TURNINGPOINT CLINICAL POLICY

Transcription

1 NOTE: For services provided on December 3, 2018 and after, Horizon Blue Cross Blue Shield of New Jersey ( Horizon BCBSNJ ) has contracted with TurningPoint Healthcare Solutions, LLC to conduct Prior Authorization and Medical Necessity Determination reviews for certain Orthopedic services ( the Program ) for members enrolled in Horizon BCBSNJ s fully insured plans. The criteria and guidelines included here apply to these members. Click here to access Horizon BCBSNJ s medical policy criteria and guidelines that apply to Horizon BCBSNJ s members in self-insured plans or plans that DO NOT participate in the Program. Policy Number: OR-1025-HZN Policy Name: Surgical Treatment of Femoroacetabular Impingement Syndrome Common Name: Femoroacetabular Arthroscopy Definition: Femoroacetabular impingement is a condition where the hip bones rub against each other because they are abnormally shaped and cause damage to the joint 1. I. Criteria for Inclusion: A. Surgical intervention for the treatment of femoroacetabular impingement syndrome (FAIS) is considered medically appropriate when ALL the following criteria has been met: 1. Patient is between years of age and skeletally mature with documented closure of the growth plates 10 ; and 2. Patient has severe symptoms of FAIS, including hip pain that is worsened by flexion activities, that interferes with their ability to perform activities of daily living; and 3. Imaging evidence of FAIS on AP or lateral x-ray, or CT scan, showing one of the following: a) Cam impingement confirmed by: i. Alpha angle > 55 degrees b) Pincer impingement confirmed by: i. Center edge angle > 39 degrees; or ii. Positive cross-over sign; or iii. Acetabular retroversion or overcoverage; or iv. Coxa profunda c) Non-spherical femoral head shape 2-4 ; and 4. Patient has minimal degeneration of the hip joint (Tönnis grade 1 or less), absence of joint space narrowing, and minimal cartilage injury (Outerbridge grade II or less) 5-6,9. 5. Symptoms have failed to respond to conservative therapy for at least 6 months, including the following 7-8 : a) Activity modification, including restriction of aggressive activities and avoidance of symptomatic movements; and b) Pharmacological intervention with NSAIDs or acetaminophen; and c) Rehabilitation of core hip musculature; and d) Intra-articular glucocorticoid injections; and 6. All other reasonable causes of pain have been ruled out. II. Criteria for Exclusion: 1 P a g e P r o p r i e t a r y & C o n f i d e n t i a l

2 A. Surgical intervention for the treatment of FAIS is not considered medically necessary when the criteria above has not been met, including but not limited to the following: 1. Advanced osteoarthritis (Tönnis grade II or more OR joint space of less than 2mm); or 2. Advanced chondral damage (Outerbridge grade III ore more); or 3. Patients with osteogenesis imperfecta or diseases associated with hypermobility of the joints (Marfan syndrome, Ehlers-Danlos syndrome). B. The use of capsular plication for the treatment of FAIS is considered investigational due to insufficient evidence showing improvement in patient outcomes. C. For persons with significant co-morbidities or complications, the medical record must contain documentation of the risk/benefit of FAIS surgery. III. Device Considerations A. Only implants with FDA approval are considered to be medically appropriate IV. Surgical Considerations A. Pre-Operative Considerations: 1. Preoperative care planning needs may include a) Routine preoperative evaluation b) Preoperative treatment, procedures, and stabilization, including i. Hip x-rays ii. Hip CT iii. Ruling out sources of infection, including dental and lower urinary tract infections iv. Dental prophylaxis as indicated c) Preoperative discharge planning as appropriate B. Intra-Operative Considerations: 1. Antibacterial wipes 2. Antibacterial nasal swab C. Post-Operative & Inpatient Considerations: 1. Hospital evaluation and care needs may include: a) Diagnostic test scheduling and completion, including: i. Complete blood count, PT and INR monitoring ii. Lower extremity Doppler study b) Treatment and procedure scheduling and completion, including: i. IV antibiotics ii. DVT prophylaxis iii. Wound management iv. Pain management c) Consultation, assessment, and other services scheduling and completion, including: i. Physical therapy ii. Occupational therapy iii. Gait training d) Monitoring patient's status for deterioration and comorbid conditions; key items include: 2 P a g e P r o p r i e t a r y & C o n f i d e n t i a l

