Proprietary
Prior Authorization Review Panel MCO Policy Submission
A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Plan: Aetna Better Health Submission Date:09/01/2020
Policy Number: 0545 Effective Date: Revision Date: 08/18/2020
Policy Name: Electrothermal Arthroscopy
Type of Submission – Check all that apply:
New PolicyRevised Policy* Annual Review – No Revisions Statewide PDL
*All revisions to the policy must be highlighted using track changes throughout the document.
Please provide any clarifying information for the policy below:
CPB 0545 Electrothermal Arthroscopy
This CPB has been revised to state that electrothermal arthroscopy is considered experimental and investigational for partial scapholunate ligament tears.
Name of Authorized Individual (Please type or print):
Benjamin Alouf, MD, MBA, FAAP
Signature of Authorized Individual:
Revised July 22, 2019
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Electrothermal Arthroscopy - Medical Clinical Policy Bulletins | Aetna Page 1 of 25
(https://www.aetna.com/)
Electrothermal Arthroscopy
Policy History
Last Review
08/18/2020
Effective: 06/22/2001
Next
Review: 06/10/2021
Review History
Definitions
Additional Information
Clinical Policy Bulletin
Notes
Number: 0545
Policy
Aetna considers electrothermal arthroscopy (also known as
electrothermally-assisted capsule shift, and electrothermally
assisted capsulorrhaphy (ETAC)) of the joint capsule,
ligaments, or tendons experimental and investigational for all
indications, including any of the following because available
scientific evidence does not permit conclusions concerning the
long-term effects on health outcomes (not an all-inclusive list):
▪ Achilles injuries; or
▪ Adhesive capsulitis; or
▪ Ankle, hip, knee, or thumb instability; or
▪ Bankart lesions; or
▪ Bony avulsion of the capsule; or
▪ Deficient or thin capsule; or
▪ Frozen shoulder; or
▪ Glenohumeral joint (shoulder) instability; or
▪ Hill-Sachs lesions; or
▪ Humeral-side avulsion of the capsule; or
▪ Ligament tear and meniscal injury of the knee; or
▪ Multi-directional instability; or
▪ Partial scapholunate ligament tears; or
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▪ Temporomandibular joint dislocation; or
▪ Wrist injuries.
See also CPB 0475 - Coblation (../400_499/0475.html).
Background
Thermal capsular shrinkage, also known as thermal
capsulorrhaphy, is an arthroscopic procedure performed under
general anesthesia that utilizes thermal energy/heat to shrink
the tendons or ligaments of the synovial joint. Thermal
capsulorrhaphy purportedly increases stability of the joint. It is
theorized that when heat is applied to the tissue a molecular
change occurs to the structure of collagen (the chief
component of connective tissue, tendons and bones) causing
the length of the collagen to shrink and tighten.
Examples of thermal capsular shrinkage devices include, but
may not be limited to: ArthroCare system 2000 CAPS X
ArthroWand; ORA-50 electrothermal system and
accessories; VULCAN EAS electrothermal arthroscopy system
and accessories; VAPR TC electrode for use with VAPR II
electrosurgical system.
The shoulder joint is a ball and socket type of joint that permits
a wide range of movement. Its bony structures include the
humerus and the shallow cavity (the glenoid) of the shoulder
blade, thus making it inherently unstable. A circle of
ligaments, tendons, muscles and cartilage form a capsule
around the joint to maintain stability. The glenoid labrum is the
fibro-cartilage ring attached to the rim of the glenoid cavity,
and acts to stabilize the humeral head inside the glenoid. The
Bankart lesion is a specific injury to a part of the shoulder joint
called the labrum.
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Shoulder instability is defined as excessive movements of the
shoulder that cause pain in daily activities or sporting
activities. Dislocations occur when the head of the humerus
completely pops out of the socket, and typically are the result
of a complete dislocation with capsulo-labral avulsion, a
tearing away of the labrum from the glenoid rim. The first few
times this happens, it is usually with significant, high-energy
trauma. After that, it can get easier and easier for the joint to
dislocate. Most shoulder dislocations are anterior.
