Toggle Menu Toggle Site Search

{{ navItem.title }} Overview

Quick Links

Policy List

Edit Policy

{{ navigationConstituentPage.title || { 'medicalpolicyhb': 'Healthy Blue Medical Policies', 'medicalpolicyih': 'InStil Health Medical Policies' }[navigationSitePage.urlName] || 'Medical Policies' }}

Knee Arthroscopy - CAM 776

General Information

  • It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted. 
  • The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Purpose
This guideline addresses the following elective, non-emergent, arthroscopic knee repair procedures: diagnostic knee arthroscopy, debridement with or without chondroplasty, meniscectomy/meniscal repair/meniscal transplant, ligament reconstruction/repair, articular cartilage restoration/repair (marrow stimulating and restorative techniques), synovectomy (major [2+ compartments], minor [1 compartment]), loose body removal, lateral release/patellar realignment, manipulation under anesthesia (MUA), and lysis of adhesions for arthrofibrosis of the knee.

Scope
Open, non-arthroplasty knee surgeries are performed instead of an arthroscopy as dictated by the type and severity of injury and/or disease.

Special Note
In order for surgeries to be considered medically necessary there must be clear medical records that demonstrate a clear surgical plan that matches the request for surgery.

GENERAL REQUIREMENTS

  • Elective arthroscopic surgery of the knee may be considered if the following general criteria are met:
    • There is clinical correlation of the individual’s subjective complaints with objective exam findings and/or imaging (when applicable)
    • Knee pain with documented loss of function: Deviation from normal knee function which may include painful weight bearing and/or inadequate range of motion (> 10 degrees flexion contracture or < 110 degrees flexion or both) to accomplish age-appropriate activities of daily living (ADLs), occupational or athletic requirements)
    • Individual is medically stable and optimized for surgery, and any treatable comorbidities are adequately medically managed such as diabetes, nicotine addiction, or an excessively high BMI. There should also be a shared decision between the patient and physician to proceed with knee surgery when comorbidities exist as it pertains to the increased risk of complications
    • Individual does not have an active local or systemic infection
    • Individual does not have active, untreated drug dependency (including but not limited to narcotics, opioids, or muscle relaxants) unless engaged in a treatment program
    • No intra-articular cortisone injections within 4 weeks of surgery(1–3)
  • Clinical notes should address:
    • Symptom onset, duration, and severity
    • Loss of function and/or limitations
    • Type and duration of non-operative management modalities (where applicable)
  • Unless otherwise stated in the subsections below, non-operative management must include at least TWO or more of the following, unless otherwise specified(4):
    • Rest or activity modifications/limitations
    • Ice/heat
    • Protected weight bearing
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
    • Brace/orthosis
    • Physical therapy modalities
    • Supervised home exercise
    • Weight optimization
    • Injections: corticosteroid, NSAID, viscosupplementation

    Background
    Meniscectomy and Arthritis of the Knee

    Studies have shown there is no difference in outcome between operative and non-operative treatment of individuals with degenerative meniscus tears, especially when associated with an arthritic knee. (9,48) Arthroscopic debridement of degenerative meniscus tears in those with visible arthritis is generally not recommended and, in some cases, may worsen the symptoms and progression of the arthritis. (9,49)

    The imaging evaluation of the knee for individuals with meniscus tears should be individualized, the goal of which is to recommend treatment for only those with no or minimal associated arthritis.

    Although most individuals that have a request for arthroscopic meniscectomy will have had BOTH an MRI AND X-rays of the knee, only one of these tests is required for approval, provided all other criteria for meniscectomy have been met. For example, if there has been a failure to improve with 6 weeks of non-operative treatment and there are physical examination findings of a meniscus tear, an MRI is not required, only weight-bearing X-rays that demonstrate no more than mild arthritis. Likewise, if an MRI describes a frank meniscus tear and does not describe any significant associated arthritis, weight-bearing X-rays are not required. However, as noted above, if an MRI demonstrates findings of more than mild arthritis, weight-bearing X-rays are required to confirm no moderate or severe articular cartilage loss.

    Grading Appendix

    Kellgren-Lawrence Grading System (Standing/weight-bearing X-rays)   (50)

    Grade

    Description

    0

    No radiographic features of osteoarthritis

    1

    Possible joint space narrowing and osteophyte formation

    2

    Definite osteophyte formation with possible joint space narrowing

    3

    Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour

    4

    Large osteophytes, marked narrowing of joint space, severe sclerosis, and definite deformity of bone contour

    Outerbridge Arthroscopic Grading System   (51)

    Grade

    Description

    0

    Normal cartilage

    I

    Softening and swelling/blistering

    II

    Partial thickness defect, fissures < 1.5cm diameter/wide

    III

    Fissures /defects down to subchondral bone with intact calcified cartilage layer, diameter > 1.5cm

    IV

    Exposed subchondral bone

    Marx Scale   (52)

    For determination of activity level in acute ACL tears. Indicate how often you performed each activity in your healthiest and most active state, in the past year.

    Activity/Movement

    Less than one time in a month

    One time in a month

    One time in a week

    2 or 3 times in a week

    4 or more times in a week

    Running: running while playing a sport or jogging

    0

    1

    2

    3

    4

    Cutting: changing directions while running

    0

    1

    2

    3

    4

    Deceleration: coming to a quick stop while running

    0

    1

    2

    3

    4

    Pivoting: turning your body with your foot planted while playing sport; For example: skiing, skating, kicking, throwing, hitting a ball (golf, tennis, squash), etc.

    0

    1

    2

    3

    4

    Tegner Scores   (53)

    For determination of activity level in acute ACL tears. Indicate in the spaces below the highest level of activity that you participated in before your injury and the highest level you are able to participate in currently.

    Level

    Activity Description

    Level 10

    Competitive sports- soccer, football, rugby (national elite)

    Level 9

    Competitive sports- soccer, football, rugby (lower divisions), ice hockey, wrestling, gymnastics, basketball

    Level 8

    Competitive sports- racquetball or bandy, squash or badminton, track and field athletics (jumping, etc.), down-hill skiing

    Level 7

    Competitive sports- tennis, running, motorcars speedway, handball

    Recreational sports- soccer, football, rugby, bandy, ice hockey, basketball, squash, racquetball, running

    Level 6

    Recreational sports- tennis and badminton, handball, racquetball, down-hill skiing, jogging at least 5 times per week

    Level 5

    Work- heavy labor (construction, etc.)