3 i. Neurovascular status ii. Transfusion need iii. Assessment of wound healing iv. Cardiac and respiratory status D. Discharge Planning & Considerations 1. Discharge planning includes: a) Assessment of needs and planning for care, including: i. Develop treatment plan (involving multiple providers as needed). ii. Evaluate and address preadmission functioning as needed. iii. Evaluate and address patient or caregiver preferences as indicated. iv. Identify skilled services needed at next level of care, with specific attention to: Medication management, adherence instruction, and side effects assessment Pain management Rehabilitation therapy or equipment coordination Wound or dressing management v. Evaluate and address psychosocial status issues as indicated (see Psychosocial Assessment for further information) b) Early identification of anticipated discharge destination; options include: i. Home, considerations include: Access to follow-up care Home safety assessment (see Home Safety Assessment for further information) Self-care ability, if appropriate (see Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) Assessment for further information) Caregiver need, ability, and availability ii. Post-acute skilled care or custodial care, as indicated (see Discharge Planning Tool for further information) c) Transition of care plan complete, which may include: i. Patient and caregiver education complete (see Hip Resurfacing: Patient Education for Clinicians) ii. Medication reconciliation completion includes: Compare patient's discharge list of medications (prescribed and over-the-counter) against physician's admission or transfer orders. Assess each medication for correlation to disease state or medical condition. Report medication discrepancies to prescribing physician, attending physician, and primary care provider, and ensure accurate medication order is identified. Provide reconciled medication list to all treating providers. Confirm that patient, family, or caregiver can acquire medication. Educate patient, family, and caregiver. Provide complete medication list to patient, family, or caregiver. Confirm that patient, family, or caregiver understands importance of presenting personal medication list to all providers at each care transition, including all physician appointments. 3 P a g e P r o p r i e t a r y & C o n f i d e n t i a l

4 Confirm that patient, family, or caregiver understands reason, dosage, and timing of medication (eg, use "teach-back" techniques). iii. Plan communicated to patient, caregiver, and all members of care team, including: Inpatient care and service providers Primary care provider All post-discharge care and service providers iv. Post-discharge appointment plans made as needed, which may include: Primary care provider Anticoagulation monitoring Orthopedic surgeon Rehabilitation therapy services v. Post-discharge testing and procedure plans made, which may include: Laboratory testing vi. Referrals made for assistance or support, which may include: Financial, for follow-up care, medication, and transportation Smoking cessation counseling or treatment vii. Medical equipment and supplies coordinated (ie, delivered or delivery confirmed) which may include: Ambulation devices (eg, cane, crutches, walker) Antiembolic or compression stockings Bath and toilet aids Syringes and needles for subcutaneous injections Wound care supplies V. Length of Stay Considerations A. Goal length of stay: not available B. Facility type criteria: not available VI. Coding Services may be Medically Necessary when criteria are met and below coding is used A. CPT Unlisted procedure, pelvis or hip joint [when specified as open procedure for femoroacetabular impingement syndrome, other than capsular plication] Arthroscopy, hip, surgical; with debridement/shaving of articular cartilage (chondroplasty), abrasion arthroplasty, and/or resection of labrum Arthroscopy, hip, surgical; with femoroplasty (ie, treatment of cam lesion) Arthroscopy, hip, surgical; with acetabuloplasty (ie, treatment of pincer lesion) Arthroscopy, hip, surgical; with labral repair [when repair of the labral tear is associated with FAIS] Unlisted procedure, arthroscopy 4 P a g e P r o p r i e t a r y & C o n f i d e n t i a l

