevent imbalance and dislocation. Examples include the revised Meuli design (MWP III), as well as the Trispherical, the Universal, and the Biaxial designs, the latter of which has been discontinued.

Other Indications

Wollstein and Carlson (2013) stated that the most common forms of salvage surgery for wrist arthritis of any stage are four corner fusion and proximal row carpectomy. Younger, high demand patients with early arthritis may not be candidates for this type of salvage surgery. These investigators described a technique and preliminary case series of a minimal radio-carpal arthroplasty aimed at patients with initial and isolated wrist arthritis (stage 1). This procedure does not preclude any procedure that may become necessary in the future. A series of 19 male heavy laborers with scapho-lunate advanced collapse (SLAC grade 1 to 2) wrist osteoarthritis that felt the wrist arthritis was prohibiting their function enough to warrant surgery, but were unwilling to undergo a salvage procedure, were treated with the technique. The average age was 57.2 (± 7.7) years. The average follow-up period was 40.3 months (9 to 63 months). All patients returned to heavy labor. No revision surgery was needed within the follow-up period. Range of motion (ROM) and grip strength did not significantly improve. Patient satisfaction was high despite imperfect results. The authors concluded that minimal arthroplasty as described may provide a temporary solution for active patients with symptomatic early wrist arthritis who are not candidates for salvage wrist surgery. Moreover, they stated that longer-term follow-up as well as investigation of additional stabilization procedures is needed.

Boeckstyns et al (2013) noted that severely destroyed post-traumatic wrists are usually treated by partial or total wrist fusion or proximal row carpectomy. The indications for and longevity of TWA are still unclear. These researchers analyzed a series in which one last-generation TWA was used as a salvage procedure for wrists with severe arthritis due to traumatic causes. The data were prospectively recorded in a web-based registry. A total of 7 centers participated; 35 cases had a minimum follow-up time of 2 years. Average follow-up was 39 (24 to 96) months. Pain had improved significantly at follow-up, mobility remained unchanged. The total revision rate was 3.7 %, and the implant survival was 92 % at 4 to 8 years. Very few studies have described specific results after TWA in post-traumatic cases and almost none using classical "third-generation" implants. The number of cases and the follow-up in the published series were small. The authors concluded that although painful post-traumatic wrists with severe joint destruction can be salvaged by partial or total fusion; evaluated at short- to midterm, TWA can be an alternative procedure and gave results that were comparable to those obtained in rheumatoid cases.

Adams (2015) stated that newer implant designs and expanding experience have led to a gradual increase in the use of TWA for the treatment of post-traumatic arthritis. New challenges, however, may be encountered with this application, including bony deformities, previous or existing hard-ware, osteonecrosis, soft tissue injuries, and severe joint stiffness. Because the goals – to relieve pain and provide a functional ROM – are the same as for more common TWA indications, these technical challenges, along with often higher patient expectations, are important considerations. The author presented possible solutions to these unique surgical challenges, including important pre-operative planning to mitigate risks, and the expected outcomes in these patients.

Nicoloff et al (2015) noted that for decades design and development of TWA has been accompanied by quite a few failures, so that it has been rejected by most surgeons until today. The difficult and complex anatomy of the wrist led to different ways of development and often ended in an impasse. Compared to knee and hip arthroplasties, which could be conceived and developed further, a consistent method could not be applied. But in the last years some new concepts have established themselves, so that TWA is now not only applied in individual cases. The indications could be expanded and standardized. At the Hand-Center Lingen more than 400 TWAs have been performed since 2005. These researchers described the mid-term results (5 years since operation) of TWA in 162 patients; 41 % suffered from rheumatoid arthritis, the remaining diseases consisted of Kienbock's disease, osteoarthritis, osteoarthritis following distal radius fracture, post-traumatic arthritis, scaphoid non-union, and scapholunate dissociation. Three different types of TWA have been applied and their benefits and disadvantages were examined. In the follow-up these investigators found an improvement in the Quick-DASH of 34 points and 5.8 points on the visual analog scale (VAS). The ROM decreased in patients with rheumatoid arthritis (RA), but it increased in patients with other diseases. In both groups of patients these researchers found an increase of force. On the whole there was a rate of complications in an average rate of holding time of 3.7 %. There was no necessity for TWA removal and secondary wrist arthrodesis. The authors concluded that their uown very positive experience corresponded with the international comparison and it further encourages a standardized indication in TWA as an equivalent treatment.

Laulan et al (2015) stated that painful wrist osteoarthritis can result in major functional impairment. Most cases are related to post-traumatic sequel, metabolic arthropathies, or inflammatory joint disease, although wrist osteoarthritis occurs as an idiopathic condition in a small minority of cases. Surgery is indicated only when conservative treatment fails. The main objective is to ensure pain relief while restoring strength. Motion-preserving procedures are usually preferred, although residual wrist mobility is not crucial to good function. The vast array of available surgical techniques includes excisional arthroplasty, limited and total fusion, total wrist denervation, partial and total arthroplasty, as well as rib-cartilage graft implantation. Surgical decisions rest on the cause and extent of the degenerative wrist lesions, degree of residual mobility, and patient's wishes and functional demand. Proximal row carpectomy and 4-corner fusion with scaphoid bone excision are the most widely used surgical procedures for stage II wrist osteoarthritis secondary to scapho-lunate advanced collapse (SLAC) or scaphoid non-union advanced collapse (SNAC) wrist. Proximal row carpectomy is not indicated in patients with stage III disease. Total wrist denervation is a satisfactory treatment option in patients of any age; who have good ROM and low functional demands; furthermore, the low morbidity associated with this procedure makes it a good option for elderly patients regardless of their ROM. Total wrist fusion can be used not only as a revision procedure, but also as the primary surgical treatment in heavy manual laborers with wrist stiffness or generalized wrist-joint involvement. The authors concluded that the role for pyrocarbon implants, rib-cartilage graft implantation, and TWA remains to be determined, given the short follow-ups in available studies.

Comminuted Distal Radius Fracture

Schmidt (2015) presented 2 case reports of successful primary shortening of the forearm and TWA using the new angle-stable Maestro Wrist Reconstructive System (WRS) for treatment of highly comminuted distal radius fracture in selected autonomous patients. In a 56-year old male patient with adequate bone stock, insertion of the non-cemented Maestro WRS was combined with ulnar shortening osteotomy. In an 84-year old female patient with poor osteoporotic bone stock, insertion of the radial cemented Maestro WRS was combined with ulnar head resection. Both patients resumed their work without additional surgery after TWA. At the 1-year follow-up, there were no changes in position of either implant without signs of loosening, no impingement, and no instability of the distal radioulnar joint or the distal ulna stump. All clinical parameters (Disabilities of the Arm Shoulder and Hand [DASH] score, pain through VAS, and grip strength) were satisfactory. Both patients reported that they would have the same procedure again. The authors stated that further experience is needed to validate this concept.

Furthermore, the American Academy of Orthopaedic Surgeons’ guideline and evidence report on “The treatment of distal radius fractures” (AAOS, 2009) did not mention wrist arthroplasty as a therapeutic option.

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Wrist Hemiarthroplasty

Wang and co-workers (2016) stated that giant cell tumor (GCT) of bone presenting in the distal radius is rare, however, when they occur, Campanacci grade-III tumors can present formidable reconstructive challenges. They are associated with a high local recurrence rate with intra-lesional treatment, therefore approaches to reconstruct the wrist after en bloc resection warrant study. These researchers examined:

  1. what are the functional outcomes after en bloc resection and reconstruction of the wrist with a unipolar prosthesis in patients with grade-III GCT of the distal radius?
  2. what complications occur with use of a unipolar prosthesis in these patients? and
  3. what are the oncologic outcomes with using en bloc resection and reconstruction with a custom unipolar wrist hemiarthroplasty for grade-III GCTs of the distal radius?

These investigators retrospectively analyzed 10 patients with Campanacci grade-III GCTs of the distal radius treated by a unipolar prosthesis after wide resection of the tumor between January 2008 and October 2013. During that period, all patients at the authors’ medical group who presented with a grade-III GCT of the distal radius were treated with wide resection and reconstruction using a custom unipolar implant. Pre- and post-operative pain at rest were assessed according to a 10-cm VAS score. The functional outcomes of the wrist were assessed using the modified Mayo wrist score, and the degenerative changes were evaluated radiographically by a new rating system based on the Knirk and Jupiter scale. These researchers also analyzed tumor recurrence, metastases, and complications associated with the reconstruction procedure. All patients were available for follow-up at a mean of 52 months (range of 24 to 90 months). Although the complication rate associated with prosthetic arthroplasty was relatively high (6 of 10), none of the patients experienced severe complications; 2 patients reported having occasional pain of the involved wrist at the time of final follow-up (VAS, pre-operative versus post-operative: 0 versus 3; 5 versus 2, respectively). The mean modified Mayo wrist score was 68 (range of 45 to 90). Degenerative changes were found in 3 wrists (grade-I, 2 patients; grade-II, 1 patient). Aseptic loosening occurred in 1 patient and wrist subluxation occurred in 2 patients. Lung metastases or local tumor recurrence were not observed. The authors concluded that due to the proportion of patients who had complications and progressive degeneration with this approach, they recommended first exploring alternatives to reconstruction with custom unipolar wrist hemiarthroplasty after resection of grade-III GCTs of the distal radius, such as fibular autografting. This prosthesis also had the disadvantage of being a custom-made prosthesis, which might not be available in all countries. However, this technique provided an alternative for patients with concerns regarding possible morbidity associated with autografting, and for situations when allograft is not available. Moreover, they stated that a larger study is needed to confirm these preliminary findings, ideally comparing this approach with other types of reconstruction. Level of evidence = IV.

Huish and colleagues (2017) noted that wrist hemiarthroplasty has emerged as a motion-sparing option for severe wrist arthritis. It is technically easy with advantages of limited bone resection and no risk of nonunion. Given the relative infancy of the procedure in clinical practice, there are limited data on patient outcomes. In this study, a total of 11 patients were treated with wrist reconstructive hemiarthroplasty. Indications included 1 patient with scaphoid nonunion advanced collapse, 9 patients with scapholunate advanced collapse, and 1 patient with capitolunate arthritis. Average age was 63 years; average follow-up was 4 years. Objective parameters included DASH, grip strength, and ROM. Implant failure defined by necessity of revision procedure; DASH scores initially improved post-operatively but were not statistically significant. Grip strength was 60 % of contralateral side. Post-operative ROM at 6 months was flexion 40.3°, extension 39.3°, supination 87.0°, pronation 77.8°, radial deviation 14.5°, and ulnar deviation 13.8°. A 45 % failure rate was observed. Complications included failure with conversion to TWA (n = 2) or wrist fusion (n = 3) secondary to development of ulnar-sided wrist pain. One additional patient experienced severe wrist pain but declined additional surgery. The authors concluded that wrist hemiarthroplasty in this small series had a significant failure rate. In each case of failure, the patient developed ulnar-sided wrist pain. In the presence of more reliable procedures, wrist hemiarthroplasty is not indicated in its current incarnation.

Herzberg and associates (2017) reported their experience with hemi-arthroplasty in irreparable fresh distal radius fracture in independent elderly patients as first-line treatment (12 fractures in 11 women; mean age of 74 years) or in second-line after clinically disabling primary failure (4 fractures in 4 women; mean age, of 78 years). In the 12 primary surgeries, at a mean 32 months' follow-up, there were no complications requiring implant ablation; mean pain score was 1/10, flexion-extension 62°, Lyon wrist score 75 %, and patient-related wrist evaluation (PRWE) 22 points. In 2 of the 4 secondary surgeries, at a mean 24 months' follow-up, there were no complications requiring implant ablation; mean pain score was 2.5/10, flexion-extension 62°, Lyon wrist score 58 %, and PRWE 50 points: i.e., slightly poorer results than in primary surgery. The authors concluded that salvage of complex fracture in independent elderly patients by hemi-arthroplasty, whether primary or secondary to failure, appeared to be a considerable progress; however, these preliminary findings need to be confirmed in larger series.

Herzberg and associates (2018) updated their results of wrist hemiarthroplasty for irreparable distal radius fracture (DRF) in the elderly, at a minimum of 2-year follow-up. Between 2011 and 2018, a total of 25 consecutive independent elderly patients (24 women, 27 wrists) were treated with wrist hemiarthroplasty for DRF at a single institution. The average age was 77 years (range of 65 to 88). They all were independent at home. A total of 19 wrists were treated at the acute stage, and 8 secondary procedures. The average follow-up was 32 months (range of 24 to 44). There was no dislocation, loosening, infection nor removal of the implants. These investigators observed 3 complex regional pain syndrome (CRPS). At final follow-up, the average VAS pain was 1/10, mean forearm pronation/supination arc was 150°, and mean active flexion-extension arc was 60°. Average wrist extension was 36°. Mean grip strength was 68 % of contralateral side. Mean Lyon wrist score was 74 %. Mean Quick DASH score was 26 %, and mean PRWE score was 25 %. The authors concluded that these findings suggested that treatment of acute irreparable DRF in the independent elderly patient with a bone-preserving primary wrist hemiarthroplasty may be a viable option. Moreover, they stated that longer-term follow-up are needed to confirm these preliminary data.