Subluxation is the feeling that the shoulder slips slightly out of
socket, then immediately comes back in place.
The cause of this instability varies. Sometimes it is the result
of an abnormal, generalized hyperlaxity of the capsule usually
caused by repetitive microtrauma, such as in overhead
throwing sports, racquet sports, and swimming. It can also
result from recurrent partial or full anterior dislocations of the
shoulder. Aching, heaviness, or sharp pains associated with
pathologic conditions of the rotator cuff, biceps, or labrum are
common presenting complaints.
The main goal for any shoulder surgery is to stabilize the
shoulder and maintain a full, pain-free range of motion. The
multiplicity of procedures that address this problem have in
common either blocking anterior displacement of the humerus
and/or tightening the joint capsule. For long-term shoulder
health, anatomic stabilization of the Bankart lesion is the first
priority because it corrects uni-directional anterior
subluxation/dislocation. The Bankart procedure involves a
small incision (1 cm) into the shoulder, and a suturing of the
labrum back to the glenoid. The Bankart repair reduces pain
and can be performed without causing a significant loss of
external rotation.
Anatomic re-attachment of the capsulo-labral complex alone
may not successfully stabilize the gleno-humeral joint. It has
been proposed that the higher recurrence rates seen in
arthroscopic repairs that secure the capsulo-labral complex
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back to the glenoid rim may be the result of failure to treat the
stretched-out capsule. Electrothermally-assisted
capsulorrhaphy (ETAC), also known as electrothermal
arthroscopy and electrothermally-assisted capsule shift,
provides an easy approach to arthroscopically advance or
tighten the capsule in conjunction with arthroscopic re
attachment procedures.
The ElectroThermal Arthroscopy System uses high-energy
radiofrequency waves to heat the collagen fibers in the joint.
This controlled thermal energy eventually causes contraction
and firming up of the soft tissue in an effort to stabilize the
joint. Initial success of this procedure appears to depend on
proper patient selection, appropriate surgical technique,
attention to the rehabilitation program, and patient
compliance. Monopolar electrothermal stabilization is
technically easy to perform, and reported peri-operative
complication rates have been low. Short-term, uncontrolled
studies of electrothermal arthroscopy for shoulder instability
have shown preservation of range of motion and more rapid
post-operative recovery than with open procedures. Although
results of short-term studies of electrothermal arthroscopy
appear to equal or exceed other surgical procedures, longer-
term clinical outcome studies with direct comparisons with
open procedures are necessary to determine the effectiveness
of electrothermal arthroscopy. Long-term follow-up is
necessary to determine whether results for this procedure will
deteriorate over time.
In this regard, a number of investigators have commented on
the need for long-term follow-up studies of electrothermal
arthroscopy for shoulder instability. Levine et al (2001)
reported that the advances in thermal treatment of the capsule
have made arthroscopic electrothermal capsulorrhaphy
increasingly attractive as an alternative to the open approach
for the primary treatment of multi-directional instability.
However, the authors concluded that longer follow-ups will be
necessary before definitive statements can be made regarding
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the arthroscopic techniques. Khan et al (2002) noted that
monopolar electrothermal stabilization of the shoulder shows
considerable promise as a treatment alternative in athletes
and patients with recurrent instability. However, long-term
follow-up is necessary to determine if results for this procedure
deteriorate over time, especially in patients with multi-
directional instability. Furthermore, Walton et al (2002) noted
that “[g]ood results have been reported with this technique in
recent short-term studies” but that “[f]urther long-term
evaluations are necessary to evaluate the technique,
indications, and results of this novel method of reducing
capsular volume”. Levitz et al (2001) cautioned that it is not
known how much the capsule should be shrunk or what long
term results will show.
Current evidence supporting the use of electrothermal
arthroscopy for shoulder instability is limited to uncontrolled
retrospective (Hovis et al, 2002; Lephart et al, 2002; Levitz et
al, 2001; Lyons et al, 2001; Reinold et al, 2003; Joseph et al,
2003) and prospective case series, with variable results
(Fitzgerald et al, 2002; Levy et al, 2000; Mishra et al, 2001;
Savoie et al, 2000; Noonan et al, 2003; and Gieringer, 2003).