    Competitive sports- cycling, cross-country skiing; Recreational sports- jogging on uneven ground at least twice weekly

    Level 4

    Work- moderately heavy labor (e.g., truck driving, etc.)

    Level 3

    Work- light labor (nursing, etc.)

    Level 2

    Work- light labor

    Walking on uneven ground possible, but impossible to backpack or hike

    Level 1

    Work- sedentary (secretarial, etc.)

    Level 0

    Sick leave or disability pension because of knee problems

    Policy
    INDICATIONS
    Diagnostic Knee Arthroscopy
    Diagnostic knee arthroscopy should rarely be required however is considered     MEDICALLY NECESSARY when the following criteria are met:

    • At least 12 weeks of knee pain with documented loss of function
    • History of painful weight bearing and/or physical examination that shows joint line tenderness, effusion and/or limited motion compared to pre-symptomatic joint range
    • Indeterminate radiographs AND Magnetic Resonance Imaging (MRI) findings. Radiographs and/or MRI should not demonstrate any of the following: Kellgren-Lawrence Grade 3-4 changes (based on weight-bearing radiographs), meniscus tears, ligament tears, loose bodies, stress fractures (including insufficiency fractures) or patellofemoral instability (lateral patellar tilt or patellar subluxation)
    • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following (4) :
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    NOTE: Subchondroplasty and In-office diagnostic arthroscopy (e.g., Mi-Eye, VisionScope) (5) are not managed by Evolent

    Chondroplasty

    Non-Patellofemoral chondroplasty (Femoral Condyle and Tibial Plateau)

    Non-Patellofemoral (femoral condyle and tibial plateau) chondroplasty is considered MEDICALLY NECESSARY when the following criteria are met (6) :

    • At least 12 weeks of knee pain with documented loss of function
    • Two or more or persistent effusion(s)
    • MRI results demonstrate evidence of an area of localized articular cartilage damage or an unstable chondral flap
    • Failure of at least 12 weeks of non-operative treatment, including at least two of the following (4) :
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Patellofemoral chondroplasty

    Patellofemoral chondroplasty is considered MEDICALLY NECESSARY when the following criteria are met (7) :

    • Anterior knee pain with documented loss of function, exacerbated by activities that load the patellofemoral joint such as ascending or descending stairs or being in seated position for extended periods of time with knee flexed
    • Other extra-articular or intra-articular sources of pain or dysfunction have been excluded (referred hip pain, radicular pain, tendinitis, bursitis, neuroma)
    • Physical exam localizes tenderness to the patellofemoral joint
    • No evidence of moderate to severe osteoarthritis (Kellgren-Lawrence Grade 3-4 based on weight-bearing radiographs and patellofemoral views [see Grading Appendix])
    • Failure of at least 12 weeks of non-operative treatment, including at least two of the following (4) :
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Meniscectomy/Meniscal Repair
    Meniscectomy and/or meniscal repair is considered MEDICALLY NECESSARY when the criteria in any of the following sections are met:

    • Section One
      • Symptomatic meniscal tear confirmed by MRI results that demonstrate a peripheral tear in the vascular zone, root tear, (8) or other tear that the requesting physician considers repairable and is associated with pain localized to the corresponding compartment upon physical examination (9,10)
      • No Kellgren-Lawrence Grade 3-4 changes on standing X-rays
    • Section Two
      • MRI demonstrates a meniscus tear (9,10) in a patient age <21 years who complains of pain or mechanical symptoms or has ANY positive meniscal findings on physical examination
    • Section Three
      • MRI demonstrates a bucket-handle tear of the meniscus and there is a history of acute injury/onset of symptoms with a locked knee and/or mechanical symptoms of locking or catching. (10)
    • Section Four: When a symptomatic meniscus tear is suspected and meets the following criteria:
      • When at least two of the following physical examination findings are present or there is at least one of the following physical examination findings and there is a history of mechanical symptoms such as 'catching' or 'locking' (9,10) :
        • Knee joint line pain with forced hyperextension upon physical exam
        • Knee joint line pain with maximum flexion upon physical exam
        • Knee pain, crepitus, or an audible or palpable click with the McMurray’s test or Apley grind test
        • Joint line tenderness to palpation upon physical exam
      • Weight-bearing X-rays (standing X-rays, Rosenberg view, 45-degree flexed PA view, etc.) demonstrate no moderate or severe osteoarthritic changes defined as Kellgren-Lawrence Grade 3-4 (see Grading Appendix); X-rays should be described as showing either no arthritis or mild/minimal arthritis only (10) OR
      • MRI results confirm a frank meniscal tear (not simply degenerative changes, i.e., fraying) and the MRI does not demonstrate any of the following: moderate or severe articular cartilage thinning, full-thickness articular cartilage loss or defects, extrusion of the meniscus, subchondral edema, more than mild osteophytes, subchondral cysts, or an impression of 'moderate' or 'advanced/severe' arthritis (see absolute and relative contraindications). If the MRI demonstrates any of the above-described findings of more than mild arthritis, weight-bearing X-rays are required to confirm no moderate or severe articular cartilage loss (see Background section). (9,10)
      • Failure of at least 6 weeks of non-operative treatment, including at least TWO of the following (11) :
        • Rest or activity modifications/limitations
        • Ice/heat
        • Protected weight bearing
        • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
        • Brace/orthosis
        • Physical therapy modalities
        • Supervised home exercise
        • Weight optimization
        • Corticosteroid injection
      • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Absolute Contraindications Meniscectomy/Meniscal Repair

    • Arthroscopic meniscectomy or meniscal repair is considered NOT MEDICALLY NECESSARY in the presence of Kellgren-Lawrence Grade 4 osteoarthritis (9) (see Grading Appendix)
    • ANY intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Relative Contraindications Meniscectomy / Meniscal Repair

    • Meniscectomy or repair is considered NOT MEDICALLY NECESSARY in the presence of Kellgren-Lawrence Grade 3 osteoarthritis (see Grading Appendix), unless (9) :
      • There has been the acute onset of locking (does not include catching, popping, cracking, etc.); AND
      • There is MRI evidence of a bucket-handle or displaced meniscal fragment that correlates with the correct compartment (i.e., medial tenderness and locking, for a medial meniscus tear)
    • If grade 3 changes are present, only a meniscectomy may be indicated, not a repair. If there is evidence of meniscal extrusion on coronal MRI, with/without subchondral edema, arthroscopy is relatively contraindicated, even if a tear is present.