The Prosthelast (an Iso-Elastic Wrist Implant)

Salazar Botero and colleagues (2018) described a new total wrist implant (Prosthelast) designed to reduce the risk of distal migration of the carpal component. The Prosthelast implant consists in a 1-block radial implant replacing the metaphysis and the articular surface fixed to a radial elastic centro-medullar wire and a carpal component in titanium with an articular condylar surface in polyethylene. These investigators operated on 5 patients (3 males and 2 females) and followed them up for 12 months on average; 2 of the patients presented with RA of the wrist, and an ulnar osteotomy (Darrach procedure) was carried out at the same time of the arthroplasty. All clinical variables improved post-operatively (Quick DASH score, pain score, ROM) except from wrist flexion that was reduced. No patients underwent revision surgery; 2 patients presented with a peri-prosthetic radiolucent loosening around the radial component, but no implant migration was observed. The authors concluded that the preliminary findings of this case series showed that the new Prosthelast implant presented comparable short-term results to those described in the literature. They will follow up the patients to verify that long-term results are as satisfactory as the short-term results.

Pyrocarbon Interposition Arthroplasty for the Treatment of Pisotriquetral Arthritis and Scaphotrapeziotrapezoid Osteoarthritis

Gauthier and associates (2017) reported the findings of arthroplasty using a mobile pyrocarbon implant (Pyrocardan) for isolated scaphotrapeziotrapezoid (STT) osteoarthritis (OA). The hypothesis was that this arthroplasty leads to functional improvement without carpal instability. A total of 20 patients (22 implants) were included with a minimum follow-up of 2 years and an average age of 59.6 years. Outcome criteria were pain (VAS scale), Quick DASH (QDASH) and PRWE scores, strength (grip and pinch), wrist mobility, the Kapandji index, carpal height and the capitol-unar angle measured on X-rays. The pre- and post-operative data were compared. The average follow-up was 3.8 years. There was a significant improvement in pain, clinical scores and pinch strength. In terms of ROM, these investigators found that amplitudes were maintained except for a significant decrease in wrist extension. X-rays did not show any carpal instability; carpal height was maintained and the capitol-unar angle was significantly improved. No implant dislocation was reported. The authors concluded that the good functional and radiographic outcomes, and the absence of surgical complications were evidence that the Pyrocardan resurfacing implant is a valid option for treating STT OA. Moreover, they stated that if this arthroplasty procedure fails, another procedure can still be done; but a long-term assessment of this technique is still needed.

Bellemere and co-workers (2018) stated that pisiformectomy is the baseline treatment for pisotriquetral arthritis when medical treatment fails to address the problem. This operation may lead to loss of mobility and strength in the wrist. These investigators reported the short-term outcomes of a new technique for treating pisotriquetral arthritis using a pisotriquetral interposition arthroplasty with a pyrocarbon implant. They performed a clinical and radiographic study on a series of 8 patients who received this treatment at a mean follow-up of 2.8 years. They also studied the mobility of the implant and assessed articular instability using dynamic radiology and fluoroscopy. These researchers observed 1 proximal dislocation of the implant in 1 hand, which was re-operated to re-position the implant and strengthen the capsule. All patients were satisfied or very satisfied with their operation and had an average functional recovery period of 1.6 months. At the last follow-up, the Mayo Wrist Score (MWS), QDASH, and PRWE scores were 89, 18, and 20, respectively. Post-operatively, there was a 22 % improvement in the grip strength of the wrists as well as improved mobility, mainly as regards the radio-ulnar deviation (47 % improvement) and the VAS pain scores decreased from 8 pre-operatively to 2 at the latest follow-up. The functional radiologic and fluoroscopic study reported good adaptive mobility of the implant in all the patients, without any indication of pisotriquetral joint instability. The authors concluded that the short-term results of pisotriquetral arthroplasty using the Pyrocardan implant were encouraging. They stated that this new surgical solution appeared to be a valid alternative to pisiformectomy or pisotriquetral arthrodesis. Moreover, they stated that long-term studies are needed to confirm these preliminary findings.

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The Universal 2 Total Wrist System

Brinkhorst and colleagues (2018) noted that many therapeutic options are available for wrist OA, with the objective of decreasing pain and preserving function. In later stages when mid-carpal and radio-carpal OA occur, 2 choices remain: total wrist arthrodesis or total wrist arthroplasty. These researchers presented the short-term functional changes following total wrist arthroplasty with the Universal 2 total wrist system (Integra Life Sciences) in patients with non-inflammatory wrist OA. Patients with severe non-inflammatory wrist OA were assessed pre-operatively, 6 and 12 months after surgery using a ROM, grip strength, pain, and the DASH score. The additional assessment was performed after 1 year for a ROM using a biaxial electro-goniometer, grip strength, DASH, and the Michigan hand questionnaire. All ROM directions and grip strength did not change from pre-operative values. The DASH score improved from 53 pre-operatively to 14 during latest follow-up. Median patients' satisfaction score decreased with approximately 20 points during the last follow-up. The authors concluded that the relatively good DASH score combined with the partly maintained wrist ROM indicated that reconstruction with the Universal 2 total wrist prosthesis should be considered in patients with end-stage non-inflammatory wrist osteoarthritis. Level of Evidence = IV. This study provided only short-term results (12 months); long-term follow-up data are needed to ascertain the safety and effectiveness of this prosthesis.

Zijlker and colleagues (2019a) noted that the Universal 2 is a total wrist implant that aims to maintain function of the wrist. Promising mid-term results of the Universal 2 total wrist implant were described in the literature. These researchers examined the long-term results in terms of implant survival and patient satisfaction. Patients who received a Universal 2 implant between 2004 and 2009 were retrospectively identified through a data-base search. Clinical outcome and complications of the implant were assessed by examination of the patient's medical records, X-rays, and a questionnaire, consisting of the Patient-Rated Wrist and Hand Evaluation questionnaire (PRWHE) and Quick DASH (QuickDASH) questionnaires and additional questions. A total of 25 patients (26 wrists) were included in this study; 21 (81 %) Universal 2 implants remained in-situ after a mean follow-up of 11 years. Moderate PRWHE (44) and QuickDASH (41) scores were found in these cases; 5 Universal 2 implants failed and were converted to a total wrist arthrodesis after a mean period of 9.2 years due to distal component loosening (n = 3), recurrent luxation (n = 1), or recurrent synovitis (n = 1); 23 (92 %) patients were (very) satisfied with the Universal 2 implant. The authors concluded that the Universal 2 demonstrated a high (81 %) implant survival with a high patient satisfaction after a mean follow-up of 11 years. Moreover, these researchers stated that prospective, long-term studies of the Universal 2 implant are needed to objectify improvement in wrist function and to provide a better comparison to other fourth-generation wrist implants.

The authors stated that this study had several drawbacks. First, and perhaps most importantly, no pre-operative patient-reported outcome measures (PROMs) were available so it was impossible to comment on improvement or deterioration of wrist function as perceived by the patients. However, one may assume an improvement since most patients were satisfied as demonstrated by the additional questionss. Second, no objective outcome measures, like strength and ROM, were collected pre-operatively nor post-operatively. Third, statistical analysis was not performed because of the small sample size. Finally, this study was prone to selection bias due to the retrospective study design and only 50 % of the patients who were treated with the Universal 2 implant were included; the other 50 % was lost to follow-up, which was also an evident weakness of this study.

Zijlker et al (2019b) stated that Universal 2 implants may be an alternative to total wrist arthrodesis for the salvage of failed Biaxial total wrist prostheses. These investigators evaluated 40 Universal 2 revision implants retrospectively; 14 of these wrists were converted to total wrist arthrodeses, and 2 wrists received a third TWA after a mean period of 5.5 years; 24 of the Universal 2 implants that remained in-situ after a mean follow-up of 9 years (range of 4 to 13 years) were re-examined, and 16 functioned satisfactorily. Patient-Rated Wrist and Hand Evaluation scores and QuickDASH scores were 53 and 47, respectively; 29 patients would choose the Universal 2 again and would also recommend it to other patients. The survival of the revision implants was 60 % at a mean follow-up of 9 years. Level of evidence = IV.

The authors stated that loosening of the distal component remains a major problem in revision implants. In their opinion, a revision system that provides less stress on the carpal fixation points might give better results and avoid failures. The polyethylene component of the Re-motion implants (Stryker, Kalamazoo, MI) allows a rotational articulation of 20° with the carpal plate. These investigators believed this reduces stress on the carpal fixation points. For this reason, they have been using the Re-motion implant as salvage procedure for failed BIAX implants since 2015.

In a retrospective study, Gendera and colleagues (2020) reported medium-term outcomes of 14 total wrist arthroplasties in patients with especially, non-rheumatoid, degenerative OA and post-traumatic OA with a mean follow-up of 5 to 10 years. Information of 14 patients (6 men and 8 women) with a mean age of 61 years, was collected before and after total wrist arthroplasty (Universal 2 prosthesis) performed by a single surgeon. Pre-operative mobility was determined by ROM and compared to post-operative ROM. Post-operative function was determined using the DASH score and the score. Grip force between the operated and non-operated hand were compared post-operatively; 3 patients experienced complications. Post-operatively, ROM improved although not significantly, due to an increase in palmar flexion. The mean DASH score was 20 % and the mean total PRWE was 54 %. The authors concluded that the findings of this study showed that total wrist arthroplasty, using the Universal 2 wrist prosthesis, provided reasonable results (survival rate of 84 %) by decreasing pain while preserving ROM in patients with degenerative OA of the wrist after 5 years; however, the 10-year survival rate decreased steeply to an unsatisfying 35 %.

Motec Total Wrist Arthroplasty

Lin and Paksima (2017) stated that TWA, first performed in the late 19th Century, is still an infrequently used operation. It is most frequently indicated in patients with RA who have pan-carpal wrist involvement. It is an alternative to total wrist arthrodesis in patients who wish to preserve joint motion. Patients must lead a low-demand lifestyle and have failed non-operative measures. Complications are not insignificant and have been reported to be as high as 43 %. Modern generation implants most often fail due to dislocation or loosening. The authors concluded that because wrist arthrodesis remains the gold standard therapy, especially in patients with higher physical demands, it remains to be seen whether TWA will gain greater acceptance as prosthetic designs evolve.

Gil and co-workers (2017) noted that TWA has been described as traditionally being performed with fixation in the radius and carpus with cement. The TWA implant used by these investigators has been associated with promising results in studies with up to 6 years follow-up; however, studies evaluating survivorship, pain, and function with this implant are limited. In a retrospective case-series study, these researchers reported ROM and pain scores after wrist reconstruction with cementless fourth-generation TWA at a mean follow-up of 9 years (range of 4.8 to 14.7); and reported complications of a cementless fourth-generation TWA and the cumulative probability of not undergoing a revision at a mean follow-up of 9 years. This trial included a total of 69 patients who were treated for pan-carpal wrist arthritis between 2002 and 2014. Of those, 31 had inflammatory arthritis (RA; n = 29, juvenile RA; n = 1, and psoriatic arthritis; n = 1); all of these patients received TWA with the cementless implant studied in this investigation. Another 38 patients had OA or post-traumatic arthritis; in this subgroup, 28 patients were 65 years or younger, and all underwent wrist fusion (none was offered TWA); 10 patients with OA were older than 65 years and all were offered TWA; of those, 8 underwent TWA, and 2 declined the procedure and instead preferred and underwent total wrist arthrodesis. The mean age of the 39 patients who had TWA was 56 ± 8.9 years (range of 31 to 78) at the time of surgery; 36 were women and 3 were men. The patients who underwent TWA were seen at a minimum of 4 years (mean of 9 years; range of 4 to 15 years), and all had been examined in 2016 as part of this study except for 1 patient who died 9 years after surgery. The dominant wrist was involved in 60 % (25) of the patients. All patients were immobilized for 4 weeks post-operatively and then underwent hand therapy for 4 to 6 weeks. Pain and ROM were gathered before surgery as part of clinical care, and were measured again at latest follow-up; at latest follow-up, radiographs were analyzed (by the senior author) for evidence of loosening, defined as any implant migration compared with any previous radiograph with evidence of peri-implant osteolysis and bone resorption. Subjective pain score was assessed by a verbal pain scale (0 to 10) and ROM was measured with a goniometer. Complications were determined by chart review and final examination. Kaplan Meier survival analysis was performed to estimate the cumulative probability of not undergoing a revision. The mean pre-operative active ROM was 34o ± 18° flexion and 36° ± 18° extension. Post-operatively, the mean active ROM was 37° ± 14° flexion and 29° ± 13° extension. The mean difference (MD) between the pre-operative pain score (8.6 ± 1.2) and post-operative pain score (0.4 ± 0.8) was 8.1 ± 1.9 (p < 0.001). Implant loosening occurred in 3 (7.7 %) patients. No other complications occurred in this series. Kaplan-Meier survivorship analysis estimated the cumulative probability of remaining free from revision as 78 % (95 % confidence interval [CI]: 62 % to 91 %) at 15 years. The authors concluded that cementless fourth-generation TWA improved pain while generally preserving the pre-operative arc of motion. The cumulative probability of remaining free from revision at 14.7 years after the index procedure was 77.7 % (95 % CI: 62.0 % to 91.4 %).