Most of these studies are small and of short duration, although
some mid-term results have been reported. There is a lack of
adequate well-controlled long-term clinical studies of the
effectiveness and durability of electrothermal arthroscopy,
comparing outcomes of this procedure with established
surgical methods of treating shoulder instability.
In a review of the literature on electrothermal arthroscopy,
Gerber and Warner (2002) of the Harvard Shoulder Service
have warned that “Currently, however, the indications for
thermal capsulorrhaphy are defined poorly, clinical outcome
has not been shown to be superior to conventional
stabilization procedures, and long-term effects on joint biology
and mechanics are not known. Based on a critical review of
the literature and personal clinical experience, the authors
conclude that additional experimental and clinical
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investigations are necessary to add this procedure to the
accepted modalities applied for the treatment of shoulder
instability”.
A technology assessment of electrothermal arthroscopy
prepared for the Washington State Department of Labor and
Industries (2003) concluded that, “[w]hile researchers have
published their findings in peer-reviewed journals, the
evidence comes primarily from case series studies with small
study populations. Therefore, findings do not substantially
show thermal shrinkage’s efficacy or effectiveness for the
treatment of shoulder instability...”.
Recent studies by Enad et al (2004) as well as D'Alessandro
et al (2004) indicated that the long-term outcome of
electrothermal arthroscopy is unsatisfactory. Enad et al (2004)
examined the effectiveness of arthroscopic electrothermal
capsulorrhaphy for the treatment of instability in overhand
athletes. Electrothermal capsulorrhaphy without labral repair
was used to treat 20 symptomatic overhand athletes (15
baseball, 3 softball, and 2 volleyball). A total of 19 patients
were evaluated at a mean of 23 months. Overall Rowe results
were 10 excellent, 4 good, 2 fair, and 3 poor, with a mean
score of 82. The overall mean American Shoulder and Elbow
Surgeons (ASES) score was 85.7 (mean pain score, 42.2;
mean score for activities of daily living, 43.5). Two failures (10
%) required open shoulder stabilization. Ten athletes returned
to their prior level of sport, 3 returned to a lower level, and 6
were unable to return to their sport. These preliminary results
indicate that treatment of the overhand athlete with isolated
electrothermal capsulorrhaphy is favorable but does not
reproduce the success of open surgery. Overall recurrence
and failure rates were high. Instability in overhand athletes
may require something other than isolated electrothermal
capsulorrhaphy to address laxity.
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D'Alessandro et al (2004) reported a “high rate of
unsatisfactory results” in a published prospective evaluations
of the effectiveness of arthroscopic electrothermal
capsulorrhaphy with 2 to 5 years follow-up. This non-
randomized prospective study evaluated the indications and
results of thermal capsulorrhaphy in 84 subjects with shoulder
instability. Subjects underwent arthroscopic thermal
capsulorrhaphy after initial assessment, radiographs, and
failure of a minimum of 3 months of non-operative
rehabilitation. Outcome measures included pain, recurrent
instability, return to work/sports, and the ASES Shoulder
Assessment score. After a median duration of follow-up of 38
months, overall results were excellent in 33 participants (39
%), satisfactory in 20 (24 %), and unsatisfactory in 31 (37 %).
The authors concluded that ”[t]he high rate of unsatisfactory
overall results (37 %), documented with longer follow-up, is of
great concern”. The authors cautioned that “[t]he enthusiasm
for thermal capsulorrhaphy should be tempered until further
studies document its efficacy”.
There is also a lack of evidence of the effectiveness of
electrothermal arthroscopy for other joints, including knee,
ankle and elbow. The most thoroughly studied indication for
electrothermal arthroscopy, other than shoulder instability, is
anterior cruciate ligament (ACL) laxity. Carter et al (2002)
reported failure at an average of 4 months post-surgery in 11
of 18 patients with laxity of the ACL treated with electrothermal
arthroscopy. Of the 7 patients with a good result, 6 were
treated for acute laxity. The investigators concluded “[e]ven
with the short-term follow-up in our study, it is evident that
thermal shrinkage using radiofrequency technology has limited
application for patients with anterior cruciate ligament laxity.
