Updates to Carelon Medical Benefits Management, Inc. Joint Surgery, Small Joint Surgery, and MSK Level of Care (MAC)

Effective for dates of service on and after November 5, 2023, the following updates will apply to the Carelon Medical Benefits Management, Inc.* Clinical Appropriateness Guidelines. As part of the Carelon Medical Benefits Management guideline review process, these updates are focused on advancing efforts to drive clinically appropriate, safe, and affordable healthcare services.

Joint Surgery updates by section

Multiple joints:

• Loose body — Added indication for removal of loose body from shoulder and for removal of loose body or foreign body from the hip and the knee
• Synovectomy — Added requirement for conservative management; added exclusion for traumatic reactive synovitis in shoulder, hip, and knee; added indications for both limited and extensive synovectomy in the knee

Shoulder:

• Rotator cuff repair — Modified diagnostic tests for full thickness rotator cuff tear; removed requirement for conservative management for high-grade partial thickness rotator cuff tear
• Revision rotator cuff repair — Added exclusion for patients with rotator cuff arthropathy
• Labrum repair — Broadened MRI findings to allow for any labral tear other than a Bankart lesion
• Adhesive capsulitis — Extended required conservative management from six weeks to 12 weeks
• Capsulorraphy — Added allowance for capsular redundancy with multidirectional instability; waived conservative management requirement in the setting of traumatic dislocation
• Subacromial decompression/acromioplasty — Added indications for symptomatic is acromial and for symptomatic mechanical impingement due to tumor or malunited fracture
• Shoulder debridement — Extended required conservative management to 12 weeks
• Biceps tenodesis/tenotomy — Broadened criteria to allow when criteria are met for any shoulder procedure, or when patient has an acute proximal biceps tear
• Added exclusion for subacromial balloon spacer and for shoulder resurfacing

Hip:

• Added indications for primary partial hip arthroplasty and partial or total hip resurfacing
• Revision total hip arthroplasty — Added indication for elevated cobalt/chromium levels in patients with a metal-on-metal implant
• Acetabuloplasty — Added indications for arthritis, hip instability, and FAIS
• Diagnostic arthroscopy — Added exclusion for non-intra-articular hip procedures
• Femoroacetabular impingement syndrome (FAIS) — Specified requirement for alpha angle greater than 55 degrees for femoroplasty
• Labral tear — Added exclusion for hip arthroscopy for lavage and debridement in advanced osteoarthritis
• Added exclusion for debridement/chondroplasty when done solely for osteoarthritis and for labral repair in untreated severe hip dysplasia

Knee:

• Total knee arthroplasty — Added indication for post-traumatic arthritis; added unicompartmental damage to existing indications for partial joint damage
• Unicompartmental knee arthroplasty — Modified requirements related to conservative management and varus/valgus deformities; allow concurrent ACL reconstruction in some scenarios
• Revision knee arthroplasty — Added indication for reconstruction after post knee replacement infection; shortened conservative management requirement to six weeks for revision attributable to prior implants
• Abrasion arthroplasty/microfracture — Aligned with osteochondral grafts criteria regarding the size of defect that can be treated
• Debridement/drainage/lavage (knee) — Reduced conservative management requirement to six weeks for consistency with lysis of adhesions criteria
• Anterolateral ligament reconstruction or extra-articular tenodesis — Added indications
• ACL reconstruction and PCL repair/reconstruction — Excluded patients with advanced knee arthritis (Kellgren-Lawrence 4)
• Added indications for posterolateral corner injury and for collateral/extra-articular ligament injury
• Patellar compression syndrome — Added exclusion for central or medial tracking of the patella
• Medial patellofemoral ligament reconstruction — Waived requirement for conservative management when function is limited due to pain

Osteochondral grafts:

• Patient selection requirements — Specified that conservative management duration must be six weeks; waived this requirement when a symptomatic loose body is present
• Osteochondritis dissecans — Added indications for surgical treatment
• Osteochondral allograft transplantation — Decreased the minimum required size of the defect to 1.0 cm² in the knee and in the talus; removed microfracture for defects in the knee
• Added exclusions for non-standard tissue bank methods and for use of larger allografts as an alternative to traditional total joint replacement
• HCPCS code added: S2118

Small Joint Surgery:

• Hallux rigidus procedures; hallux valgus and bunionette procedures; lesser toe deformities — Removed poor wound healing as a contraindication
• Hallux valgus surgery — Add allowance for pre-ulcer (Wagner grade 0 to 1 lesion); added criterion for simple exostectomy/resection medial eminence; separated bunionette surgery indications from hallux valgus surgery
• First MTP joint arthrodesis for hallux valgus — Added indication
• Metatarsal osteotomy — Separated criteria into standalone indication; added exclusion for improved cosmesis
• Ankle arthritis — Added indication for revision total ankle arthroplasty
• Ankle arthroplasty — Removed severe ankle deformity and peripheral neuropathy as contraindications

Level of Care for Musculoskeletal Surgery:

• Added total or partial primary shoulder arthroplasty to ambulatory surgery center with 23-hour observation to address the addition of hemiarthroplasty and total shoulder arthroplasty 
• CPT^® codes added to level of care review: 23470 and 23472

As a reminder, ordering and servicing providers may submit prior authorization requests to Carelon Medical Benefits Management by: 

• Accessing Carelon Medical Benefits Management’s ProviderPortal_SM directly at providerportal.com:
  • Online access is available 24/7 to process orders in real-time and is the fastest and most convenient way to request authorization.

If you have questions related to guidelines, please contact Carelon Medical Benefits Management via email at MedicalBenefitsManagement.guidelines@Carelon.com. Additionally, you may access and download a copy of the current and upcoming guidelines here.