The authors stated that the findings of this study as well as those of previous investigations that assessed the same system used in this trial suggested that the fourth-generation implant may be more durable, and the TWA has shifted from a surgical option that is controversial to one that is more predictable and reliable for patients with RA and post-traumatic osteoarthritis. Their experience and data from the current study have caused them to broaden their current indications in patients with OA and post-traumatic arthritis who are younger than 65 years. These researchers stated that future studies are needed to examine if this would result in measurable improvements in patient-reported outcomes. Furthermore, future studies should compare alternative approaches for patients with end-stage wrist arthritis; such evaluations, which might compare TWA implants, or TWAs with arthrodesis. will need to be multi-center, as the problem is relatively uncommon.

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Giwa and colleagues (2018) noted that the Motec cementless modular metal-on-metal ball-and-socket wrist arthroplasty is an implant with promising intermediate results. An alternative to primary wrist fusion, TWA is an option for active patients, who wish to retain their wrist function. It is indicated in cases of degenerative OA, post-traumatic arthritis and rheumatoid (inflammatory) arthritis. These researchers carried out a prospective review of patient demographics, pre- and post-operative DASH, MAYO wrist scores, ROM and grip strengths. All complications in follow-up were recorded across the 4-year period. This trial included a total of 25 implants on 23 patients over 5.5 years, mean age of 61 years; 8 women and 15 men; 10 patients with SLAC, 3 SNAC, 5 inflammatory and 7 patients with generalized OA. Subjects showed significant improvements of MAYO and DASH scores post-operatively, as well as the flexion/extension arc and grip strengths. There was just 1 case of implant loosening – the radial screw after a wound infection, which was revised with a longer screw. Two implants were converted to Motec fusion due to pain. One implant was dislocated and relocated. The remaining patients have had good wrist function. Only 6 patients were unable to return to work. The authors concluded that similar to published studies, this series showed the Motec implant to be a good motion preserving alternative to total wrist fusion; providing promising mid-term results (4 years).

Karjalainen and associates (2018) described 2 cases of articulation-related failures resulting in revision surgery after a Motec TWA: 1 with an adverse reaction to metal debris and the other with an adverse reaction to polyether ether ketone. In the first case, blood cobalt and chrome levels were elevated and magnetic resonance imaging (MRI) showed clear signs of a pseudotumor. In the second case, subject had an extensive release of polyether ether ketone particles into the surrounding synovia due to adverse wear conditions in the cup, leading to the formation of a fluid-filled cyst sac with a black lining and diffuse lymphocyte-dominated inflammation in the synovia. The authors recommended regular follow-up including x-rays, monitoring of cobalt and chrome ion levels, and a low threshold for cross-sectional imaging in patients who have undergone TWA with a Motec joint prosthesis. These researchers noted that wear-related problems could also develop in implants in which polyether ether ketone was the bulk material.

Furthermore, there is a clinical trial on “Motec versus ReMotion total wrist arthroplasty - A prospective study” (2018) that is active, but not recruiting. The objective of this trial is to determine the difference in the results between Motec and ReMotion wrist arthroplasty in the treatment of non-rheumatoid wrist arthritis.

The ReMotion Total Wrist System

Herzberg and associates (2012) reported the current findings of an international multi-center study of one last generation TWA ("ReMotion" Small Bone Innovation, Morristown, PA). The first and second authors built a Web-based prospective database including clinical and radiological pre-operative and post-operative reports of "ReMotion" TWA at regular intervals. The cases of 7 centers with more than 15 inclusions were considered for this article. A total of 215 wrists were included. In the RA (129 wrists) and non-RA (86 wrists) groups, there were respectively 5 % and 6 % complications requiring implant revision with a survival rate of 96 % and 92 %, respectively, at an average follow-up of 4 years. Within the whole series, only 1 dislocation was observed in 1 non-RA wrist. A total of 112 wrists (75 RA and 37 non-RA) had more than 2 years of follow-up (minimum of 2 years, maximum of 8 years). In RA and non-RA group, VAS pain score improved by 48 and 54 points, respectively, and QuickDASH score improved by 20 and 21 points, respectively, with no statistical differences. Average post-operative arc of wrist flexion-extension was 58 degrees in rheumatoid wrists (loss of 1 degree) compared with 63 degrees in non-RA wrists (loss of 9 degrees) with no statistical differences. Grip strength improved respectively by 40 % and 19 % in RA and non-RA groups (p = 0.033). Implant loosening was observed in 4 % of the RA wrists and 3 % of the non-RA wrists with no statistical differences. A Web-based TWA international registry was presented. The authors concluded that these findings suggested that the ReMotion TWA was feasible in the mid-term and may be used in selected non-RA patients. Moreover, these researchers stated that these findings need to be confirmed at a longer follow-up. The authors stated that this study had several drawbacks. It wa a multi-center study, and the current follow-up was only a mid-term follow-up. The radiographs were not gathered electronically and the radiological criteria were based on surgeon's judgment. This may have led to slightly different interpretations. Level of evidence = IV.

Yeoh and Tourret (2015) reviewed the evidence on total wrist replacement from the last 5 years; 8 articles met a minimum set standard. The results of 405 prostheses were available, including 7 different manufacturers. The mean follow-up was 2.3 to 7.3 years with an average age of 52 to 63 years. Rheumatoid arthritis was the indication in 42 % of patients. Motec demonstrated the best post-operative DASH scores. Only Maestro achieved a defined functional ROM post-operatively. Universal 2 displayed the highest survival rates (100 % at 3 to 5 years), while Elos had the lowest (57 % at 5 years). Bi-axial had the highest complication rates (68.7 %), while Remotion had the lowest (11 %). Wrist arthroplasty preserves some ROM; functional scores improved and were maintained over the mid- to long-term. Complication rates were higher than wrist fusion, with reports of radiological loosening and osteolysis. The authors stated that the evidence does not support the widespread use of arthroplasty over arthrodesis, and careful patient selection is essential.

Froschauer and colleagues (2019) examined outcomes of the ReMotion Total Wrist System in 39 non-rheumatoid patients. The mean follow-up was 7 years (range of 3 to 12). Post-operative wrist flexion-extension and radial-ulnar deviation as well as the scores of the DASH questionnaire and the VAS pain scores improved significantly. Complications occurred in 13 wrists, 5 of which required further surgery. The most frequent complication was impingement between the scaphoid and the radial implant (n = 5), which can be avoided by complete or almost complete scaphoid resection. Peri-prosthetic radiolucency developed around the radial component in 3 cases and 3 radial screws loosened. The authors concluded that despite the incidence of high implant survival in 38 of 39 wrists over 7 years (97 %), the complication rate was not satisfying. These researchers stated that knowledge of the risk of complications and patient selection are essential when making the decision to choose wrist arthroplasty over arthrodesis. Level of evidence= IV.

Long-Term Follow-Up of Total Wrist Arthroplast

Matsui and associates (2020) examined the longitudinal clinical outcomes using a new semi-constrained wrist prosthesis for the treatment of severe RA of the wrist. A total of 20 patients with RA (20 wrists) underwent TWA with the prosthesis in a clinical trial. The pre-operative Larsen classification was grade-IV in 16 wrists and grade-V in 4 wrists. Assessments were performed before surgery, 1.5 years after surgery, and at final follow-up (greater than or equal to 5 years after surgery) using the VAS for pain, Figgie wrist score, Japanese version of the DASH questionnaire, and plain radiographs. At final follow-up, no patient had wrist pain. The pre-operative flexion-extension arc at final follow-up was similar to the pre-operative range. The mean 1.5-year post-operative Figgie score was significantly improved and was unchanged at final follow-up. The DASH score significantly improved from before surgery to 1.5 years after surgery; the DASH score was improved further at final follow-up, but not significantly; 5 of the 19 wrists evaluated had radiographic findings indicating carpal component loosening at final follow-up; however, all patients with the loosening were asymptomatic and had not undergone revision surgery. The authors concluded that TWA using this wrist prosthesis led to favorable clinical outcomes regarding pain relief and retained ROM of the wrist

Fischer and colleagues (2020) examined long-term implant survival in TWA, comparing 4 different implants. In a prospective cohort of 124 patients, 136 TWAs were evaluated 5 years and 10 years after surgery. The TWAs were implanted between 2005 and 2009. The primary outcome was implant survival. Survival analysis was performed with revision and radiographic loosening as the final end-point. Revision was defined as exchange of whole or parts of the prosthesis. Implant loosening was assessed using radiographic examination at the 5-year and 10-year follow-up. Secondary outcome measures included wrist ROM, hand grip strength, VAS pain scores, and PROMs, including DASH, PRWE, and Canadian Occupational Performance Measure (COPM). Total cumulative implant survival was 92 % with revision as the primary end-point. When including a non-revised radiographic loose implant as a failure, total implant survival was 75 %. Radiographic loosening differed significantly between the implants with a range in frequency from 0 % to 37.5 %. At the 10-year follow-up, assessing the non-revised TWAs, ROM was preserved compared with pre-operative values. Significant improvement was recorded for hand grip strength, VAS pain scores, and patient-related outcome measures at the 10-year follow-up compared with pre-operative values. The authors concluded that high 10-year implant survival was found when defining the primary end-point as revision of any cause. When including radiographic loosening of the implant in the survival analysis, implant survival was considerably lower. However, radiographic loosening did not appear to correlate with changes in secondary outcome measures, questioning the need for revision surgery in these cases.

(Video) Woundcon 2021 13.06.2021

Table: CPT Codes / HCPCS Codes / ICD-10 Codes

Information in the [brackets] below has been added for clarification purposes.&nbspCodes requiring a 7th character are represented by"+":

CPT codes covered if selection criteria are met:

25446Arthroplasty with prosthetic replacement; distal radius and partial or entire carpus (total wrist)

HCPCS codes not covered for indications listed in the CPB:

Universal 2 total wrist - no specific code:

ICD-10 codes covered if selection criteria are met:

M05.00 - M14.89Rheumatoid arthritis

ICD-10 codes not covered for indications listed in the CPB:

S52.591+ - S52.599+Other fracture of lower end of radius [comminuted]

Wrist hemiarthroplasty - no specific code:

ICD-10 codes not covered for indications listed in the CPB:

C40.00 - C40.02Malignant neoplasm of scapula and long bones of upper limb [giant cell tumors of the distal radius]
M12.531 - M12.539Traumatic arthropathy, wrist [scapholunate advanced collapse]
M19.031 - M19.039Primary osteoarthritis, wrist
M19.131 - M19.139Post-traumatic osteoarthritis, wrist
M19.231 - M19.239 Secondary osteoarthritis, wrist
S62.001K - S62.036K - 7th character must be "K" Fracture of navicular [scaphoid] bone of wrist [nonunion]

Pyrocarbon interposition arthroplasty - no specific code :

Prosthelast - no specific code:

ICD-10 codes not covered for indications listed in the CPB:

M13.811 - M13.89Other specified arthritis [pisotriquetral arthritis]
M19.041 - M19.049Primary osteoarthritis, hand [scaphotrapeziotrapezoid osteoarthritis]

The above policy is based on the following references:

  1. Adams BD. Total wrist arthroplasty for posttraumatic arthritis with radius deformity. J Wrist Surg. 2015;4(3):164-168
  2. American Academy of Orthopaedic Surgeons. Guideline and evidence report: The treatment of distal radius fractures. AAOS: Rosemont, IL. 2009. Available at: http://www.aaos.org/research/guidelines/drfguideline.pdf. Accessed August 30, 2016.
  3. Bellemere P, Aribert M, Choughri H, et al. Treatment of pisotriquetral arthritis by pyrocarbon interposition arthroplasty. J Wrist Surg. 2018;7(1):2-10.
  4. Berber O, Garagnani L, Gidwani S. Systematic review of total wrist arthroplasty and arthrodesis in wrist arthritis. J Wrist Surg. 2018;7(5):424-440.
  5. Biehl C, Stoll M, Heinrich M, et al. Long-term results of the modular physiological wrist prosthesis (MPW ®) in patients with inflammatory diseases. Life (Basel). 2021;11(4):355.
  6. Boeckstyns ME, Herzberg G, Sorensen AI, et al. Can total wrist arthroplasty be an option in the treatment of the severely destroyed posttraumatic wrist? J Wrist Surg. 2013;2(4):324-329.
  7. Bosco JA 3rd, Bynum DK, Bowers WH. Long-term outcome of Volz total wrist arthroplasties. J Arthroplasty. 1994;9(1):25-31.
  8. Botero SS, Igeta Y, Facca S, et al. Surgical technique: About a new total and isoelastic wrist implant (Prosthelast®). Eur J Orthop Surg Traumatol. 2018;28(8):1525-1530.
  9. Brinkhorst ME, Selles RW, Dias JJ, et al. Results of the Universal 2 prosthesis in noninflammatory osteoarthritic wrists. J Wrist Surg. 2018;7(2):121-126.
  10. Cavaliere CM, Chung KC. A systematic review of total wrist arthroplasty compared with total wrist arthrodesis for rheumatoid arthritis. Plastic Reconstruct Surg. 2008;122(3):813-825.
  11. Ferreres A, Lluch A, Del Valle M. Universal total wrist arthroplasty: Mid-term follow-up study. J Hand Surg Am. 2011;36(6):967-973.
  12. Fischer P, Sagerfors M, Jakobsson H, Pettersson K. Total wrist arthroplasty: A 10-year follow-up. J Hand Surg Am. 2020;45(8):780.e1-780.e10.
  13. Froschauer SM, Zaussinger M, Hager D, et al. Re-motion total wrist arthroplasty: 39 non-rheumatoid cases with a mean follow-up of 7 years. J Hand Surg Eur Vol. 2019;44(9):946-950.
  14. Gauthier E, Truffandier MV, Gaisne E, Bellemère P. Treatment of scaphotrapeziotrapezoid osteoarthritis with the Pyrocardan® implant: Results with a minimum follow-up of 2 years. Hand Surg Rehabil. 2017;36(2):113-121.
  15. Gendera H, Chandrasegaram-Shanmuganathan S, Walbeehm R, Samijo S. Medium term outcomes of the Universal 2 total wrist arthroplasty in patients with degenerative or posttraumatic osteoarthritis of the wrist. Acta Orthop Belg. 2020;86(3):549-554.
  16. Gil JA, Kamal RN, Cone E, Weiss AC. High survivorship and few complications with cementless total wrist arthroplasty at a mean followup of 9 years. Clin Orthop Relat Res. 2017;475(12):3082-3087.
  17. Giwa L, Siddiqui A, Packer G. Motec wrist arthroplasty: 4 years of promising results. J Hand Surg Asian Pac Vol. 2018;23(3):364-368.
  18. Herzberg G, Boeckstyns M, Sorensen AI, et al. "Remotion" total wrist arthroplasty: Preliminary results of a prospective international multicenter study of 215 cases. J Wrist Surg. 2012;1(1):17-22.
  19. Herzberg G, Merlini L, Burnier M. Hemi-arthroplasty for distal radius fracture in the independent elderly. Orthop Traumatol Surg Res. 2017;103(6):915-918.
  20. Herzberg G, Walch A, Burnier M. Wrist hemiarthroplasty for irreparable DRF in the elderly. Eur J Orthop Surg Traumatol. 2018;28(8):1499-1503.
  21. Hinds RM, Capo JT, Rizzo M, et al. Total wrist arthroplasty versus wrist fusion: Utilization and complication rates as reported by ABOS part II candidates. Hand (N Y). 2017;12(4):376-381.
  22. Huish EG Jr, Lum Z, Bamberger HB, Trzeciak MA. Failure of wrist hemiarthroplasty. Hand (N Y). 2017;12(4):369-375.
  23. Karjalainen T, Pamilo K, Reito A. Implant failure after Motec wrist joint prosthesis due to failure of ball and socket-type articulation -- two patients with adverse reaction to metal debris and polyether ether ketone. J Hand Surg. 2018;43(11):1044.e1-1044.e4
  24. Laulan J, Marteau E, Bacle G. Wrist osteoarthritis. Orthop Traumatol Surg Res. 2015;101(1 Suppl):S1-S9.
  25. Lestienne V, Chaves C, Tanwin Y, et al. Results of interposition arthroplasty with the Amandys® pyrocarbon implant in rheumatoid wrist at a mean 5 years' follow-up. Hand Surg Rehabil. 2021 May 24 [Online ahead of print].
  26. Levadoux M, Legre R. Total wrist arthroplasty with Destot prostheses in patients with posttraumatic arthritis. J Hand Surg[Am], 28(3): 405-13 2003.
  27. Lin E, Paksima N. Total wrist arthroplasty. Bull Hosp Jt Dis (2013). 2017;75(1):9-14.
  28. Matsui Y, Minami A, Kondo M, et al. A minimum 5-year longitudinal study of a new total wrist arthroplasty in patients with rheumatoid arthritis. J Hand Surg Am. 2020;45(3):255.e1-255.e7.
  29. Melamed E, Marascalchi B, Hinds RM, et al. Trends in the utilization of total wrist arthroplasty versus wrist fusion for treatment of advanced wrist arthritis. J Wrist Surg. 2016;5(3):211-216.
  30. Meuli HC, Fernandez DL. Uncemented total wrist arthroplasty. J Hand Surg [Am]. 1995;20(1):115-122.
  31. National Institute for Clinical Excellence (NICE). Total wrist replacement.Interventional Procedure Guidance271. London, UK: NICE; August 2008.
  32. Nicoloff M. Total wrist arthroplasty -- indications and state of the art. Z Orthop Unfall. 2015;153(1):38-45
  33. Oslo University Hospital. Motec versus Remotion total wrist arthroplasty - A prospective study. ClinicalTrials.gov. Identifier NCT01842724. Bethesda, MD: National Library of Medicine; updated: November 28, 2018.
  34. Petscavage-Thomas JM, Gustas-French C, Walker EA, et al. Radiologic update on arthroplasties in the wrist and hand. Semin Musculoskelet Radiol. 2019;23(2):151-161.
  35. Politikou O, Giesen T, Reissner L, Calcagni M. Hand and wrist joint procedures in patients with scleroderma: A systematic review. J Hand Surg Eur Vol. 2019;44(4):402-407.
  36. Reigstad O, Røkkum M. Wrist arthroplasty using prosthesis as an alternative to arthrodesis: Design, outcomes and future. J Hand Surg Eur Vol. 2018;43(7):689-699.
  37. Schmidt I. Can total wrist arthroplasty be an option for treatment of highly comminuted distal radius fracture in selected patients? Preliminary experience with two cases. Case Rep Orthop. 2015;2015:380935.
  38. Slagel BE, Luenam S, Pichora DR. Management of post-traumatic malunion of fractures of the distal radius. Orthop Clin North Am. 2007;38(2):203-216.
  39. Terral TG, Freeland AE. Early salvage reconstruction of severe distal radius fractures. Clin Orthop. 1996;(327):147-151.
  40. Turner RG, Faber KJ, Athwal GS. Complications of distal radius fractures. Orthop Clin North Am. 2007;38(2):217-228.
  41. Wang B, Wu Q, Liu J, et al. What are the functional results, complications, and outcomes of using a custom unipolar wrist hemiarthroplasty for treatment of grade III giant cell tumors of the distal radius? Clin Orthop Relat Res. 2016;474(12):2583-2590.
  42. Weiss KE, Rodner CM. Osteoarthritis of the wrist. J Hand Surg. 2007;32A:725-746.
  43. Wollstein R, Carlson L. A minimal wrist arthroplasty for early wrist osteoarthritis. J Wrist Surg. 2013;2(2):176-179.
  44. Yeoh D, Tourret L. Total wrist arthroplasty: A systematic review of the evidence from the last five years. J Hand Surg Eur Vol. 2015;40(5):458-468.
  45. Zijlker HJA, Berkhout MJ, Ritt MJPF, et al. Universal 2 total wrist arthroplasty for the salvage of failed Biaxial total wrist arthroplasty. J Hand Surg Eur Vol. 2019b;44(6):614-619.
  46. Zijlker HJA, Ritt MJPF, IJsselstein CB. Long-term results of Universal 2 total wrist arthroplasty. J Wrist Surg. 2019a;8(4):317-320.

Joint replacement surgery in the wrist may be used to help patients who have painful wrist arthritis that does not respond to other treatments. During the surgery, the damaged parts of the wrist bones are removed and replaced with artificial components, called a prosthesis.

Joint replacement surgery of the wrist is less common than knee or hip replacement, but can be an option if you have painful arthritis that does not respond to other treatments.. On the hand side of the wrist, there are two rows of bones that connect the end of the forearm to the hand.. All forms of arthritis may affect the strength and motion of the wrist and result in limited use of the hand.. Currently available wrist joint replacement implants are much less robust than hip, knee, and shoulder replacement implants.. Most have two components, one for each side of the joint.. The component that inserts into the hand bones (the carpal component) has a flat surface that faces the first component.

Number: 0837

For members with significant conditions or co-morbidities, the risk/benefit of total shoulder arthroplasty, hemiarthroplasty, reverse shoulder arthroplasty, or shoulder arthroplasty revision or replacement should be appropriately addressed in the medical record.. Aetna considers total shoulder arthroplasty, shoulder hemiarthroplasty, reverse shoulder arthroplasty, and shoulder arthroplasty revision or replacement experimental and investigational for all other indications.. Table: Microfracturing of the shoulder, application of acellular dermal extracellular matrix - no specific code 23472Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder) [not covered for those who have an irreparable rotator cuff tear] Cage glenoid - no specific code0054TComputer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) 20985Computer-assisted surgical navigational procedure for musculoskeletal procedures, image-less763763D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; not requiring image postprocessing on an independent workstation763773D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality with image postprocessing under concurrent supervision; requiring image postprocessing on an independent workstation Custom joint prosthetics- no specific codeC1776Joint device (implantable)C40.00 - C40.02Malignant neoplasm of scapula and long bones of upper limb [malignancy of glenohumeral joint or surrounding soft tissue]C49.10 - C49.12Malignant neoplasm of connective and other soft tissue of upper limb, including shoulder [malignancy of glenohumeral joint or surrounding soft tissue]C76.40 - C76.42Malignant neoplasm of upper limb M05.00 - M05.9 Rheumatoid arthritisM12.511 - M12.519Traumatic arthropathy, shoulder M19.011 - M19.019Osteoarthrosis, localized, primary, shoulder region [not covered for those who have an irreparable rotator cuff tear] M19.111 - M19.119Post-traumatic osteoarthritis, shoulder M19.211 - M19.219 Osteoarthrosis, localized, secondary, shoulder region M24.811 - M24.819Other specific joint derangement of shoulder, not elsewhere classified [crepitus]M87.021 - M87.029Idiopathic aseptic necrosis of humerus [head]S42.001+ - S42.199+ [7th character K or P]Malunion or nonunion of fracture of shoulderS42.201+ - S42.496+Fracture of humerusM14.811 - M14.819Arthropathies in other specified diseases classified elsewhere, shoulder [ochronotic arthritis]M75.100 - M75.122Unspecified rotator cuff tear or rupture of unspecified shoulder, not specified as traumatic23472Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder) [reverse shoulder arthroplasty]0054TComputer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure)20985Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-lessC1776Joint device (implantable)C40.00 - C40.02Malignant neoplasm of scapula and long bones of upper limb [reconstruction after a tumor resection] C43.60 - C43.62, D03.60 - D03.63Malignant melanoma of skin of upper limb, including shoulder [reconstruction after a tumor resection]C44.601 - C44.609Unspecified malignant neoplasm of skin of lupper limb, including shoulder [reconstruction after a tumor resection]C49.10 - C49.12 Malignant neoplasm of connective and other soft tissue of upper limb, including shoulder [reconstruction after a tumor resection]C76.40 - C76.42Malignant neoplasm of upper limb [reconstruction after a tumor resection]M12.811 - M12.819Other specified arthropathies NEC, shoulder [glenohumeral arthropathy]M75.50 - M75.52Bursitis of shoulderM75.100 - M75.102Unspecified rotator cuff tear or rupture of shoulder, not specified as traumatic [rotator cuff syndrome]M75.110 - M75.112Incomplete rotator cuff tear or rupture of shoulder, not specified as traumatic M75.120 - M75.122Complete rotator cuff tear or rupture of shoulder, not specified as traumatic S42.201+ - S42.296+Fracture of upper end of humerus [not repairable or cannot be reconstructed with other techniques]Z96.611 - Z96.619Presence of artificial shoulder joint [failed hemiarthroplasty or failed total shoulder arthroplasty with failed rotator cuff that is nonrepairable]23470Arthroplasty, glenohumeral joint; hemiarthroplasty0054TComputer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) 20985Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-lessC1776Joint device (implantable)M05.00 - M05.9 Rheumatoid arthritis M12.511 - M12.519 Traumatic arthropathy, shoulder M19.011 - M19.019Osteoarthrosis, localized, primary, shoulder region M19.111 - M19.119Post-traumatic osteoarthritis, shoulder M19.211 - M19.219 Osteoarthrosis, localized, secondary, shoulder region M24.811 - M24.819 Other specific joint derangement of shoulder, not elsewhere classified [crepitus] M75.80 - M75.82Other shoulder lesions [Rotator cuff tear arthropathy with severe rotator cuff tearing]M87.021 - M87.029 Idiopathic aseptic necrosis of humerus [head] [without glenoid involvement]S42.001+ - S42.199+ [7th character K or P] Malunion or nonunion of fracture of shoulder S42.201+ - S42.496+Fracture of humerus23333Removal of foreign body, shoulder; deep (subfascial or intramuscular)23334Removal of prosthesis, includes debridement and synovectomy when performed; humeral or glenoid component23335Removal of prosthesis, includes debridement and synovectomy when performed; humeral and glenoid components (eg, total shoulder)23473 - 23474Revision of total shoulder arthroplasty, including allograft when performed; humeral and/or glenoid component0054TComputer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) 20985Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-lessC1776Joint device (implantable)M12.211 – M12.219Villonodular synovitis (pigmented), shoulderM65.111 – M65.119Other infective (teno)synovitis, shoulderM65.811 – M65.819Other synovitis and tenosynovitis, shoulderM67.311 – M67.319Transient synovitis, shoulderM97.31XA - M97.32XSPeriprosthetic fracture around internal prosthetic shoulder jointS43.001+ - S43.086Subluxation and dislocation of shoulder joint; anterior, posterior or inferiorT84.038+ - T84.039+Mechanical loosening of prosthetic joint [shoulder]T84.018+ - T84.019Broken internal joint prosthesis [shoulder] T84.038+ - T84.039+Mechanical loosening of other internal prosthetic joint [shoulder] T84.59x+Infection and inflammatory reaction due to other internal joint prosthesis [shoulder] 23800Arthrodesis, glenohumeral joint23802Arthrodesis, glenohumeral joint; with autogenous graft (includes obtaining graft)0054TComputer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) 20985Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-lessA15.0 - A19.9Tuberculous infectionA80.0 - A80.9Acute poliomyelitis [paralytic disorders of infancy]C40.00 - C40.02 Malignant neoplasm of scapula and long bones of upper limb [resection of tumor] [resection of tumor]C49.10 - C49.12Malignant neoplasm of connective and other soft tissue of upper limb, including shoulder [resection of tumor] [resection of tumor]G54.0Brachial plexus disorders [with flail shoulder]G80.0 - G80.9Cerebral palsy [paralytic disorders of infancy]M75.120 - M75.122Complete rotator cuff tear or rupture of shoulder, not specified as traumatic P11.4, P11.9, P14.2, P14.8 - P14.9 Other cranial and peripheral nerve injuries due to birth trauma [paralytic disorders of infancy]S43.001+ - S43.086Subluxation and dislocation of shoulder joint [recurrent]S43.421+ - S43.429+Sprain of rotator cuff capsuleZ96.611 - Z96.619Presence of artificial shoulder joint [failed total shoulder arthroplasty]A00.0 - B99.9Certain infectious and parasitic diseases [active infection of the joint, active systemic bacteremia or active skin infection] G20 - G21.9Parkinson's disease [rapidly progressive neurological disease] G56.80 - G56.83Other mononeuritis of upper limb [rapidly progressive neurological disease] G58.7Mononeuritis multiplex [rapidly progressive neurological disease] G61.0Guillain-Barre syndrome [rapidly progressive neurological disease] L08.0 - L08.9Other local infections of skin and subcutaneous tissue [active skin infection] T56.0X1A - T56.94xSToxic effect of metals T78.49xA - T78.49xSOther allergy [allergy to components of the implant (e.g., cobalt, chromium or alumina] Shoulder arthroplasty (also known as shoulder replacement surgery) was first carried out in the United States in the 1950s for the treatment of severe glenohumeral joint fractures.. A total of 7 studies with 238 patients were included.. Patients with advanced OA of the glenohumeral joint who underwent TSA were followed up for 2 years.. The authors concluded that although RTSA after failed ORIF has a higher rate of complications compared with acute RTSA, the revision and re-operation rate as well as clinical outcomes and shoulder function remained comparable.. The authors concluded that RTSA is a reasonable surgical option for irreparable rotator cuff repair without arthritis.. Studies that assessed the outcomes of RSA in patients with MIRCT without OA (with at least 2 years of follow-up) were included.. For these patients, there were statistically significant improvements in VAS, Simple Shoulder Test, and American Shoulder and Elbow Surgeons scores as compared with pre-operative values at long-term follow-up (p < 0.05 for all), without any significant change from short-term (mean of 2.3 years) to long-term (mean of 10.2 years) follow-up.. Reverse total shoulder arthroplasty is indicated for patients with glenohumeral arthritis and a poorly functioning rotator cuff.. There were no other significant differences in the other complications studied.. Ferlauto HR, Wickman JR, Lazarides AL, et al.. Reverse total shoulder arthroplasty versus hemiarthroplasty for proximal humeral fractures: A systematic review.. Total shoulder arthroplasty.