Although it may be useful in treating patients with an acutely
injured native anterior cruciate ligament, further study is
needed to see if the ligament stretches out over time or is at
increased risk of reinjury.” Indelli and co-workers (2003)
reported their experience using monopolar thermal repair on
28 consecutive knees with partial ACL tears. Based on
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measurements of ACL stability 2 or more years after surgery,
the authors found the results to be comparable to experience
with ACL re-constructions with allograft. The authors stated,
however, that longer follow-up and the results of other studies
will better define the selection, methods, and results of thermal
repair of partial ACL tears. Oakes and McAllister (2003) stated
that although the use of thermal energy to selectively shrink
tissues may ultimately prove to be an invaluable tool, the lack
of well-designed, randomized controlled studies to firmly
establish its efficacy in the treatment of partial cruciate injuries
mandates cautious use of this technique at this time. A
technology assessment prepared for the Washington State
Department of Labor and Industries (2003) concluded that
there is inadequate evidence of the effectiveness of
electrothermal arthroscopy for ACL laxity.
In a review on thermal modification of the lax ACL by means of
radiofrequency, Lubowitz (2005) stated that results of
shrinkage of a lax, intact native ACL using radiofrequency
seems promising, but complications of catastrophic,
spontaneous ACL rupture have been reported. The author
noted that more research is needed to define treatment
techniques, indications, and selection criteria for ACL thermal
shrinkage using radiofrequency and to compare its outcomes
with traditional ACL reconstructive surgery.
In a a multi-center study, Smith and colleagues (2008)
prospectively evaluated the mid-term results (beyond 2 years)
of thermal shrinkage on both lax native ACL and lax re
constructions and determined the effectiveness of this
procedure. A total of 64 patients underwent electrothermal
shrinkage for a lax ACL, both native and previous re
constructions. They were followed-up past 2 years with KT
1000 measurements. Failure criteria were subsequent
operations for instability and KT-1000 measurements greater
than 5 mm. Three patients were lost to follow-up. Among the
61 patients followed-up past 2 years, failure occurred in 31
(50.8 %). The failure rate for lax grafts alone was 78.9 %, and
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there was a failure rate of 38.1 % for lax native ligaments. The
authors concluded that electrothermal shrinkage of lax native
or re-constructed ACLs is not an appropriate treatment.
Chloros et al (2008) reviewed the recent literature on
arthroscopic treatment of distal radius fractures (DRFs),
triangular fibro-cartilage complex injuries, inter-carpal ligament
injuries, and ganglion cysts, including the use of electrothermal
devices. A major advantage of arthroscopy in the treatment of
DRFs is the accurate assessment of the status of the articular
surfaces and the detection of concomitant injuries. Non-
randomized studies of arthroscopically assisted reduction of
DRFs show satisfactory results, but there is only 1 prospective
randomized study showing the benefits of arthroscopy
compared with open reduction-internal fixation. Wrist
arthroscopy plays an important role as part of the treatment for
DRFs; however, the treatment for each practitioner and each
patient needs to be individualized. Wrist arthroscopy is the
gold standard in the diagnosis and treatment of triangular
fibro-cartilage complex injuries. Type 1A injuries may be
successfully treated with debridement, whereas the repair of
type 1B, 1C, and 1D injuries gives satisfactory results. For
type 2 injuries, the arthroscopic wafer procedure is equally
effective as ulnar shortening osteotomy but is associated with
fewer complications in the ulnar positive wrist. With
interosseous ligament injuries, arthroscopic visualization
provides critical diagnostic value. Debridement and pinning in
the acute setting of complete ligament tears are promising and
proven. In the chronic patient, arthroscopy can guide re-
constructive options based on cartilage integrity. The
preliminary results of wrist arthroscopy using electrothermal
devices are encouraging; however, complications have been
reported, and therefore, their use is controversial. In dorsal
wrist ganglia, arthroscopy has shown excellent results, a lower
rate of recurrence, and no incidence of scapholunate
interosseous ligament instability compared with open
ganglionectomy. Arthroscopy in the treatment of volar wrist
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ganglia has yielded encouraging preliminary results; however,
further studies are warranted to evaluate the safety and
effectiveness of arthroscopy.