    Meniscal Transplant

    Meniscal Transplants is considered MEDICALLY NECESSARY when the following criteria are met (10,12) :

    • Individual is < 40 years of age
    • Individual has no evidence of arthritic changes
    • Symptomatic meniscal deficiency confirmed by MRI results that show a meniscal deficient compartment, OR previous arthroscopy photographs or video showing subtotal or total meniscectomy
    • Failure of at least 6 weeks of non-operative treatment, including at least two of the following:
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection

    Absolute Contraindications: Meniscal Transplant   (12)

    • Uncorrected (staged or simultaneous) ligamentous insufficiency affecting one or more primary knee stabilizers Uncorrected (staged or simultaneous) malalignment greater than 5 degrees varus or 5 degrees valgus
    • Uncorrected (staged or simultaneous) full-thickness articular cartilage isolated defects (International Cartilage Research Society Grade 3 or 4; Outerbridge Grade IV [see Grading Appendix])
    • Kellgren-Lawrence Grade 3 or 4 osteoarthritis (see Grading Appendix)
    • Intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Ligament Reconstruction or Repair
    Anterior Cruciate Ligament (ACL) Repair or Reconstruction with Allograft or Autograft, With or Without Extraarticular Augmentation

    ACL reconstruction or repair is considered MEDICALLY NECESSARY when the criteria in any of the following sections are met and individual has no evidence of severe arthritis defined as Kellgren-Lawrence grade 3 or 4 (If the MRI results demonstrate an ACL tear and there is no mention of significant arthritis, especially in the younger individual, X-rays are not required. However, in others with significant MRI evidence of arthritis, standing X-rays are required to confirm that no Kellgren-Lawrence grade 3 or 4 changes are present) (13,14) :

    • Section One
      • Acute ACL tear confirmed by MRI in high demand occupation or competitive athlete(as quantified by Marx activity score for athletics (any score > 4) and Tegner activity score for athletics and/or occupation ((score > 2)) (15) (see Grading Appendix)
    • Section Two
      • MRI results confirm an ACL tear associated with other ligamentous instability or repairable meniscus
    • Section Three
      • When the following criteria are met
        • Patient history of instability at the time of an acute injury or history of recurrent knee instability (as defined subjectively as 'giving way', 'giving out', 'buckling', two-fist sign)
        • Physical examination findings demonstrate a positive Lachman test, Lachman test 1A, 1B, 2A, 2B, 3A, 3B, anterior drawer, pivot shift test, or instrumented (KT-1000 or KT-2000) laxity of greater than 3 mm side-side difference
        • MRI results confirm complete ACL tear or substantial partial tear with a non-functioning ACL as demonstrated on physical examination

    NOTE: Requests for ACL repair or reconstruction in individuals < age 13 will be reviewed on a case-by-case basis (16)

    Posterior Cruciate Ligament (PCL) Reconstruction
    PCL reconstruction or repair is considered MEDICALLY NECESSARY when the following criteria are met  (17,18) :

    • Knee instability (as defined subjectively as 'giving way', 'giving out' or 'buckling') with clinical findings of any of the following signs/tests: positive posterior drawer, posterior sag, quadriceps active, dial test at 90 degrees knee flexion or reverse pivot shift test
    • MRI results confirm complete PCL tear
    • Failure of at least 12 weeks of non-operative treatment, including physical therapy emphasizing quadriceps strengthening
    • Absence of medial and patellofemoral K-L grade 3-4 changes in chronic tears [see Grading Appendix]

    The following clinical scenarios will be considered and decided on a case-by-case basis (19) :

    • Pediatric and adolescent tears in individuals with open physis or growth plates
    • Symptomatic partial tears with persistent instability despite non-operative treatment (18,19)
    • Incidental Kellgren-Lawrence grade 2-3 osteoarthritis [see Grading Appendix] in acute/subacute tears with unstable joint
    • Acute PCL repair or reconstruction when surgery is also required for the ACL, Medial Collateral Ligament (MCL), or Lateral Collateral Ligament (LCL)
    • Tears in individuals < age 13

    Collateral Ligament Repair or Reconstruction

    Collateral ligament repair or reconstruction should rarely occur independent of additional ligament repair or reconstruction surgery (ACL, MCL, LCL).

    All non-traumatic collateral ligament repair/reconstruction requests will be reviewed on a case-by-case basis.

    Articular Cartilage Restoration/Repair

    Skeletally Immature Indications

    Articular cartilage reparative or stimulation procedures is considered MEDICALLY NECESSARY when the following criteria in ANY of the following sections are met (20–22) :

    • Section One
      • Skeletally immature patient
      • Individual is symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion)
      • Asymptomatic patients will be reviewed on a case-by-case basis
      • Radiographic findings (X-ray or MRI) of a displaced osteochondral lesion
    • Section Two
      • Skeletally immature patient
      • Individual is symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion)
      • Radiographic findings (X-ray or MRI) findings of a stable osteochondral lesion
      • Failure of at least 12 weeks of non-operative treatment, including at least two of the following:
        • Rest or activity modifications/limitations
        • Ice/heat
        • Protected weight bearing
        • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
        • Brace/orthosis
        • Physical therapy modalities
        • Supervised home exercise
        • Weight optimization
        • Corticosteroid injection

    Exclusion (applies to all criteria above)

    • Exclude individuals with evidence of meniscal deficiency and/or malalignment if these are not being addressed (meniscal transplant and/or lateral release/patellar realignment procedure) at the same time as the cartilage restoration procedure

    Skeletally Mature Indications

    Articular cartilage reparative marrow stimulation procedures

    Reparative marrow stimulation techniques such as microfracture & drilling (23,24) is considered MEDICALLY NECESSARY when the following criteria are met:

    • Skeletally mature adult (25)
    • Individuals are symptomatic with anterior knee pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion (26)
    • For trochlea or patellar lesions physical examination findings should be localized to the patellofemoral joint (25,27)
    • MRI confirms an isolated full-thickness chondral or osteochondral lesion of the femoral condyle, trochlea, or patella < 2.0 cm2 (25,27)
    • Physical exam findings and/or (imaging) results confirm no ligamentous instability (25–27)
    • For femoral condyle lesions, no evidence of prior meniscectomy in same compartment unless concurrent meniscal transplant performed (27)
    • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following (25) :
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    NOTE: Abrasion arthroplasty is included in coding but is not indicated

    Articular cartilage restorative procedures – femoral condyle and trochlea
    Restorative procedures for articular cartilage loss may include the following: osteochondral autograft transfer (OAT), osteochondral allograft transplantation (OCA), autologous chondrocyte implantation (ACI), or matrix autologous chondrocyte implantation (MACI). The OAT or OCA procedures are preferable if the lesion involves subchondral bone. (23,28)