Number: 0888

Assessment of migration and wear of orthopedic implants (e.g., evaluation of the migration following total knee replacement and wear measurement for reverse total shoulder arthroplasty) Assessment of spinal fusion, spinal motion and disorders Evaluation of hip joint pathomechanics (e.g., femoro-acetabular impingement) Evaluation of stability after locked lateral plating of distal femur fractures Evaluation of stability in lateral calcaneal lengthening osteotomies Evaluation of stability of cervical disc arthroplasty Evaluation of sternal instability Evaluation of unicompartmental knee arthroplasty Evaluation of upper limb arthroplasty Measurement of implant displacement in the shoulder Measurement of knee joint kinematics Prediction of long-term outcome in total hip arthroplasty.. Fong et al (2011) conducted a study to design and evaluate a RSA marker insertion protocol to evaluate the stability of the bone-implant interface of a total ankle arthroplasty (TAA) prosthesis, and to validate that this marker insertion protocol can be combined with MBRSA technology to provide clinically adequate precision in assessing the micromotion of the TAA prosthesis.. They noted that this study demonstrated a reliable RSA marker insertion technique in both the tibia and talus and confirmed that the insertion and MBRSA technique allows the typical high precision demonstrated in other RSA studies (standard deviation less than or equal to 0.25 mm or 0.6 degrees).. The authors concluded that all patients had inducible micro-motions of the tibial component during step-cycle motion; RLLs and a high posterior slope increased the magnitude of inducible micro-motions suggesting that dynamic RSA is a valuable clinical tool for the evaluation of functional implant fixation.The authors stated that this study had drawbacks including small group size (n = 15), marginal group stratification, and multiple hypothesis testing, which increased the risk of type-I and type-II error.. These researchers therefore encourage the authors of the RSA studies included to assess their patient cohorts after 5 and 10 years, to provide adequate follow-up data, and given the predictive value of early migration in total knee and hip arthroplasty, RSA is an important tool in the development, introduction, and evaluation of orthopedic implants.. These researchers evaluated the precision of model-based RSA in TWAs measured in a phantom model and in patients; the number of bone markers necessary to ensure the precision; as well as the accuracy of model-based RSA in a phantom model.. The authors concluded that this was the first RSA for RTSA study, with results comparable to those validating the use of RSA for hip and knee arthroplasties (accepted as 0.05 to 0.50 mm and 0.15 to 1.15°), justifying the potential use of RSA as a tool for measuring implant displacement in the shoulder.. Table: CPT Codes / HCPCS Codes / ICD-10 Codes 0348TRadiologic examination, radiostereometric analysis (RSA); spine, (includes, cervical, thoracic and lumbosacral, when performed) 0349TRadiologic examination, radiostereometric analysis (RSA); upper extremity(ies), (includes shoulder, elbow and wrist, when performed) 0350TRadiologic examination, radiostereometric analysis (RSA); lower extremity(ies), (includes hip, proximal femur, knee and ankle, when performed) M25.851 - M25.859Other specified joint disorders, hip [femoro-acetabular impingement]M50.30 - M50.33Other cervical disc degenerationM53.2X3 - M53.2X5 Spinal instabilities [Sternal instability]M53.80 - M53.89Other specified dorsopathies [Spinal motion and disorders]S72.414 - S72.416Nondisplaced unspecified condyle fracture of lower end of femurS72.424 - S72.426Nondisplaced fracture of lateral condyle of femur S72.434 - S72.436Nondisplaced fracture of medial condyle of femur S72.444 - S72.446Nondisplaced fracture of lower epiphysis (separation) of femurS72.454 - S72.456Nondisplaced supracondylar fracture without intracondylar extension of lower end of femurS72.464 - S72.466Nondisplaced supracondylar fracture with intracondylar extension of lower end of femurT84.020A - T84.029SDislocation of internal joint prosthetics T84.060A - T84.069S Wear of articular bearing surface of internal prosthetic joint T84.110A - T84.498SMechanical complications of other internal fixation device Z47.1Aftercare following joint replacement surgeryZ96.651 - Z96.659Presence of artificial knee jointZ96.611 - Z96.619Presence of artificial shoulder joint Bottner F, Su E, Nestor B, et al. Radiostereometric analysis: The hip.

Number: 0287

Pain and functional disability that interferes with activities of daily living (ADLs) from injury due to osteoarthritis, rheumatoid arthritis, avascular necrosis, or post-traumatic arthritis of the hip joint; and Limited range of motion (ROM), antalgic gait, and pain in hip joint with passive ROM on physical examination: and Radiographic evidence of either of the following: Avascular necrosis (osteonecrosis) with stage III collapse of the femoral head; or Moderate/severe osteoarthritis or rheumatoid arthritis of the hip joint (Tonnis grade 2 or 3; see Appendix for Tonnis grading scale); and. Fracture of the femoral neck by imaging; or Malunion of acetabular, femoral head or proximal femur fracture with pain interfering with ADLs; or Nonunion by imaging or failure of previous hip fracture surgery; or Malignancy of the joint involving the bones or soft tissues of the pelvis or proximal femur by imaging; Anti-inflammatory medications or analgesics; and Flexibility and muscle strengthening exercises, and Activity modification; and Supervised physical therapy (in-person as opposed to home or virtual physical therapy; ADLs diminished despite completing a plan of care); and Assistive device use (required for persons with relative contraindications to joint replacement, optional for others); and Therapeutic injections into the hip (required for persons with relative contraindications to joint replacement, optional for others); or. Aseptic loosening of one or more prosthetic components confirmed by imaging, or Fracture or mechanical failure of 1 or more components of the prosthesis confirmed by imaging, or Confirmed periprosthetic infection confirmed by gram stain and culture, or Displaced periprosthetic fracture confirmed by imaging, or Progressive or substantial periprosthetic bone loss confirmed by imaging, or Bearing surface wear leading to symptomatic synovitis or local bone or soft tissue reaction, or Recurrent (2 or more) dislocations confirmed by imaging not responsive to a reasonable course of conservative management or irreducible dislocation confirmed by imaging; or Clinically significant leg length discrepancy; or Upon individual case review, persistent hip pain of unknown etiology not responsive to a period of non-surgical care for six (6) months, and the member does not have any of the following contraindications to total hip revision or replacement: Loss of musculature (in particular hip abductor musculature), neuromuscular compromise or vascular deficiency in the affected limb, rendering the procedure unjustifiable; or Osteoporosis or other osseous abnormalities which would make the likelihood of a poor outcome more probable; or Poor skin coverage; or Severe instability due to anatomic causes that would make the likelihood of a poor surgical outcome more probable.. Minimal incision or minimally invasive THA an acceptable alternative to conventional THA; FDA-approved custom-made implant for Paprosky type III acetabular defects where the feature of the defect cannot be handled with standard implants, and member meets criteria for revision total hip arthroplasty listed above; Prophylactic use of tranexamic acid in total hip arthroplasty to decrease blood loss.. Measurement of synovial C-reactive protein, and the alpha-defensin test (Synovasure) as a marker for peri-prosthetic infection in THA; Obturator nerve blocks for management of post-operative pain following THA Computer-assisted surgical navigation (e.g., MAKOplasty/MAKO Tactile Guidance System) for total hip replacement because there is a lack of reliable evidence that it improves clinical outcomes of total hip arthroplasty.. Table: 27130Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft [minimally invasive or conventional approach]27132Conversion of previous hip surgery to total hip arthroplasty, with or without autograft or allograft [minimally invasive or conventional approach]0054TComputer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) [MAKOplasty/MAKO Tactile Guidance System]20985Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-less64450Injection, anesthetic agent; other peripheral nerve or branch [obturator nerve blocks]86140 - 86141 C-reactive protein [as a marker for peri-prosthetic infection]C1776Joint device (implantable)C40.20 - C40.22Malignant neoplasm of long bones of lower limb [proximal femur]C79.51Secondary malignant neoplasm of bone [proximal femur]M05.00 - M14.89Rheumatoid arthritis M12.551 - M12.559Traumatic arthropathy, hipM16.0 - M16.9Osteoarthritis of hipM24.851,M24.852,M24.859Other specific joint derangements of hip, not elsewhere classified [Paprosky type III acetabular defects]M80.051+ - M80.059+, M80.851+ - M80.859+, M84.451+ - M84.453+, M84.459+, M84.551+ - M84.559+, M84.651+ - M84.659+Pathologic fracture of neck of femur (hip)M84.750+ - M84.759+Atypical femoral fractureM85.651- M85.659Other cyst of bone, thigh [cyst femoral head]M87.00, M87.10, M87.20, M87.30, M87.80, M87.9, M90.50Osteonecrosis of bone, site unspecifiedM87.051 - M87.059, M87.151 - M87.159, M87.251 - M87.255, M87.351 - M87.353, M87.851 - M87.859, M90.551 - M90.559Osteonecrosis of femurM97.01x+ - M97.02x+Periprosthetic fracture around internal prosthetic hip jointS32.411+ - S32.9xx+Fracture of acetabulum, closed and openS72.001+ - S72.26x+Fracture of head and neck of femurT84.010 - T84.011, T84.020 - T84.021, T84.030 - T84.031, T84.050 - T84.051, T84.060 - T84.061, T84.090 - T84.091Mechanical complication of internal orthopedic device, implant, and graftZ96.641 - Z96.649Presence of artificial hip jointA00.0 - B99Infectious and parasitic diseases [active infection of the joint, active systemic bacteremia or active skin infection]G82.20 - G82.54 Paraplegia (paraparesis) and quadriplegia (quadriparesis)M00.051 - M00.059, M00.151 - M00.159, M00.251 - M00.259, M00.851 - M00.859, M00.9 Pyogenic arthritis involving pelvic region and thighM01.X51 - M01.X59Direct infection of hip in infection and parasitic diseases classified elsewhereM62.81Muscle weakness (generalized) [permanent or irreversible muscle weakness preventing ambulation in the absence of painR62.50, R62.59 Lack of expected normal physiological development in childhood [skeletal immaturity]S71.001+ - S71.159Open wound of hip and thighT56.2x1+ - T56.2x4+Toxic effect of chromium and its compounds [not covered for metallosis alone without evidence of loosening or malposition]T56.811+ - T56.894Toxic effect of other metals [not covered for metallosis alone without evidence of loosening or malposition]T78.40x+Allergy, unspecified27125Hemiarthroplasty, hip, partial (eg, femoral stem prosthesis, bipolar arthroplasty) [Revision of resurfacing arthroplasty]27130Arthroplasty, acetabular and proximal femoral prosthetic replacement (total hip arthroplasty), with or without autograft or allograft [revision of resurfacing arthroplasty]27134 - 27138Revision of total hip arthroplasty; with or without autograft or allograft0054TComputer-assisted musculoskeletal surgical navigation orthopedic procedure, with image-guidance based on fluoroscopic images0055TComputer-assisted musculoskeletal surgical navigational orthopedic procedure, with image-guidance based on CT/MRI images (List separately in addition to code for primary procedure) [MAKOplasty/MAKO Tactile Guidance System]20985Computer-assisted surgical navigation procedure for musculoskeletal procedures, image-less64450Injection, anesthetic agent; other peripheral nerve or branch [obturator nerve blocks]C1776Joint device (implantable)S2118Metal-on-metal total hip resurfacing, including acetabular and femoral componentsT84.010+ - T84.099Mechanical complication of internal joint prosthesisT84.50x+ - T84.59x+Infection and inflammatory reaction due to internal joint prosthesisT84.51xA - T84.52xSInfection and inflammatory reaction due to internal hip prosthesis Portable Accelerometer-Based Navigation System- no specific code Z96.641 - Z96.649Presence of artificial hip joint Previously, most total hip prostheses utilize an acetabular cup either lined with polyethylene or composed entirely of polyethylene articulating against a cobalt-chromium-molybdenum (CoCr) or ceramic femoral head.. There is no adequate evidence that metal-on-metal or ceramic-on-ceramic total hip implants offer clinically significant benefits over standard metal-on-polyethylene hip implants for older patients.. A technology assessment of hip implants by the Institute for Clinical Effectiveness and Health Policy (Augustovsky et al, 2006) found that the clinical trials comparing ceramic against conventional prostheses found no significant differences in the revision rate among the different types of prostheses.. In a meta-analysis, Smith and colleagues (2010) compared the clinical and radiological outcomes and complication rates of hip resurfacing (HRS) and total hip arthroplasty (THA).. An UpToDate review on "Total hip arthroplasty" (Erens et al, 2014) states that: "Contraindications -- Total hip arthroplasty (THA) should not be undertaken in a number of clinical settings, including:. Patients underwent 29 revision total knee arthroplasties (TKAs) and 11 revision THAs; 12 patients had a confirmed PJI based on Musculo-Skeletal Infection Society (MSIS) criteria, and 28 patients were considered aseptic.. the meta-analysis indicated that there were no significant differences in the 2 groups in terms of total blood loss ([mean difference (MD) = -14.74, 95 % CI: -89.21 to 59.74, p = 0.7], transfusion rates [RD = -0.02, 95 % CI: -0.05 to 0.02, p = 0.39]; no significant differences were found regarding the incidence of adverse effects (AEs) such as DVT [RD = 0.00, 95 % CI: -0.01 to 0.01, p = 1.00], PE [RD = 0.00, 95 % CI: -0.01 to 0.01, p = 0.71], or wound infection [RD = -0.01, 95 % CI: -0.06 to 0.04, p = 0.66]).. A Veteran's Health Administration assessment (VHA, 2014) found evidence for use of TXA in patients undergoing total knee arthroplasty and total hip arthroplasty.. Froschen FS, Randau TM, Hischebeth GTR, et al. Mid-term results after revision total hip arthroplasty with custom-made acetabular implants in patients with Paprosky III acetabular bone loss.. The clinical and radiological outcomes of hip resurfacing versus total hip arthroplasty: A meta-analysis and systematic review.

