Arthrocentesis or Needling of Bursa (ARCHIVED)

Policy ID: S-31-032

Section: Surgery

Effective Date: April 01, 2019

Revised Date: July 23, 2024

Revision Effective Date: September 02, 2024

Last Reviewed: July 16, 2024

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective September 02, 2024. Click the Archive tab above for more information.

Policy ID: S-31-031

Section: Surgery

Effective Date: April 01, 2019

Revised Date: May 03, 2021

Revision Effective Date: September 06, 2021

Last Reviewed: July 26, 2023

Archived Date: September 02, 2024

Applies To: Commercial and Medicaid Expansion

Description

Arthrocentesis or aspiration is the removal of fluid from a joint or bursa. Bursas are saclike structures between skin and bone or between tendons, ligaments, and bone. The bursa are lined by synovial tissue, which produces fluid that lubricates and reduces friction between these structures.

Criteria

Arthrocentesis or needling of a bursa may be considered medically necessary when ALL of the following criteria are met:

"Conservative therapy (rest area and avoid activity, cryotherapy, compression dressings, elevation of affected area above heart, other modalities like electrical stimulation/ultrasonography/phonophoresis, NSAIDs, or steroids) to control pain and inflammation has failed; and
Affected area continues with symptoms of severe pain along with swelling and inflammation; and
Movement of joint remains limited due to pain; and
The response to therapy must be documented for medical review prior to additional therapy authorizations.

*Conservative therapy is considered a failure of treatment if no improvement or resolution of pain within four (4) weeks from the start of therapy.

Procedure Codes

20600

20604

20605

20606

20610

20611

76942

77002

Diagnosis Codes

Not Applicable

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 3-16-2020 Annual Review - no changes

Internal Medical Policy Committee 9-21-2020 Revision

Updated Language; and
Added procedure code 77002

Internal Medical Policy Committee 5-20-2021 Revision

Removed Reimbursement language.

Internal Medical Policy Committee 7-21-2022 Annual Review - no changes in criteria

Internal Medical Policy Committee 7-26-2023 Annual Review - no changes in criteria

Internal Medical Policy Committee 7-16-2024 Archived Policy - Effective September 02, 2024

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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