    An articular cartilage restorative procedure may be medically necessary when the following criteria are met:

    • Skeletally mature adult (25)
    • Individual has been symptomatic (pain, swelling, mechanical symptoms of popping, locking, catching, or limited range of motion) for at least 6 months (26)
    • Individual is < 50 years of age (24)
    • BMI < 35kg/m2 (optimal outcomes if patient BMI < 30kg/m2) (27)
    • No prior meniscectomy in same compartment (unless concurrent or staged meniscal transplant performed) (27)
    • MRI results confirm an isolated full thickness chondral or osteochondral lesion of the femoral condyles or trochlea with stable surrounding articular cartilage (25–27) :
      • < 2.0 cm2 - OAT
      • > 2.0 cm2 - ACI, MACI, OCA
    • MRI and/or physical findings confirm knee has normal alignment as defined as +/- 3 degrees from neutral on full-length mechanical axis long-leg x-ray (unless concurrent or staged tibial or femoral osteotomy performed) and stability (unless concurrent ligamentous repair or reconstruction performed)
    • MRI and/or X-rays shows no evidence of osteoarthritis (no greater than Kellgren-Lawrence Grade 2 changes on weight-bearing X-rays [see Grading Appendix]) (25–27)
    • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following (25) :
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
    • No prior meniscectomy in same compartment (unless concurrent or staged meniscal transplant performed) (27)
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Articular cartilage restorative procedures - patella
    Restorative procedures for articular cartilage loss of the patella may include the following: osteochondral autograft transfer (OAT), osteochondral allograft transplantation (OCA), autologous chondrocyte implantation (ACI), or matrix autologous chondrocyte implantation (MACI), with or without tibial tubercle osteotomy.* (23,29)

    An articular cartilage restorative procedure may be medically necessary when the following criteria are met (25–27) :

    • Anterior knee pain and loss of function
    • Individual is < 50 years of age (24)
    • BMI < 35kg/m2 (optimal outcomes if patient BMI < 30kg/m2) (27)
    • Other extra-articular or intra-articular sources of pain or dysfunction have been excluded (referred pain, radicular pain, tendinitis, bursitis, neuroma)
    • Physical exam localizes tenderness to the patellofemoral joint with pain aggravated by activities that load the joint (single leg squat, descending > ascending stairs or stair climbing, and being in seated position for extended periods of time with knee flexed)  (26,27)
    • MRI results confirm an isolated full thickness chondral or osteochondral lesion of the patella (25–27) :
      • < 2.0 cm2 - OAT
      • > 2.0 cm2 - ACI, MACI, OCA
    • No evidence of associated osteoarthritis greater than Kellgren-Lawrence 2 of the patellofemoral joint or medial/lateral compartments on weight bearing X-rays (see Grading Appendix) (25–27)
    • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following (25) :
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    *NOTE: Patellofemoral Chondrosis

    • For isolated tibial tubercle osteotomy for patellofemoral chondrosis without articular cartilage restoration procedures, the same criteria above apply except patellofemoral X-rays should document Kellgren-Lawrence grade 3 or 4 changes with no more than K-L 2 changes of the medial and lateral compartments on weight-bearing X-rays.

    Articular Cartilage Restoration and Repair Exclusions

    • These requests are excluded from consideration:
      • Micronized cartilage extracellular matrix (BioCartilage)
      • Autologous Matrix-Induced Chondrogenesis (AMIC)
      • Bone marrow aspirate concentrate (BMAC) implantation
      • Hybrid ACI/OAT procedure
      • Particulated juvenile allograft cartilage (PJAC, DeNovo)
      • Particulated autologous cartilage implantation (PACI)
      • Viable cartilage allograft putty (CartiMax)
      • Decellularized Osteochondral Allograft Plugs (e.g., Chondrofix)
      • Cryopreserved viable osteochondral allograft (CVOCA; Cartiform and ProChondrix)
      • Aragonite biphasic osteochondral scaffolds (Agili-C™)
      • Human umbilical cord blood-derived mesenchymal stem cells (CARTISEM)

    Synovectomy (Major [2+ compartments], Minor [1 compartment])

    Synovectomy may be medically necessary when the criteria in any of the following sections are met:

    • Section One
      • Proliferative rheumatoid synovium (in individuals with established rheumatoid arthritis)
      • Non-responsive to disease modifying drug (DMARD) therapy for at least 6 months  (30,31)
      • At least one instance of aspiration of joint effusion and corticosteroid injection (if no evidence of infection) (30)
      • Failure of at least 6 weeks of non-operative treatment, including at least two of the following:
        • Rest or activity modifications/limitations
        • Ice/heat
        • Protected weight bearing
        • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
        • Brace/orthosis
        • Physical therapy modalities
        • Supervised home exercise
        • Weight optimization
        • Corticosteroid injection
    • Section Two
      • Hemarthrosis from injury, (30) coagulopathy or bleeding disorder confirmed by physical exam, joint aspiration, and/or MRI
    • Section Three
      • Proliferative pigmented villonodular synovitis, synovial chondromatosis, sarcoid synovitis, or similar proliferative synovial disease, traumatic hypertrophic synovitis, cyclops lesion, or fat pad syndrome confirmed by history, MRI, or biopsy (32,33)
      • At least one instance of aspiration of joint effusion and injection of corticosteroid (if no evidence of infection) (30)
      • Failure of at least 6 weeks of non-operative treatment, including at least two of the following:
        • Rest or activity modifications/limitations
        • Ice/heat
        • Protected weight bearing
        • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
        • Brace/orthosis
        • Physical therapy modalities
        • Supervised home exercise
        • Weight optimization
        • Corticosteroid injection
    • Section Four (34)
      • Patient is symptomatic and there is detection of a painful plica confirmed by physical exam
      • MRI confirms the presence of a plica
      • Failure of at least 12 weeks of non-operative treatment, including at least two of the following:
        • Rest or activity modifications/limitations
        • Ice/heat
        • Protected weight bearing
        • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
        • Brace/orthosis
        • Physical therapy modalities
        • Supervised home exercise
        • Weight optimization
        • Corticosteroid injection
      • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Loose Body Removal

    Loose body removal may be medically necessary when the following criteria are met:

    • Documentation of mechanical symptoms that cause limitation or loss of function
    • X-ray, CT, or MRI documentation of a loose body
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Lateral Release/Patellar Realignment

    This guideline describes indications for surgical procedures to address patellofemoral pain disorders and abnormal alignment of the extensor mechanism of the knee by arthroscopic and/or open surgical techniques.

