K1004, Low frequency ultrasonic diathermy treatment device for home use
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- ISA candidates in trials had symptomatic medial compartment OA and had failed 6 months or more of conservative therapy ("received an ISA for symptomatic medial knee OA after failing 6 months or more of conservative therapy").
- Arthroscopic meniscal procedures in some studies were performed after non-operative management and in populations characterized by tear type (traumatic vs degenerative) and by age (e.g., 18 to 55 or middle-aged 45 to 60 in cohort studies) — documentation of prior conservative care and tear characterization was part of enrollment criteria in multiple studies.
- For percutaneous calcium phosphate injection trials, exclusions included mechanical axis deviation measurement (>8°) and MRI documentation of flipped displaced non-degenerative meniscal tear at level of BME lesions (these imaging/measurement data were required to determine eligibility in the study).
Key Coverage Criteria
- Arthroscopic debridement (with or without partial meniscectomy) for persons presenting with mild-to-moderate (Outerbridge classification I and II, not III or IV) osteoarthritis (OA) with knee pain plus mechanical symptoms due to loose bodies and/or meniscal tears;
- Arthroscopic partial meniscectomy for traumatic meniscal tears unless there is moderate or severe osteoarthritis present (Outerbridge classification III or IV);
- Intra-articular glucocorticoid injections for the treatment of knee OA.
- CPT/HCPCS/ICD-10 codes listed as "covered if selection criteria are met": e.g., CPT 29874 (Arthroscopy, knee, surgical; for removal of loose body or foreign body), G0289, CPTs 29880/29881 for arthroscopic partial meniscectomy, ICD-10 M17.0–M17.9 (Osteoarthritis of knee), M23.000–M23.369 (Derangement of meniscus due to old tear or injury), M25.561–M25.569 (Pain in knee), M25.661–M25.669 (Stiffness of knee), Q68.6 (Discoid meniscus) — when the CPB selection criteria are met.
- Moderate-to-severe knee pain with radiographically confirmed knee OA (Kellgren-Lawrence (KL) grade II/III).
- cryoneurolysis of the IPBSN resulted in statistically significant decreased knee pain and improved symptoms compared to sham treatment for up to 150 days; and appeared safe and well-tolerated.
8 Active Policies
AETNA-CPB-0673, Knee Arthroscopy / Osteoarthritis of the Knee
AETNA-CPB-0232, Back Pain - Noninvasive Treatments
AETNA-CPB-0540, Heating Devices
BCBSIL-THE801.039, Stationary Ultrasonic Diathermy Devices
BCBSMT-THE801.039, Stationary Ultrasonic Diathermy Devices
Related Codes
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