5 B. HCPCS No specified HCPCS codes C. ICD-9 Procedure Arthroscopy; unspecified site Arthroscopy; hip D. ICD-10 Procedure 0SJ94ZZ Inspection of Right Hip Joint, Perc Endo Approach 0SJB4ZZ Inspection of Left Hip Joint, Perc Endo Approach E. ICD-9 Diagnosis , , , , , , , , 719.7, , F. ICD-10 Diagnosis M16.9, M24.459, M24.859, M24.9, M25.159, M25.551, M25.552, M25.559, M25.659, M25.851, M25.852, M25.859, M24.9, R26.2, S73.199A 5 P a g e P r o p r i e t a r y & C o n f i d e n t i a l

6 References 1. AAOS. (2010). Femoroacetabular impingement (FAI). Retrieved from 2. Tibor, L., & Sekiya, J. (2014). Differential diagnosis of pain around the hip joint. Arthroscopy-The Journal Of Arthroscopic And Related Surgery, 24(12), Kassarjian, A., & Belzile, E. (2008). Femoroacetabular impingement: presentation, diagnosis, and management. Seminars In Musculoskeletal Radiology, 12(2), Pfirrmann, C., Mengiardi, B., Dora, C., Kalberer, F., Zanetti, M., & Hodler, J. (2006). Cam and pincer femoroacetabular impingement: Characteristic MR arthrographic findings in 50 patients. Radiology, 240(3), Larson, C., Giveans, M., & Taylor, M. (2011). Does arthroscopic FAI correction improve function with radiographic arthritis?. Clinical Orthopaedics And Related Research, 469(6), Philippon, M., Schroder E Souza, B., & Briggs, K. (2012). Hip arthroscopy for femoroacetabular impingement in patients aged 50 years or older. Arthroscopy: The Journal Of Arthroscopy & Related Surgery, 28(1), Samora, J. B., Ng, V. Y., & Ellis, T. J. (2011). Femoroacetabular impingement: a common cause of hip pain in young adults. Clinical Journal Of Sport Medicine, 21(1), Wall, P., Fernandez, M., Griffin, D., & Foster, N. (2013). Nonoperative treatment for femoroacetabular impingement: a systematic review of the literature. Pm&R, 5(5), Ng, V., Arora, N., Best, T., Xueliang, P., & Ellis, T. (2010). Efficacy of surgery for femoroacetabular impingement: a systematic review. American Journal Of Sports Medicine, 38(11), doi: / Saadat, E., Martin, S. D., Thornhill, T. S., Brownlee, S. A., Losina, E., & Katz, J. N. (2014). Factors associated with the failure of surgical treatment for femoroacetabular impingement: review of the literature. American Journal Of Sports Medicine, 42(6), Griffin D.R., Dickenson E.J., O'Donnell J., & Bennell, K.L. (2016). The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. British Journal of Sports Medicine, 50(19), Sangal R.B., Waryasz G.R., & Schiller J.R. (2013). Femoroacetabular impingement: a review of current concepts. Rhode Island Medical Journal, 97(11), Sanders T.L., Reardon P., Levy B.A., & Krych A.J. (2017). Arthroscopic treatment of global pincertype femoroacetabular impingement. Knee Surgery, Sports Traumatology, Arthroscopy, 25(1), Welton K.L., Jesse M.K., Kraeutler M.J., Garabekyan T., & Mei-Dan O. (2018). The anteroposterior pelvic radiograph. The Journal of Bone and Joint Surgery, 100-1(1), P a g e P r o p r i e t a r y & C o n f i d e n t i a l

7 Regulatory Data Policy Number/Name: OR-1025 Initial Approval and Effective Date: 02/05/2015 Reviewed Dates: 02/05/2015; 02/05/2016; 8/2/2016; 2/17/2017; 1/16/2018, 7/23/2018 All Approval Dates: 02/05/2015; 02/05/2016; 2/17/2017; 1/19/2018, 7/28/2018 Approval Authority: Utilization Management Committee Business Owner: Utilization Management Applicable lines of business: All Board approval, if appropriate: N/A Approval Signature: On file URAC Standards: State Requirements: CMS/Federal Requirements: Corresponding policies: 7 P a g e P r o p r i e t a r y & C o n f i d e n t i a l