    Lateral Patellar Compression Syndrome

    Surgical intervention for the treatment of lateral patellar compression syndrome is indicated when the following criteria are met (35–37) :

    • No evidence of patellar dislocation
    • Reproducible isolated lateral patellofemoral pain with patellar tilt test
    • Evidence of lateral patellar tilt from radiologic images (patellofemoral view: Merchant (45 degrees flexion; and/or skyline (60-90 degrees flexion); and/or sunrise (60-90 degrees flexion)
    • Associated lateral patella facet Kellgren-Lawrence changes grade 1, 2, or 3 (see Grading Appendix)
    • No evidence of medial patellofemoral changes (Kellgren-Lawrence Grade 2 osteoarthritis or higher [see Grading Appendix])
    • Failure of at least 6 months of non-operative treatment, including quadriceps strengthening and appropriate hamstring/IT band stretching and patellar mobilization techniques, and at least one of the following:
      • Rest or activity modifications/limitations
      • Ice/heat
      • Protected weight bearing
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
      • Brace/orthosis
      • Physical therapy modalities
      • Supervised home exercise
      • Weight optimization
      • Corticosteroid injection
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Patellar Malalignment and/or Patellar Instability

    Surgical intervention for the treatment of patellar malalignment and/or patellar instability is indicated when the following criteria in any of the following sections are met (38–41) :

    • Section One
      • Acute traumatic patellar dislocation is associated with an osteochondral fracture, loose body, vastus medialis obliquus/medial patellofemoral ligament muscle avulsion, or other intra-articular injury that requires urgent operative management
    • Section Two
      • First time patellar dislocation (not subluxation)
      • Age < 25
      • Any of the following:
        • Imaging demonstrates a TT-TG distance ≥15 mm
        • Moderate to severe trochlear dysplasia (38,39)
        • Patella alta
    • Section Three
    • History of 2 or more patellar dislocations
      • Radiologic confirmation of MPFL (medial patellofemoral ligament) deficiency (including evidence of acute or remote injury, scarring, incomplete healing, etc.) and there is a TT-TG distance ≥15 mm, trochlear dysplasia, or patella alta
      • Physical examination demonstrates evidence of patellar instability (positive apprehension test, increased lateral patellar translation, etc.)
    • Section Four
      • When ALL of the following criteria have been met:
        • Patient complains of patellar subluxation or has a history of only one patellar dislocation (see Section Two above)
        • Physical exam has patellofemoral tenderness and abnormal articulation of the patella in the femoral trochlear groove (patellar apprehension or positive J sign)
        • Radiologic and/or advanced images (CT or MRI) rule out fracture or loose body, and show abnormal articulation, trochlear dysplasia, abnormal TT-TG distance (tibial tubercle-trochlear groove)* or other abnormality related to malalignment
        • Failure of at least 6 months of non-operative treatment, including at least 3 months of physical therapy, and ONE of the following:
          • Rest or activity modifications/limitations
          • Ice/heat
          • Protected weight bearing
          • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, analgesics, tramadol
          • Brace/orthosis
          • Supervised home exercise
          • Weight optimization
          • Corticosteroid injection
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    *NOTE: The tibial tubercle-trochlear groove (TT-TG) distance is normally 5-10 mm. Some authors use 13 mm as a cut-off and most agree that a TT-TG of 15 mm or over is abnormal. (42) TT-TG values over 17 mm indicate other possible bony abnormalities such as increased femoral anteversion that may cause patellar instability. (40,43)

    Manipulation Under Anesthesia (MUA)

    MUA may be indicated when the following criteria are met  (44–46) :

    • Individual is less than 20 weeks after ligamentous or joint reconstruction
    • Physical exam findings demonstrate inadequate range of motion of the knee defined as less than 110 degrees of flexion or lack of full extension (extension deficit greater than 5 degrees) (45,46)
    • Failure to improve range of motion of the knee despite 6 weeks (12 visits) of documented physical therapy

    Lysis of Adhesions for Arthrofibrosis of the Knee

    Surgical indications are based on relevant clinical symptoms, physical exam, radiologic findings, time from primary surgery, and response to conservative management when medically appropriate. Improved range of motion may be accomplished through arthroscopically assisted or open lysis of adhesions with general anesthesia, regional anesthesia, or sedation. (45,47)

    Lysis of adhesions for arthrofibrosis of the knee may be indicated when all the following criteria are met:

    • Individual is > 12 weeks post-surgery fracture or resolved infection
    • Physical exam findings demonstrate inadequate range of motion of the knee, defined as < 110 degrees of flexion or lack of full extension
    • Failure to improve range of motion of the knee despite 6 weeks (12 visits) of documented physical therapy
    • No intra-articular cortisone injections within 4 weeks of surgery (1–3)

    Rationale
    Summary of Evidence

    Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline (4) :

    • Study Design: This is an evidence-based clinical practice guideline for the management of osteoarthritis of the knee (non-arthroplasty). It is based on a systematic review of the literature and includes recommendations for various non-pharmacologic and pharmacologic interventions.
    • Target Population: Adults diagnosed with osteoarthritis of the knee.
    • Key Factors: The guideline covers a wide range of interventions, including lateral wedge insoles, canes, braces, oral/dietary supplements, topical treatments, supervised exercise, neuromuscular training, self-management, patient education, weight loss intervention, manual therapy, massage, laser treatment, acupuncture, transcutaneous electrical nerve stimulation, percutaneous electrical nerve stimulation, pulsed electromagnetic field therapy, extracorporeal shockwave therapy, oral NSAIDs, oral acetaminophen, oral narcotics, hyaluronic acid, intra-articular corticosteroids, platelet-rich plasma, denervation therapy, lavage/debridement, partial meniscectomy, and tibial osteotomy.

    Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary (11) :

    • Study Design: This is a clinical practice guideline based on a systematic review of published studies for the treatment of acute isolated meniscal pathology. It includes three recommendations and six options to assist orthopedic surgeons and other qualified physicians.
    • Target Population: Patients with acute isolated meniscal pathology, which can occur in individuals of all ages but is more common in younger, active individuals.
    • Key Factors: The guideline highlights the incidence of meniscus tears, the goal of treatment (pain relief, improved function, and return to activities), and the risks associated with surgical treatment. It also discusses the importance of preserving healthy meniscal tissue and the use of MRI for diagnosis.