Chu and colleagues (2009) examined if radiofrequency
electrothermal treatment of thumb basal joint instability could
produce clinical improvement and result in successful
functional outcomes for patients. From August 2001 to April
2006, these researchers treated 17 thumbs with symptomatic
thumb basal joint instability using arthroscopic electrothermal
shrinkage of the volar ligaments and joint capsule with a
monopolar radiofrequency probe. The sample included 11
men and 6 women with a mean age of 35.3 years (range of 20
to 60 years). All patients underwent regular clinical follow-up
at a mean of 41 months (range of 24 to 80 months). Pain
improved in all thumbs after surgery. Thumb pinch strength
significantly improved in all thumbs after surgery (p < 0.01).
All patients were satisfied with the results and returned to their
pre-injury activities. The authors concluded that by use of the
described method of arthroscopic electrothermal shrinkage of
the volar ligaments and joint capsule in patients with
symptomatic thumb basal joint instability, most patients had
good subjective results and the pinch strength improved
significantly in most patients. Of 17 thumbs, 16 had
satisfactory subjective and functional stability at a minimum 2
years' follow-up. This was a small, non-controlled study; its
findings need to be validated by well-designed studies.
Torres and McCain (2012) noted that acute
temporomandibular joint dislocation is a common occurrence
that is generally treated by conservative therapy. In some
patients, this can become a chronic recurrent condition. This
recurrent temporomandibular joint dislocation (RTD) can
significantly decrease the patient's quality of life and require
some form of surgical intervention for correction. These
researchers examined the effectiveness of a minimally
invasive alternative treatment for RTD using operative
arthroscopy. A total of 11 patients treated for RTD between
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2004 and 2010 were retrospectively analyzed. Electrothermal
capsulorrhaphy was performed using a standard double
puncture operative arthroscopy with a Hol:YAG laser and/or
electrocautery. Post-operatively, the patients were monitored
for 6 months to 6 years. Of the 11 subjects, 2 suffered a
recurrence of temporomandibular dislocation and required
open arthrotomy for correction. The other 9 patients had no
signs of recurrence or any significant post-operative loss of
function. The authors concluded that electrothermal
capsulorrhaphy is an effective and minimally invasive method
for the treatment of RTD. The findings of this small, non-
controlled study need to be validated by well-designed studies.
The triangular fibro-cartilage complex (TFCC) is formed by the
triangular fibro-cartilage discus, the radio-ulnar ligaments and
the ulno-carpal ligaments. Garcia-Lopez et al (2012)
evaluated the clinical and occupational outcomes of
arthroscopic treatment with electrothermal shrinkage for TFCC
tears. These researches retrospectively reviewed 162
patients. All patients had ulnar-sided wrist pain that limited
their occupational and sporting activities. The surgical
technique consisted of electrothermal collagen shrinkage of
the TFCC. Pain relief, range of motion, complications, re-
operation rate, time to return to work and workers'
compensation claims were evaluated. Exclusion criteria were
distal radioulnar joint instability and association of other wrist
lesions. Complete pain relief was noted in 80.3 % of the
patients, incomplete pain relief in 14.8 %, and only 4.9 %
required re-operation because of pain-persistence. The
average range of motion was over 90 % compared to the
opposite hand. Worker's compensation claims were
introduced by 20 patients, of which 6 did not return to their
previous occupation. The authors concluded that
electrodiathermy may be a useful option for arthroscopic
treatment of TFCC tears in cases without distal radioulnar joint
instability. The findings of this study need to be validated by
well-designed studies.