Number: 0399

Aetna considers myoelectric upper limb prostheses and hand prostheses (e.g., the Dynamic Mode Control hand, the i-LIMB, the Liberty Mutual Boston Elbow prosthetic device, the LTI Boston Digital Arm System, the Ottobock bebionic hand, the OttoBock System Electrohand, and the Utah Elbow System) medically necessary for members with traumatic amputation or congenital absence of upper limb at the wrist or above (e.g., forearm or elbow) when the following criteria are met:. Aetna considers implantable myoelectric sensors for upper limb prostheses and hand prostheses experimental and investigational because their effectiveness has not been established.. Myoelectric utilizes muscle activity from the residual limb for control of joint movement.. Myoelectric hand prostheses provide improved function and range of functional position as compared to “hook” prostheses.. Partial-hand myoelectric prostheses are designed to replace the function of digits in individuals missing 1 or more fingers as a result of a partial-hand amputation.. Implantable wireless EMG systems improve control by recording signals directly from muscle, compared with surface EMG.. Table: CPT Codes / HCPCS Codes / ICD-10 Codes24900 - 24935, 25900 - 25931, 26910 - 26952Surgical amputation, upper extremity Prosthetic sheaths/socks, including a gel cushion layer, replacement liners and socket inserts for upper limb - no specific code L6000Partial hand, thumb remainingL6010Partial hand, little and/or ring finger remainingL6020Partial hand, no finger remainingL6050Wrist disarticulation, molded socket, flexible elbow hinges, triceps padL6055Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps padL6100Below elbow, molded socket, flexible elbow hinge, triceps padL6110Below elbow, molded socket, (muenster or northwestern suspension types)L6120Below elbow, molded double wall split socket, step-up hinges, half cuffL6130Below elbow, molded double wall split socket, stump activated locking hinge, half cuffL6200Elbow disarticulation, molded socket, outside locking hinge, forearmL6205Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearmL6250Above elbow, molded double wall socket, internal locking elbow, forearmL6300Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearmL6310Shoulder disarticulation, passive restoration (complete prosthesis)L6320Shoulder disarticulation, passive restoration (shoulder cap only)L6629Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equalL6632Upper extremity addition, latex suspension sleeve, eachL6680Upper extremity addition, test socket, wrist disarticulation or below elbowL6687Upper extremity addition, frame type socket, below elbow or wrist disarticulationL6703Terminal device, passive hand/mitt, any material, any sizeL6704Terminal device, sport/recreational/work attachment, any material, any sizeL6706Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlinedL6707Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlinedL6708Terminal device, hand, mechanical, voluntary opening, any material, any sizeL6709Terminal device, hand, mechanical, voluntary closing, any material, any sizeL6711Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatricL6712Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatricL6713Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatricL6714Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatricL6715Terminal device, multiple articulating digit, includes motor(s), initial issue or replacementL6721Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlinedL6722Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlinedL6810Addition to terminal device, precision pinch deviceL6880Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)L6882Microprocessor control feature, addition to upper limb prosthetic terminal deviceL6890Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustmentL6925Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceL6935Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceL6945Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceL6955Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceL6965Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceL6975Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal deviceL7007 - L7008Electric hand, switch or myoelectric controlled, adult or pediatricL7009, L7045Electric hook, switch or myoelectric controlled, adult or pediatricL7190 - L7191Electronic elbow, variety village or equal, myoelectronically controlled, adolescent or childL7259Electronic wrist rotator, any type L7368Lithium ion battery charger L7400Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)L7403Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic materialL8465Prosthetic shrinker, upper limb, eachL6026Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s) L7360Six volt battery, eachL7362Battery charger, six volt, eachL7364Twelve volt battery, eachL7366Battery charger, twelve volt, eachL7367Lithium ion battery, rechargeable, replacementL7368Lithium ion battery charger, replacement onlyQ71.00 - Q71.53Q71.811 - Q71.93Reduction defects of upper limbS48.011+ - S48.929+Traumatic amputation of shoulder and upper armS58.011+ - S58.929+Traumatic amputation of elbow and forearmS68.411+ - S68.429+,S68.711+ - S68.729+Traumatic amputation of handS48.911+, S48.921+,S58.911+, S58.921+[S48.912+, S48.922+, S58.912+, S58.922+ also required]Traumatic amputation of shoulder and upper arm and forearm, level unspecified (complete) (partial), bilateral Z89.011 - Z89.239Acquired absence of upper limbG00 - G99Diseases of nervous system [neuromuscular disease that interferes with prosthesis function]T87.31Neuroma of amputation stump, right upper extremityT87.32Neuroma of amputation stump, left upper extremity Abi-Rafeh J, ElHawary H, Azzi AJ, Thibaudeau S. Pyrocarbon arthroplasty implants in the upper extremity: A systematic review of outcomes and pooled analysis of complications.. Myoelectric prostheses.. Targeted muscle reinnervation for improved control of myoelectric upper limb prostheses.

Number: 0204

On physical examination, patients with a frozen shoulder will have at least a 50 % reduction in both active and passive range of motion (ROM) compared with the unaffected shoulder (Anderson, 2008).. In a Cochrane review, Green et al (2000) examined the effectiveness of common interventions for shoulder pain.. The ROM improved in all patients over the 6 months, but was not significantly different between the groups.. Kivimäki and colleagues (2007) examined the effect of MUA in patients with frozen shoulder.. Manipulation under anesthesia is indicated in total knee arthroplasty having less than 90 degrees ROM 4 to 12 weeks following surgery, with no progression or regression in ROM (Pariente et al, 2006; Magit,et al, 2007).. Frozen shoulder.. Chronic cervical spine pain treated with manipulation under anesthesia.. Manipulation under anaesthesia for the treatment of frozen shoulder.. Manipulation for cervical spinal dislocation under general anaesthesia: Serial review for 4 years.

For those who suffer from advanced arthritis, wrist arthroplasty allows damaged components of the wrist bone to be replaced and offers a new lease on life.

But this is only one cause of wrist pain.. There are many treatments including wrist arthroplasty that can help you regain normal function.. It contains 8 small carpal bones and the end of the radius which is the forearm bone above the thumb.. The scaphoid bone is the carpal bone near the base of your thumb.. Wrist pain can result from disease or injury .. When you have a fracture, the pain is often intense and prevents you from moving your hand, wrist, or thumb.. Medical problems, often called repetitive motion injury, include tendon and nerve disorders.. This allows for an increased understanding of your pain and how much you can move your wrist.. The procedure may release a ligament or other tissue that is pressing on a nerve and causing pain.. This surgical procedure replaces the diseased or damaged wrist joint with an artificial joint.. The surgeon may place a cast on your arm after the surgery.. This involves moving your operative hand up and down using your other hand.. As hand specialists, we treat the hand, wrist, fingers, elbow, thumb pain and other problems.