    International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus (12) :

    • Study Design: This document is a consensus statement from the International Meniscus Reconstruction Experts Forum (IMREF) on the practice of meniscal allograft transplantation (MAT). It is based on a consensus group technique and includes 15 statements generated from the IMREF 2015 survey.
    • Target Population: Patients with symptomatic knee after the loss of a functional meniscus, including those with unicompartmental pain, ACL deficiency, and articular cartilage repair.
    • Key Factors: The consensus statement covers indications for MAT, surgical techniques, postoperative care, and the importance of a functional meniscus. It also discusses the evolution of MAT, the role of the meniscus in knee function, and the need for careful patient selection.

    Analysis of Evidence

    Shared Findings:

    • Effectiveness of Arthroscopy:
      • All three articles discuss the effectiveness of knee arthroscopy in treating various knee conditions. They agree that arthroscopy can be beneficial for certain conditions, such as meniscal tears and osteoarthritis, but the extent of its effectiveness varies.
      • Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline provides a comprehensive review of various treatments for knee osteoarthritis, including arthroscopy, and concludes that arthroscopy with lavage and/or debridement is not recommended for primary knee osteoarthritis. (4)
      • Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary emphasizes the high rate of improvement in function and return to sports or other activities following arthroscopic surgery for acute meniscal pathology. (11)
      • International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus highlights the evolution of meniscal allograft transplantation (MAT) and its role in improving joint stability and function, particularly in cases of meniscus deficiency. (12)
    • Risks and Complications:
      • All three articles acknowledge the potential risks and complications associated with knee arthroscopy, such as infection, thromboembolism, nerve damage, and persistent or recurrent pain.
      • Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline highlights the increased risk of adverse events with oral NSAIDs and the importance of considering patient comorbidities.  (4)
      • Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary mentions specific risks like pulmonary embolus and re-tear of the meniscus. (11)
      • International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus discusses the variability in MAT outcomes and the need for careful patient selection to optimize clinical results. (12)

    Differing Findings:

    • Recommendations for Use:
      • Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline offers a broader range of recommendations for managing knee osteoarthritis, including the use of lateral wedge insoles, canes, braces, dietary supplements, and various non-surgical treatments. (4)
      • Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary provides specific recommendations for the use of MRI in diagnosing acute meniscal pathology and emphasizes the importance of preserving as much functional meniscal tissue as possible. (11)
      • International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus focuses on the indications for MAT, including unicompartmental pain, ACL deficiency, and articular cartilage repair, and provides detailed guidelines for graft procurement, preparation, and surgical techniques. (12)
    • Evidence and Methodology:
      • Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline is a comprehensive clinical practice guideline developed by the American Academy of Orthopaedic Surgeons (AAOS) and includes a detailed review of the literature, methodology, and recommendations for various treatments. (4)
      • Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary is based on a systematic review of published studies and provides evidence-based clinical practice guidelines for managing acute isolated meniscal pathology. (11)
      • International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus  presents a consensus statement from the International Meniscus Reconstruction Experts Forum (IMREF) and emphasizes the importance of standardized approaches to MAT. (12)