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Mohtadi et al (2014) noted that radiofrequency technology for
shoulder instability was rapidly adopted despite limited clinical
evidence and a poor understanding of its indications. Reports
of serious adverse events followed, leading to its
abandonment. These researchers presented findings from a
multi-center randomized clinical trial evaluating the safety and
effectiveness of ETAC compared with open inferior capsular
shift (ICS) and reviewed the role of randomized trials in
adopting new technology. Patients (greater than 14 years)
diagnosed with multi-directional instability or multi-directional
laxity with antero-inferior instability and failed non-operative
treatment were enrolled. Patients with bone lesions or labral,
biceps anchor, or full-thickness rotator cuff tears were
excluded intra-operatively. Outcomes included Western
Ontario Shoulder Instability Index, function and recurrent
instability at 2 years post-operatively, and surgical times. A
total of 54 subjects (mean age of 23 years; 37 women) were
randomized to ETAC (n = 28) or open ICS (n = 26). The
groups were comparable at baseline, except for external
rotation at the side. At 2 years post-operatively, there were no
statistically or clinically significant differences between groups
for the Western Ontario Shoulder Instability Index (p = 0.71),
American Shoulder and Elbow Surgeons score (p = 0.43),
Constant score (p = 0.43), and active range of motion.
Recurrent instability was not statistically different (ETAC, 2;
open, 4; p = 0.41). Electrothermally-assisted capsulorrhaphy
(23 minutes) was significantly shorter than open ICS (59
minutes) (p < 0.01) surgery. Three subjects (1 ETAC, 2 open)
had stiff shoulders. The authors concluded that at 2 years post
operatively, quality of life and functional outcomes between
groups were not clinically different; ETAC had fewer
complications and episodes of recurrence compared with open
surgery. They stated that this evidence reinforced the need to
critically evaluate new technology before widespread clinical
use.
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UpToDate reviews on “Overview of surgical therapy of knee
and hip osteoarthritis” (Mandl and Marin, 2015), “Synovectomy
for inflammatory arthritis of the knee” (Wright, 2015) do not
mention electrothermal arthroscopy/ETAC as a therapeutic
option.
McRae and associates (2016) noted that ETAC was
introduced as an adjunct to shoulder stabilization surgery to
address capsular laxity in the treatment of traumatic anterior
dislocation. No previous randomized controlled trial (RCT) has
compared arthroscopic Bankart repair with ETAC of the medial
gleno-humeral ligament and anterior band of the inferior gleno
humeral ligament versus undergoing arthroscopic Bankart
repair alone. These investigators hypothesized that there
would be no difference in quality of life (QOL) between these 2
groups. Complication/failure rates were also compared. A
total of 88 patients were randomly assigned to receive
arthroscopic Bankart repair with (n = 44) or without ETAC (n =
44). Post-operative visits occurred at 3, 6, 12, and 24 months
with WOSI, ASES, and Constant scores completed, and rates
of dislocation/subluxation were determined. Data on 74
patients were analyzed, with the rest lost to follow-up. There
were no differences between groups at any post-surgery time
points for WOSI, ASES, or Constant scores (non-significant.);
8 patients in the no-ETAC group and 7 in the ETAC group
were considered failures (non-significant). The authors
concluded that no benefits in patient-reported outcome or
recurrence rates using ETAC were found. Mean WOSI scores
2 years post-surgery were virtually identical for the 2 groups;
ETAC could not be shown to provide benefit or detriment when
combined with arthroscopic labral repair for traumatic anterior
instability of the shoulder.
UpToDate reviews on “Anterior cruciate ligament
injury” (Friedberg, 2017) and “Meniscal injury of the
knee” (Cardone and Jacobs, 2017) do not mention
electrothermal arthroscopy as a therapeutic option.
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Partial Scapholunate Ligament Tears
In a prospective study, Romero and colleagues (2020)
examined the outcomes of arthroscopic electrothermal
shrinkage for partial scapholunate (SL) ligament tears, isolated
or with associated triangular fibrocartilage complex (TFCC)
injuries. This trial included 20 patients with symptomatic
instability of SL ligament (14 of them also with TFCC wrist
injuries) treated with arthroscopic electrothermal shrinkage
using a monopolar radiofrequency probe. No patient showed
radiologic signs of static dissociation (mean SL interval =of
2.2 ± 0.6 mm; mean SL angle of 41.4° ± 6.7°) before surgery.