Number: 0710

Defining lithium response dimensions in bipolar disorders Detection of seizures during sleep Diagnosis of hypertension Diagnosis of sleep disorders (e.g., central disorders of hypersomnolence, insomnia, periodic limb movements of sleep, sleep-disordered breathing, and sleep-wake disturbance) Evaluation of depression Evaluation of disruptive mood dysregulation disorder Evaluation of motor fluctuations in persons with Parkinson's disease Evaluation of post-traumatic stress disorder Evaluation of schizophrenia Improving walking ability and quality of life (QOL) in individuals with intermittent claudication (IC) In the setting of opioid detoxification Monitoring of treatment response to interventions for sleep and circadian rhythm dysfunction associated with depression Screening for idiopathic rapid eye movement (REM) sleep behavior disorder.. Evaluating functional ability in the elderly Differential diagnosis of tremor syndromes Evaluating sleep disturbances in Parkinson’s disease Gait analysis in persons with hip osteoarthritis Improving walking ability and QOL in individuals with IC Measuring disease activity in children with eczema Monitoring of physical activity during rehabilitation of persons with stroke Monitoring of physical activity in critically ill persons; and after stroke Monitoring of physical motion and muscle activity to quantify kinematics of movement disorder symptoms (e.g., tremor).. Data may be expressed graphically as actograms or reported numerically as total activity counts per epoch, thereby estimating sleep latency, total sleep time, number and frequency of awakenings, and “sleep efficiency.” The Actiwatch has been proposed as a diagnostic parameter for a number of sleep disorders including insomnia, restless legs syndrome/periodic limb movement disorder, circadian-rhythm disorders, and sleep apnea.. The authors stated the pitfalls of actigraphy testing are: validity has not been established for all scoring algorithms or devices, or for all clinical groups; actigraphy is not sufficient for diagnosis of sleep disorders in individuals with motor disorders or high motility during sleep; and the use of computer scoring algorithms without controlling for potential artifacts can lead to inaccurate and misleading results.. In a review on ambulatory monitoring of sleep disorders, Tahmasian et al (2010) noted that actigraphy can not stand alone as a diagnostic tool for all clinical groups; especially so with those diagnosed with sleep disorders with significant motility or long catatonic periods of wakefulness during sleep.. These researchers analyzed data from 2,148 participants of the Sueno Sleep Ancillary Study of the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), who underwent 1 week of wrist actigraphy to characterize sleep duration, sleep efficiency, sleep fragmentation index, and day-time naps.. A total of 21 youths (mean age ± standard deviation, 11.7 ± 3 years) wore a wrist actigraph for 9 consecutive days (including both school days and non-school days), to measure sleep parameters: sleep latency, sleep efficiency and the number and duration of periods of wakefulness after sleep onset (WASO).. A total of 70 patients diagnosed with sleep disorders causing different motor manifestations during sleep (iRBD, sleep apnea, restless legs syndrome) and 20 subjects without any relevant motor manifestation during sleep, underwent video-polysomnography (vPSG) and 2 weeks of actigraphy, completed 6 validated RBD screening questionnaires, and sleep apps use was assessed.. (Conditional) We suggest that clinicians use actigraphy integrated with home sleep apnea test devices to estimate total sleep time during recording (in the absence of alternative objective measurements of total sleep time) in adult patients suspected of sleep-disordered breathing.. Table: CPT Codes / HCPCS Codes / ICD-10 Codes0381TExternal heart rate and 3-axis accelerometer data recording up to 14 days to assess changes in heart rate and to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional0382T review and interpretation only0383TExternal heart rate and 3-axis accelerometer data recording from 15 to 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional.0384T review and interpretation only0385TExternal heart rate and 3-axis accelerometer data recording more than 30 days to assess changes in heart rate to monitor motion analysis for the purposes of diagnosing nocturnal epilepsy seizure events; includes report, scanning analysis with report, review and interpretation by a physician or other qualified health care professional 0386T review and interpretation only0533T - 0536TContinuous recording of movement disorder symptoms95803Actigraphy testing, recording, analysis, interpretation and report (minimum of 72 hours to 14 consecutive days of recording)F11.20 - F11.29Opioid dependenceF20.0 - F23Schizophrenia, schizotypal disorder, delusional disorders and brief psychotic disorderF31.10 – F31.9Bipolar disorderF32.0 – F33.9Major depressive disorder, single and recurrentF34.81Disruptive mood dysregulation disorderF43.10 - F43.12Post-traumatic stress disorderG20 Parkinson's disease G21.0 - G21.9Secondary ParkinsonismG25.0 - G25.2Essential and other specified forms of tremorG40.001 - G40.919Epilepsy and recurrent seizuresG47.00 - G47.9Sleep disordersI10 - I16.9Hypertensive diseasesI63.00 - I63.9Cerebral infarctionI69.00 - I69.998Sequelae of cerebrovascular disease [monitoring physical ability after stroke]I70.211 – I70.219Atherosclerosis of native arteries of extremities with intermittent claudicationI70.311 – I70.319Atherosclerosis of unspecified type of bypass graft(s) of the extremities with intermittent claudicationI70.411 – I70.419Atherosclerosis of autologous vein bypass graft(s) of the extremities with intermittent claudicationI70.51Atherosclerosis of nonautologous biological bypass graft(s) of the extremities intermittent claudicationI70.611 – I70.619Atherosclerosis of nonbiological bypass graft(s) of the extremities with intermittent claudicationI70.71Atherosclerosis of other type of bypass graft(s) of the extremities with intermittent claudicationL23.0 - L25.9Contact dermatitisM15.3Secondary multiple arthritis M15.4Erosive (osteo)arthritisM15.8Other polyosteoarthritisM16.0 - M16.12Primary osteoarthritis of hipM16.2 - M16.9Osteoarthritis of hip [secondary and unspecified]R25.1Tremor, unspecifiedR56.00 - R59.9Convulsions, not elsewhere classifiedZ04.8Encounter for examination and observation for other specified reasons [diagnosis of central disorders of hypersomnolence, insomnia, and sleep-disordered breathing]Z79.8Other long term (current) drug therapy [not covered for defining lithium response dimensions in bipolar disorders] Acebo C, LeBourgeois MK.

Introduction knee replacement kr is a clinically proven procedure typically offered to patients with severe knee osteoarthritis oa to relieve

Introduction Knee replacement (KR) is a clinically proven procedure typically offered to patients with severe knee osteoarthritis (OA) to relieve pain and improve quality of life.. PubMed Journals helped people follow the latest biomedical literature by making it easier to find and follow journals, browse new articles, and included a Journal News Feed to track new arrivals news links, trending articles and important article updates.. The cost-effectiveness of total joint replacement procedures has been broadly studied; however, there is a compelling need to improve beyond the value afforded by off-the-shelf knee implants.. The Journal of Arthroplasty brings together the clinical and scientific foundations for joint replacement.This peer-reviewed journal publishes original research and manuscripts of the highest quality from all areas relating to joint replacement or the treatment of its complications, including those dealing with clinical series and experience, prosthetic design, biomechanics, ..... Aetna considers any of the following injections or procedure medically necessary for the treatment of back pain; provided that only one invasive modality or procedure will be considered medically necessary at a time.. Facet joint injections.. Knee replacement, also known as knee arthroplasty, is a surgical procedure to replace the weight-bearing surfaces of the knee joint to relieve pain and disability, most commonly offered when joint pain is not diminished by conservative sources and also for other knee diseases such as rheumatoid arthritis and psoriatic arthritis.In patients with severe deformity from advanced ..... The American Journal of Surgery (R) is a peer-reviewed journal which features the best surgical science focusing on clinical care; translational, health services, and qualitative research, surgical education, leadership, diversity and inclusion, and other domains of surgery.. Original research studies that can improve decision making in clinical medicine, public health, health care policy, medical education, or biomedical research.. The Archives of Physical Medicine and Rehabilitation publishes original, peer-reviewed research and clinical reports on important trends and developments in physical medicine and rehabilitation and related fields.This international journal brings researchers and clinicians authoritative information on the therapeutic utilization of physical, behavioral and ..... Patel NK, Hadley CJ, Leite S, Brahmabhatt S, Mazur D, Parvizi J, Ciccotti MG. Knee Arthroplasty with Prior Ligamentous Knee Surgery: A Matched Case-Control Study... Intermittent urinary catheters: catheter selection:- For patients performing intermittent self-catheterisation over the long term, what is the clinical and cost effectiveness of single-use non-coated versus single-use hydrophilic versus single-use gel reservoir versus reusable non-coated catheters with regard to the following outcomes ....

Osteoarthritis (OA) is common in weight-bearing joints. Although the wrist is not such a joint, OA of the wrist is not an uncommon presentation encountered by orthopedic surgeons in day-to-day practice.

Ulnar-head resection is commonly performed in RA because the distal radioulnar joint is more often involved in RA than in OA of the wrist.. Patients with lunate-triquetrum joint arthritis usually have ulnar wrist pain.. Total wrist fusion (TWF) is indicated in patients with pancarpal arthritis and is a successful option in patients with OA of the wrist from any cause (see images below).. The results after total wrist arthroplasty are improving as new implants are developed.. Wrist arthroplasty in rheumatoid arthritis of the wrist.. This is a novel procedure for radiocarpal arthritis, during which previously partial fusion or proximal row carpectomy is performed.. Bone Joint J .. Promising clinical results of the universal total wrist prosthesis in rheumatoid arthritis.. Rheumatoid arthritis of the wrist.. Wrist arthroplasty in rheumatoid arthritis of the wrist.