    References

    1. Belk JW, Keeling LE, Kraeutler MJ, et al. Risk of Infection in Knee Arthroscopy Patients Undergoing Corticosteroid Injections in the Perioperative Period. Orthop J Sports Med. 2021;9(8). doi:10.1177/23259671211032941
    2. Forsythe B, Forlenza EM, Agarwalla A, et al. Corticosteroid Injections 1 Month Before Arthroscopic Meniscectomy Increase the Risk of Surgical-Site Infection. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021;37(9):2885-2890.e2. doi:10.1016/j.arthro.2021.02.047
    3. Lee W, Bhattacharjee S, Lee MJ, Ho SW, Athiviraham A, Shi LL. A Safe Interval between Preoperative Intra-articular Corticosteroid Injections and Subsequent Knee Arthroscopy. Journal of Knee Surgery. 2022;35(1):47-53. doi:10.1055/s-0040-1712949
    4. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline. American Academy of Orthopaedic Surgeons. August 31, 2021. https://www.aaos.org/oak3cpg
    5. DeClouette B, Birnbaum A, Campbell H, Bi AS, Lin CC, Struhl S. Needle Arthroscopy Demonstrates High Sensitivity and Specificity for Diagnosing Intra-Articular Shoulder and Knee Pathology. Cureus. 2022;14(12):e33189. doi:10.7759/cureus.33189
    6. Anderson DE, Rose MB, Wille AJ, Wiedrick J, Crawford DC. Arthroscopic Mechanical Chondroplasty of the Knee Is Beneficial for Treatment of Focal Cartilage Lesions in the Absence of Concurrent Pathology. Orthop J Sports Med. 2017;5(5):232596711770721. doi:10.1177/2325967117707213
    7. Mabrouk A, Kaiser K. Patellofemoral Arthritis Continuing Education Activity.
    8. Krych AJ, Lamba A, Wang AS, et al. Nonoperative Management of Degenerative Medial Meniscus Posterior Root Tears: Poor Outcomes at a Minimum 10-Year Follow-up. American Journal of Sports Medicine. 2023;51(10):2603-2607. doi:10.1177/03635465231185132
    9. Burgess CJ, De Cicco FL. Meniscectomy. StatPearls. Published online May 23, 2023. https://www.ncbi.nlm.nih.gov/books/NBK559105/
    10. Raj MA, Bubnis MA. Knee Meniscal Tears. StatPearls. Published online July 17, 2023. https://www.ncbi.nlm.nih.gov/books/NBK431067/
    11. Brophy RH, Best MJ. Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary: Management of Acute Isolated Meniscal Pathology. Journal of the American Academy of Orthopaedic Surgeons . 2025;33(13):e724-e730. doi:10.5435/JAAOS-D-25-00135
    12. Getgood A, LaPrade RF, Verdonk P, et al. International Meniscus Reconstruction Experts Forum (IMREF) 2015 Consensus Statement on the Practice of Meniscal Allograft Transplantation. Am J Sports Med. 2017;45(5):1195-1205. doi:10.1177/0363546516660064
    13. Evans J, Mabrouk A, Nielson J l. Anterior Cruciate Ligament Knee Injury. StatPearls. Published online November 17, 2023. https://www.ncbi.nlm.nih.gov/books/NBK499848/
    14. Filbay SR, Grindem H. Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture. Best Pract Res Clin Rheumatol. 2019;33(1):33-47. doi:10.1016/j.berh.2019.01.018
    15. Bosco F, Giustra F, Masoni V, et al. Combining an Anterolateral Complex Procedure With Anterior Cruciate Ligament Reconstruction Reduces the Graft Reinjury Rate and Improves Clinical Outcomes: A Systematic Review and Meta-analysis of Randomized Controlled Trials. American Journal of Sports Medicine. 2024;52(8):2129-2147. doi:10.1177/03635465231198494
    16. Shultz SJ, Cruz MR, Casey E, et al. Sex-Specific Changes in Physical Risk Factors for Anterior Cruciate Ligament Injury by Chronological Age and Stages of Growth and Maturation From 8 to 18 Years of Age. J Athl Train. 2022;57(9-10):830-876. doi:10.4085/1062-6050-0038.22
    17. Bedi A, Musahl V, Cowan JB. Management of Posterior Cruciate Ligament Injuries. Journal of the American Academy of Orthopaedic Surgeons. 2016;24(5):277-289. doi:10.5435/JAAOS-D-14-00326
    18. Raj MA, Mabrouk A, Varacallo M. Posterior Cruciate Ligament Knee Injuries. StatPearls. Published online August 8, 2023. https://www.ncbi.nlm.nih.gov/books/NBK430726/
    19. Scarcella MJ, Yalcin S, Scarcella NR, Saluan P, Farrow LD. Outcomes of Pediatric Posterior Cruciate Ligament Reconstruction: A Systematic Review. Orthop J Sports Med. 2021;9(9):232596712110325. doi:10.1177/23259671211032539
    20. Chau MM, Klimstra MA, Wise KL, et al. Osteochondritis Dissecans. Journal of Bone and Joint Surgery. 2021;103(12):1132-1151. doi:10.2106/JBJS.20.01399
    21. Salzmann GM, Niemeyer P, Hochrein A, Stoddart MJ, Angele P. Articular Cartilage Repair of the Knee in Children and Adolescents. Orthop J Sports Med. 2018;6(3):232596711876019. doi:10.1177/2325967118760190
    22. Valtanen RS, Arshi A, Kelley B V., Fabricant PD, Jones KJ. Articular Cartilage Repair of the Pediatric and Adolescent Knee with Regard to Minimal Clinically Important Difference: A Systematic Review. Cartilage. 2020;11(1):9-18. doi:10.1177/1947603518783503
    23. Cong B, Sun T, Zhao Y, Chen M. Current and Novel Therapeutics for Articular Cartilage Repair and Regeneration. Ther Clin Risk Manag. 2023;19:485-502. doi:10.2147/TCRM.S410277
    24. Niemeyer P, Laute V, Zinser W, et al. A Prospective, Randomized, Open-Label, Multicenter, Phase III Noninferiority Trial to Compare the Clinical Efficacy of Matrix-Associated Autologous Chondrocyte Implantation With Spheroid Technology Versus Arthroscopic Microfracture for Cartilage Defects of the Knee. Orthop J Sports Med. 2019;7(7). doi:10.1177/2325967119854442
    25. Hinckel BB, Thomas D, Vellios EE, et al. Algorithm for Treatment of Focal Cartilage Defects of the Knee: Classic and New Procedures. Cartilage. 2021;13(1_suppl):473S-495S. doi:10.1177/1947603521993219
    26. Filho JPAG, Sousa EB de. Tratamento das lesões condrais no joelho. Rev Bras Ortop (Sao Paulo). 2023;58(04):e551-e556. doi:10.1055/s-0043-1772196
    27. Mall NA, Harris JD, Cole BJ. Clinical Evaluation and Preoperative Planning of Articular Cartilage Lesions of the Knee. Journal of the American Academy of Orthopaedic Surgeons. 2015;23(10):633-640. doi:10.5435/JAAOS-D-14-00241
    28. Weishorn J, Wiegand J, Zietzschmann S, et al. Factors Influencing Long-term Outcomes After Matrix-Induced Autologous Chondrocyte Implantation: Long-term Results at 10 Years. American Journal of Sports Medicine. 2024;52(11):2782-2791. doi:10.1177/03635465241270152
    29. Ginesin E, Chari NS, Barnhart J, Wojnowski N, Patel RM. Cartilage Restoration for Isolated Patellar Chondral Defects: An Updated Systematic Review. Orthop J Sports Med. 2023;11(5). doi:10.1177/23259671231153422
    30. Badin D, Leland CR, Bronheim RS, Balmuri N, Lee RJ. Synovectomy in juvenile idiopathic arthritis: A protocol for systematic review and meta-analysis. Medicine. 2022;101(49):E32278. doi:10.1097/MD.0000000000032278
    31. Chalmers PN, Sherman SL, Raphael BS, Su EP. Rheumatoid Synovectomy: Does the Surgical Approach Matter? Clin Orthop Relat Res. 2011;469(7):2062-2071. doi:10.1007/s11999-010-1744-3
    32. Chandra AA, Agarwal S, Donahue A, Handorf E, Abraham JA. Arthroscopic Versus Open Management of Diffuse-Type Tenosynovial Giant Cell Tumor of the Knee: A Meta-analysis of Retrospective Cohort Studies. JAAOS: Global Research and Reviews. 2021;4(12). doi:10.5435/JAAOSGlobal-D-21-00217
    33. Fecek C, Carter KR. Pigmented Villonodular Synovitis. StatPearls. Published online August 7, 2023. https://www.ncbi.nlm.nih.gov/books/NBK549850/
    34. Casadei K, Hermena S. Plica Syndrome Continuing Education Activity.
    35. Abukar A, Li D. Lateral Patellar Compression Syndrome. Accessed November 4, 2025. https://www.ncbi.nlm.nih.gov/books/NBK535362/
    36. Petersen W, Ellermann A, Gösele-Koppenburg A, et al. Patellofemoral pain syndrome. Knee Surgery, Sports Traumatology, Arthroscopy. 2014;22(10):2264-2274. doi:10.1007/s00167-013-2759-6
    37. Saper MG, Shneider DA. Diagnosis and Treatment of Lateral Patellar Compression Syndrome. Arthrosc Tech. 2014;3(5):e633-e638. doi:10.1016/j.eats.2014.07.004
    38. Samelis P V, Koulouvaris P, Savvidou O, Mavrogenis A, Samelis VP, Papagelopoulos PJ. Patellar Dislocation: Workup and Decision-Making. Cureus. Published online October 9, 2023. doi:10.7759/cureus.46743
    39. Dennis ER, Gruber S, Marmor WA, Shubin Stein BE. Evaluation and management of patellar instability. Ann Jt. 2022;7:2-2. doi:10.21037/aoj-2020-02
    40. Severino NR, Severino FR, De Camargo OPA, Guglielmetti LGB, De Oliveira VM, Cury RDPL. Update on Patellar Instability. Rev Bras Ortop (Sao Paulo). 2021;56(2):147-153. doi:10.1055/s-0040-1713389
    41. Wolfe S, Varacallo M, Thomas JD, Carroll JJ, Kahwaji CI. Patellar Instability. StatPearls. Published online February 13, 2023. https://www.ncbi.nlm.nih.gov/books/NBK557657/
    42. Brady JM, Rosencrans AS, Shubin Stein BE. Use of TT-PCL versus TT-TG. Curr Rev Musculoskelet Med. 2018;11(2):261-265. doi:10.1007/s12178-018-9481-4
    43. Barbosa RM, da Silva MV, Macedo CS, Santos CP. Imaging evaluation of patellofemoral joint instability: a review. Knee Surg Relat Res. 2023;35(1). doi:10.1186/s 43019-023-00180-8
    44. Colacchio ND, Abela D, Bono J V., Shah VM, Bono OJ, Scott RD. Efficacy of manipulation under anesthesia beyond three months following total knee arthroplasty. Arthroplast Today. 2019;5(4):522-527. doi:10.1016/j.artd.2019.08.002
    45. Fackler N, Chin G, Karasavvidis T, et al. Outcomes of Arthroscopic Lysis of Adhesions for the Treatment of Postoperative Knee Arthrofibrosis: A Systematic Review. Orthop J Sports Med. 2022;10(9). doi:10.1177/23259671221124911
    46. Walsh JM, Sullivan TC, Varghese B, Incavo SJ, Brown TS, Park KJ. Manipulation Under Anesthesia After Primary Total Knee Arthroplasty. Journal of Arthroplasty. 2025;40(9):S535-S544. doi:10.1016/j.arth.2025.05.032
    47. Eggeling L, Klepsch L, Akoto R, Frosch KH. Clinical results after very early, early and late arthroscopic arthrolysis of the knee. Int Orthop. 2022;46(2):265-271. doi:10.1007/s00264-021-05193-0
    48. Kise NJ, Risberg MA, Stensrud S, Ranstam J, Engebretsen L, Roos EM. Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ. Published online July 20, 2016:i3740. doi:10.1136/bmj.i3740
    49. Migliorini F, Oliva F, Eschweiler J, Cuozzo F, Hildebrand F, Maffulli N. No evidence in support of arthroscopic partial meniscectomy in adults with degenerative and nonobstructive meniscal symptoms: a level I evidence-based systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2023;31(5):1733-1743. doi:10.1007/s00167-022-07040-0
    50. Kellgren JH, Lawrence JS. Radiological Assessment of Osteo-Arthrosis. Ann Rheum Dis. 1957;16(4):494-502. doi:10.1136/ard.16.4.494
    51. Slattery C, Kweon CY. Classifications in Brief: Outerbridge Classification of Chondral Lesions. Clin Orthop Relat Res. 2018;476(10):2101-2104. doi:10.1007/s11999.0000000000000255
    52. Marx RG, Stump TJ, Jones EC, Wickiewicz TL, Warren RF. Development and Evaluation of an Activity Rating Scale for Disorders of the Knee. Am J Sports Med. 2001;29(2):213-218. doi:10.1177/03635465010290021601
    53. Tegner Y, Lyscolm J. Rating Systems in the Evaluation of Knee Ligament Injuries. Clin Orthop Relat Res. 1985;198(NA;):42???49. doi:10.1097/00003086-198509000-00007