All participants underwent follow-up at the authors’ clinic
regularly for an average of 50.6 months (range of 29 to 80
months). The modified Mayo wrist score improved from a
mean of 59 ± 17.1 points pre-operatively to 88.3 ± 16.2 points
at the final follow-up. At the final clinical examination, a painful
Watson scaphoid shift test was found in 3 patients (15 %).
The mean flexion-extension arc was unchanged (132° ± 19°),
and mean grip strength improved 12 kg. No patient showed
radiologic signs of arthritis or instability after surgery (mean SL
interval of 1.9 ± 0.7 mm; mean SL angle of 42.7° ± 7.3°). Of
the 14 patients with combined TFCC injuries, 3 patients
continued complaining of ulnar-sided point tenderness. At the
end of the follow-up, 80 % of the subjects were satisfied or
very satisfied. The authors concluded that SL ligament and
TFCC electrothermal shrinkage effectively provided pain relief
and grip strength increase for most of the patients treated.
Level of Evidence = IV. This was a small (n = 20) study that
provided Level IV evidence; these findings need to be
validated by well-designed studies.
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Proprietary
Code Code Description
CPT codes not covered for indications listed in the CPB:
Electrothermal arthroscopy - no specific code
Other CPT codes related to the CPB:
29804 Arthroscopy, temporomandibular joint, surgical
29806 -
29828
Arthroscopy, shoulder, surgical
29843 -
29847
Arthroscopy, wrist, surgical
29848 Endoscopy, wrist surgical, with release of
transverse carpal ligament
29861 -
29863
Arthroscopy, hip, surgical
29870 -
29887
Arthroscopy, knee [not covered for
electrothermal arthroscopy]
29891 -
29899
Arthroscopy, ankle
29905 Arthroscopy, subtalar joint, surgical; with
synovectomy
29906 with debridement
29907 with subtalar arthrodesis
HCPCS codes not covered for indications listed in the CPB:
S2300 Arthroscopy, shoulder, surgical; with thermally-
induced capsulorrhaphy
ICD-10 codes not covered for indications listed in the CPB (not all-inclusive):
M23.000
- M23.92
Internal derangement of knee
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Proprietary
Code Code Description
M24.00 -
M25.9
Other specific joint derangements
M26.601
- M26.69
Temporomandibular joint disorders
M65.871
-
M65.879
Other synovitis and tenosynovitis of ankle and
foot
M75.00 -
M75.02
Adhesive capsulitis of shoulder
M76.60 -
M76.62
Achilles tendinitis
Numerous
options
Sprains and strains of wrist [Codes not listed
due to expanded specificity]
Numerous
options
Sprains and strains of ankle and foot [Codes
not listed due to expanded specificity]
Numerous
options
Injury, elbow, forearm, and wrist [Codes not
listed due to expanded specificity]
S03.00x+
-
S03.02x+
Dislocation of jaw
S63.511A
-
S63.519S
Sprain of carpal (joint) of wrist [partial
scapholunate ligament tears]
S76.111A
-
S76.119S
Strain of quadriceps muscle, fascia and tendon
S83.200A
-
S83.32xS
Tear of meniscus, current injury
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Proprietary
Code Code Description
S83.401A
-
S83.429S
Sprain of collateral ligament of knee
S83.501A
-
S83.529S
Sprain of cruciate ligament of knee
Electrothermal Arthroscopy - Medical Clinical Policy Bulletins | Aetna Page 17 of 25
The above policy is based on the following references:
1. An YH, Friedman RJ. Multidirectional instability of the
glenohumeral joint. Orthop Clin North Am. 2000;31
(2):275-285.
2. Anderson K, Warren RF, Altchek DW, et al. Risk factors
for early failure after thermal capsulorrhaphy. Am J
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Copyright © 2001-2020 Aetna Inc.
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AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number: 0545 Electrothermal
Arthroscopy
There are no amendments for Medicaid.
www.aetnabetterhealth.com/pennsylvania revised 08/18/2020
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