Policy Attachment Attachment to Policy # 12.01.01ba Attachment: A Policy #: 12.01.01ba Description: Experimental/Investigational Services Represented by a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code. Title: Experimental/Investigational Services EXPERIMENTAL/INVESTIGATIONAL SERVICES REPRESENTED BY A SPECIFIC CPT/HCPCS CODE This list is not all-inclusive and may not include services that were identified after the date of the policy. These services will be subject to review under the policy. Additions and deletions will be made as changes occur or if the experimental/investigational status of a service changes. The following list does not include those services that are sometimes covered based on criteria. More specific medical policies may be applicable. CPT CODES CodeEffective Date of E/I Coverage Position 1910501/01/2007 2098301/01/2015 2258601/01/2013​3046801/01/2021​ 3164701/27/2020 3165101/27/2020 3327401/01/2019 3328901/01/2019 4320601/01/2013 4694801/01/2020 5385501/01/2010 5386001/01/2011​5588001/01/2021​​57465​01/01/2021 5867401/01/2017 6228004/01/2018 6228104/01/2018 6228204/01/2018 6229101/01/2017 6229204/01/2018 6440510/01/2015 6445401/01/2020 6462401/01/2020 ​​64625​​01/01/20216463201/01/2019 6464001/01/2019 6491201/01/2018 6491301/01/2018 7760501/01/2017 8150612/28/2011 8217211/01/2016 8277701/01/2013 8300612/28/2011 8369510/01/2016 8369804/01/2015 8370010/01/2016 8370110/01/2016 8370401/01/2016 8372201/01/2019 8615201/01/2013 8615301/01/2013 8630501/01/2010 8635711/01/2016 8667711/01/2016 8762301/01/2015 8837501/01/2013 9087501/01/1997 9087601/01/1997 9111201/01/2014 9111701/01/2011 9113201/01/2001 9113301/01/2001 9214501/01/2015 9254807/18/2017 9254901/01/2020 9305001/01/2016 9326401/01/2019 9335601/01/2020 9359001/01/2017 9359101/01/2017 9359201/01/2017 9389501/01/2015 9693101/01/2016 9693201/01/2016 9693301/01/2016 9693401/01/2016 9693501/01/2016 9693601/01/2016 Code​Effective Date of E/I Coverage Position 0010M 07/01/2015 ​0015M​10/01/2020 0198T01/01/2009 ​​0200T01/01/2021​​0201T​01/01/20210202T07/01/2009 0207T01/01/2010​0213T​01/01/2021​0214T​​01/01/2021​0215T​01/01/2021​​0216T​​01/01/2021​0217T​01/01/2021​​0218T​​01/01/2021 0219T01/01/2010 0220T01/01/2010 0221T01/01/2010 0222T01/01/2010 0263T07/01/2011 0264T07/01/2011 0265T07/01/2011 0266T07/01/2011 0267T07/01/2011 0268T07/01/2011 0269T07/01/2011 0270T07/01/2011 0271T07/01/2011 0272T07/01/2011 0273T07/01/2011 0278T01/01/2012 0290T01/01/2012 0329T07/01/2013 0330T07/01/2013 0331T07/01/2013 0332T07/01/2013 0333T07/01/2018 0335T01/01/2014 0338T01/01/2014 0339T01/01/2014 0347T07/01/2014 0348T07/01/2014 0349T07/01/2014 0350T07/01/2014 0351T07/01/2014 0352T07/01/2014 0353T07/01/2014 0354T07/01/2014 0356T07/01/2014 0358T07/01/2014 0378T01/01/2015 0379T01/01/2015 0404T01/01/2016 0408T01/01/2016 0409T01/01/2016 0410T01/01/2016 0411T01/01/2016 0412T01/01/2016 0413T01/01/2016 0414T01/01/2016 0415T01/01/2016 0416T01/01/2016 0417T01/01/2016 0418T01/01/2016 0419T01/01/2016 0420T01/01/2016 0422T01/01/2016 0423T01/01/2016 0424T01/01/2016 0425T01/01/2016 0426T01/01/2016 0427T01/01/2016 0428T01/01/2016 0429T01/01/2016 0430T01/01/2016 0431T01/01/2016 0432T01/01/2016 0433T01/01/2016 0434T01/01/2016 0435T01/01/2016 0436T01/01/2016 0437T07/01/2016 0440T07/01/2016 0441T07/01/2016 0442T07/01/2016 0443T07/01/2016 0444T07/01/2016 0445T07/01/2016 0451T01/01/2017 0452T01/01/2017 0453T01/01/2017 0454T01/01/2017 0455T01/01/2017 0456T01/01/2017 0457T01/01/2017 0458T01/01/2017 0459T01/01/2017 0460T01/01/2017 0461T01/01/2017 0462T01/01/2017 0463T01/01/2017 0464T01/01/2017 0465T01/01/2017 0470T07/01/2017 0471T07/01/2017 0475T07/01/2017 0476T07/01/2017 0477T07/01/2017 0478T07/01/2017 0483T01/01/2018 0484T01/01/2018 0485T01/01/2018 0486T01/01/2018 0487T01/01/2018 0489T01/01/2018 0490T01/01/2018 0491T01/01/2018 0492T01/01/2018 0493T01/01/2018 0499T01/01/2018 0506T07/01/2018 0507T07/01/2018 0511T01/01/2019 0512T01/01/2019 0513T01/01/2019 0514T01/01/2019 0515T01/01/2019 0516T01/01/2019 0517T01/01/2019 0519T01/01/2019 0520T01/01/2019 0521T01/01/2019 0522T01/01/2019 0523T01/01/2019 0525T01/01/2019 0526T01/01/2019 0527T01/01/2019 0528T01/01/2019 0529T01/01/2019 0533T01/01/2019 0534T01/01/2019 0535T01/01/2019 0536T01/01/2019 0541T01/01/2019 0542T01/01/2019 0543T07/01/2019 0544T07/01/2019 0545T07/01/2019 0546T07/01/2019 0547T07/01/2019 0548T07/01/2019 0549T07/01/2019 0553T07/01/2019 0559T07/01/2019 0560T07/01/2019 0561T07/01/2019 0562T07/01/2019 0563T01/01/2020 0567T01/01/2020 0568T01/01/2020 0571T01/01/2020 0572T01/01/2020 0574T01/01/2020 0575T01/01/2020 0576T01/01/2020 0577T01/01/2020 0578T01/01/2020 0579T01/01/2020 0581T01/01/2020 0582T01/01/2020 0583T01/01/2020 0587T01/01/2020 0589T01/01/2020 0590T01/01/2020 0594T07/01/2020 0596T07/01/2020 0597T07/01/2020 0598T07/01/2020 0599T07/01/2020 0600T07/01/2020 0601T07/01/2020 0602T07/01/2020 0603T07/01/2020 0604T07/01/2020 0605T07/01/2020 0606T07/01/2020 0607T07/01/2020 0608T07/01/2020 0609T07/01/2020 0610T07/01/2020 0611T07/01/2020 0612T07/01/2020 0613T07/01/2020 0614T07/01/2020 0615T07/01/2020 0616T07/01/2020 0617T07/01/2020 0618T07/01/2020 0619T07/01/2020​0620T01/01/2021​0621T​01/01/2021​0622T01/01/2021​​0623T​01/01/2021​0624T​01/01/2021​0625T01/01/2021​​0626T01/01/2021​​0627T01/01/2021​​0628T01/01/2021​​0629T01/01/2021​​0630T01/01/2021​​0631T01/01/2021​​0632T​01/01/2021​0633T01/01/2021​​0634T01/01/2021​​0635T01/01/2021​​0636T01/01/2021​​0637T01/01/2021​0638T​01/01/2021​​0639T​01/01/2021 0021U10/01/2017 0024U01/01/2018 0025U01/01/2018 0043U 04/01/2018 0044U 04/01/2018 0052U 07/01/2018 0061U 07/01/2018 0062U 10/01/2018 0063U 10/01/2018 0066U 10/01/2018 0080U 01/01/2019 0083U 01/01/2019 0092U07/01/2019 0095U07/01/2019 0105U10/01/2019 0106U10/01/2019 0107U10/01/2019 0108U10/01/2019 0119U10/01/2019 0121U10/01/2019 0122U10/01/2019 0123U10/01/2019 0139U01/01/2020 0165U04/01/2020 0167U04/01/2020 0174U07/01/2020 0176U07/01/2020 0178U07/01/2020​0206U​10/01/2020​0207U10/01/2020​​0243U04/01/2021​​0247U​04/01/2021 HCPCS CODES CodeNarrativeEffective Date of E/I Coverage Position A4563Rectal control system for vaginal insertion, for long term use, includes pump and all supplies and accessories, any type each01/01/2019 A4639Replacement pad for infrared heating pad system, each01/01/2003 A6000Noncontact wound-warming wound cover for use with the noncontact wound-warming device and warming card01/01/2002​C1062​Intravertebral body fracture augmentation with implant (e.g., metal, polymer)​01/01/2021 C1734Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)01/01/2020 C1748Endoscope, single-use (i.e. disposable), upper gi, imaging/illumination device (insertable)07/01/2020​C1825​Generator, neurostimulator (implantable), non-rechargeable with carotid sinus baroreceptor stimulation lead(s)​01/01/2021 C1886Catheter extravascular tissue ablation, any modality, (insertable)01/01/2012 C1824Generator, cardiac contractility modulation (implantable)01/01/2020 C1839Iris prosthesis01/01/2020 C1982Catheter, pressure-generating, one-way valve, intermittently occlusive01/01/2020 C2624Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system components01/01/2015 C8937Computer-aided detection, including computer algorithm analysis of breast mri image data for lesion detection/characterization, pharmacokinetic analysis, with further physician review for interpretation (list separately in addition to code for primary procedure)01/01/2019 C9752Destruction of intraosseous basivertebral nerve, first two vertebral bodies, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum01/01/2019 C9753Destruction of intraosseous basivertebral nerve, each additional vertebral body, including imaging guidance (e.g., fluoroscopy), lumbar/sacrum (list separately in addition to code for primary procedure)01/01/2019 C9756Intraoperative near-infrared fluorescence lymphatic mapping of lymph node(s) (sentinel or tumor draining) with administration of indocyanine green (ICG) (List separately in addition to code for primary procedure)07/01/2019​C9757​Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and excision of herniated intervertebral disc, and repair of annular defect with implantation of bone anchored annular closure device, including annular defect measurement, alignment and sizing assessment, and image guidance; 1 interspace, lumbar​07/12/2021 C9758Blinded procedure for nyha class iii/iv heart failure; transcatheter implantation of interatrial shunt or placebo control, including right heart catheterization, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study01/01/2020 C9759Transcatheter intraoperative blood vessel microinfusion(s) (e.g., intraluminal, vascular wall and/or perivascular) therapy, any vessel, including radiological supervision and interpretation, when performed07/01/2020 C9760Non-randomized, non-blinded procedure for nyha class ii, iii, iv heart failure; transcatheter implantation of interatrial shunt, including right and left heart catheterization, transeptal puncture, trans-esophageal echocardiography (tee)/intracardiac echocardiography (ice), and all imaging with or without guidance (e.g., ultrasound, fluoroscopy), performed in an approved investigational device exemption (ide) study07/01/2020 C9764Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, includes angioplasty within the same vessel(s), when performed07/01/2020 C9765Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty  within the same vessel(s), when performed07/01/2020 C9766Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel(s), when performed07/01/2020 C9767Revascularization, endovascular, open or percutaneous, any vessel(s); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel(s), when performed07/01/2020 ​​C9768​Endoscopic ultrasound-guided direct measurement of hepatic portosystemic pressure gradient by any method (list separately in addition to code for primary procedure)​10/01/2020​C9769​C9769 Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts​10/01/2020​C9771​Nasal/sinus endoscopy, cryoablation nasal tissue(s) and/or nerve(s), unilateral or bilateral01/01/2021​​C9772​Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies), with intravascular lithotripsy, includes angioplasty within the same vessel (s), when performed​01/01/2021​C9773​Revascularization, endovascular, open or percutaneous,  tibial/peroneal artery(ies); with intravascular lithotripsy, and transluminal stent placement(s), includes angioplasty  within the same vessel(s), when performed​01/01/2021​C9774​Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and atherectomy, includes angioplasty within the same vessel (s), when performed​01/01/2021C9775​Revascularization, endovascular, open or percutaneous, tibial/peroneal artery(ies); with intravascular lithotripsy and transluminal stent placement(s), and atherectomy, includes angioplasty within the same vessel (s), when performed​01/01/2021​​C9776​Intraoperative near-infrared fluorescence imaging of major extra-hepatic bile duct(s) (e.g., cystic duct, common bile duct and common hepatic duct) with intravenous administration of indocyanine green (icg) (list separately in addition to code for primary procedure)​04/01/2021​C9777Esophageal mucosal integrity testing by electrical impedance, transoral (list separately in addition to code for primary procedure)​​04/01/2021E0221Infrared heating pad system01/01/2002 E0231Noncontact wound warming device (temperature control unit, AC adapter and power cord) for use with warming card and wound cover01/01/2002 E0232Warming card for use with the noncontact wound warming device and noncontact wound warming wound cover01/01/2002 E0487Spirometer, electronic, includes all accessories01/01/2009 E0762Transcutaneous electrical joint stimulation device system, includes all accessories01/01/2006 G0281Electrical stimulation, (unattended), to one or more areas, for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic ulcers, and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care, as part of a therapy plan of care04/01/2020 G0282Electrical stimulation, (unattended), to one or more areas, for wound care other than described in G028104/01/2020 G0295Electromagnetic stimulation, to one or more areas, for wound care other than described in G0329 or for other uses04/01/2020 G0329Electromagnetic therapy, to one or more areas for chronic Stage III and Stage IV pressure ulcers, arterial ulcers, diabetic and venous stasis ulcers not demonstrating measurable signs of healing after 30 days of conventional care as part of a therapy plan of care04/01/2020 ​G0428​Collagen meniscus implant procedure for filling meniscal defects (e.g., CMI, collagen scaffold, Menaflex)01/01/2021​G9147Outpatient Intravenous Insulin Treatment (OIVIT) either pulsatile or continuous, by any means, guided by the results of measurements for: respiratory quotient; and/or urine urea nitrogen (UUN); and/or, arterial, venous or capillary glucose; and/or potassium concentration 04/01/2010 J9285Injection, olaratumab, 10 mg 10/01/2019 K1001Electronic positional obstructive sleep apnea treatment, wi​th sensor, includes all components and accessories, any type01/01/2020 K1004Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories01/01/2020 ​K1007​Bilateral hip, knee, ankle, foot device, powered, includes pelvic component, single or double upright(s), knee joints any type, with or without ankle joints any type, includes all components and accessories, motors, microprocessors, sensors​10/01/2020​K1009Speech volume modulation system, any type, including all components and accessories​10/01/2020​​​K1016​Transcutaneous electrical nerve stimulator for electrical stimulation of the trigeminal nerve​04/01/2021​​K1017Monthly supplies for use of device coded at K1016​04/01/2021​​K1018​External upper limb tremor stimulator of the peripheral nerves of the wrist​04/01/2021​K1019Monthly supplies for use of device coded at K1018​​04/01/2021L2006Knee ankle foot device, any material, single or double upright, swing and/or stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type activation, with or without ankle joint(s), custom fabricated01/01/2020 L8605Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies01/01/2013 L8701Elbow, wrist, hand device, powered, with single or double upright(s), any type joint(s), includes microprocessor, sensors, all components and accessories01/01/2019 L8702Elbow, wrist, hand, finger device, powered, with single or double upright(s), any type joint(s), includes microprocessor, sensors, all components and accessories01/01/2019 M0076Prolotherapy01/01/1986 ​Q4150​Allowrap ds or dry, per square centimeter​10/01/2020Q4212Allogen, per cc10/01/2019 Q4213Ascent, 0.5 mg10/01/2019 Q4226MyOwn skin, includes harvesting and preparation procedures, per square centimeter10/01/2019 Q4240Corecyte, for topical use only, per 0.5 cc07/01/2020 Q4241Polycyte, for topical use only, per 0.5 cc07/01/2020 Q4242Amniocyte plus, per 0.5 cc07/01/2020 S2117Subtalar Arthroereisis07/01/2010 S3650Saliva test, hormone level; during menopause01/01/2000 S3652Saliva test, hormone level; to assess preterm risk01/01/2000 S3722 Dose optimization by area under the curve (AUC) analysis, for infusional 5-Fluorouracil01/01/2012 S8080Scintimammography (radioimmunoscintigraphy of the breast), unilateral, including supply of radiopharmaceutical01/01/2001 S9988Services provided as part of a Phase 1 clinical trial04/01/2004 S9990Services provided as part of a Phase II clinical trial01/01/2000 S9991Services provided as part of a Phase III clinical trial01/01/2000 S9994Lodging costs (e.g., hotel charges) for clinical trial participant and one caregiver/companion01/01/2000 S9996Meals for clinical trial participant and one caregiver/companion01/01/2000 ​ Version Effective Date: 7/12/2021 Version Issued Date: 7/12/2021 Version Reissued Date:

EXPERIMENTAL/INVESTIGATIONAL SERVICES REPRESENTED BY A SPECIFIC CPT/HCPCS CODE This list is not all-inclusive and may not include services that were identified after the date of the policy.. These services will be subject to review under the policy.. ​0015M​10/01/2020​​0200T01/01/2021​​01/01/2021​0213T​01/01/2021​0214T​​01/01/2021​0215T​01/01/2021​​0216T​​01/01/2021​0217T​01/01/2021​​0218T​​01/01/2021​0620T01/01/2021​0621T​01/01/2021​0622T01/01/2021​​0623T​01/01/2021​0624T​01/01/2021​0625T01/01/2021​​0626T01/01/2021​​0627T01/01/2021 ​ ​0628T01/01/2021​​0629T01/01/2021​​0630T01/01/2021​​0631T01/01/2021​​0632T​01/01/2021​0633T01/01/2021​​0634T01/01/2021​​0635T01/01/2021​​0636T01/01/2021​​0637T01/01/2021​0638T​01/01/2021​​0639T​01/01/2021​10/01/2020​0207U10/01/2020​​0243U04/01/2021​​0247U​04/01/2021 HCPCS CODES Effective Date of E/I Coverage Position. Notification Experimental/Investigational Services. This version of the policy will become effective 07/12/2021 .. Attachment to Policy #. Experimental/Investigational Services Represented by a Specific Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) Code.. Version Effective Date:

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