    Coding Section

    Code Number Description

    CPT

    27332

    Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial or lateral

     

    27333

    Arthrotomy, with excision of semilunar cartilage (meniscectomy) knee; medial and lateral

     

    27403

    Arthrotomy with meniscus repair, knee

     

    27405

    Repair, primary, torn ligament and/or capsule, knee; collateral

     

    27407

    Repair, primary, torn ligament and/or capsule, knee; cruciate

     

    27409

    Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate ligaments

     

    27412

    Autologous chondrocyte implantation, knee

     

    27415

    Osteochondral allograft, knee, open

     

    27416

    Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])

     

    27418

    Anterior tibial tubercleplasty (eg, maguet type procedure)

     

    27420

    Reconstruction of dislocating patella; (eg, hauser type procedure)

     

    27422

    Reconstruction of dislocating patella; with extensor realignment and/or muscle advancement or release (eg, campbell, goldwaite type procedure)

     

    27424

    Reconstruction of dislocating patella; with patellectomy

     

    27425

    Lateral retinacular release, open

     

    27427

    Ligamentous reconstruction (augmentation), knee; extra-articular

     

    27428

    Ligamentous reconstruction (augmentation), knee; intra-articular (OPEN)

     

    27429

    Ligamentous reconstruction (augmentation), knee; intra-articular (OPEN) and extra-articular

     

    27570

    Manipulation of knee joint under general anesthesia (includes application of traction or other fixation devices)

     

    29866

    Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])

     

    29867

    Arthroscopy, knee, surgical; osteochondral autograft (eg, mosaicplasty)

     

    29868

    Arthroscopy, knee, surgical; meniscal transplantation (include arthrotomy for meniscal insertion), medial or lateral

     

    29870

    Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)

     

    29873

    Arthroscopy, knee, surgical; with lateral release

     

    29874

    Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)

     

    29875

    Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)

     

    29876

    Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)

     

    29877

    Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)

     

    29879

    Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture

     

    29880

    Arthroscopy, knee, surgical; with meniscectomy (medial and lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

     

    29881

    Arthroscopy, knee, surgical; with meniscectomy (medial or lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed

     

    29882

    Arthroscopy, knee, surgical; with meniscus repair (medial or lateral)

     

    29883

    Arthroscopy, knee, surgical; with meniscus repair (medial and lateral)

     

    29884

    Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)

     

    29885

    Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion)

     

    29886

    Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion

     

    29887

    Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation

     

    29888

    Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction

     

    29889

    Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction

    HCPCS

    G0289

    Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee

    Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

    This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.

    "Current Procedural Terminology © American Medical Association. All Rights Reserved" 

    History From 2026 Forward

    07/01/2026 Annual review, no change to policy intent. Updating policy for clarity and concistency. Also updating general information, adding special note, rationale, and references. 
    04/01/2026 New Policy

     

     

     

Complementary Content
${loading}