Clinical UM Guideline


Subject: Knee Arthroscopy
Guideline #:  CG-SURG-43 Publish Date:    08/29/2018
Status: Reviewed Last Review Date:    07/26/2018



This document addresses knee arthroscopy surgery when done primarily for therapeutic intervention of confirmed pathology.


Clinical Indications

Medically Necessary:

Knee arthroscopy is considered medically necessary (after the appropriate diagnostic imaging has been completed first) for any of the following:

*Note: Conservative therapy consists of an appropriate combination of:

  1. Medication (for example, non-steroidal anti-inflammatory drugs [NSAIDs], analgesics); and
  2. Physical therapy with muscle strengthening and flexibility exercises; and
  3. Activity modification, weight loss, walking aids, bracing or other interventions based on the individual's specific presentation, physical findings and imaging results.

Not Medically Necessary:

Knee arthroscopy is considered not medically necessary for osteoarthritis of the knee, meniscal tear in chronic degenerative knee joint (excluding mechanical symptoms, such as locked knee or catching, deemed on basis of history, physical examination and diagnostic testing to be due to the loose body or meniscal tear as opposesd to solely osteoarthritis), isolated medial or collateral ligament injury or when the above criteria are not met.


The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.




Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)


Arthroscopy, knee, surgical; for infection, lavage and drainage


Arthroscopy, knee, surgical; with lateral release


Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragmentation, chondral fragmentation)


Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure)


Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral)


Arthroscopy, knee, surgical; debridement/ shaving or articular cartilage (chondroplasty)


Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture


Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/ shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed


Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) including debridement/ shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed


Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral)


Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral)


Arthroscopy, knee, surgical; with lysis of adhesions, with or without manipulation (separate procedure)


Arthroscopy, knee, surgical; drilling for osteochondritis dissecans with bone grafting, with or without internal fixaiton (including debridement of base of lesion)


Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion


Arthroscopy, knee, surgical; drilling for intact osteochondritis dissecans lesion with internal fixation


Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction


Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction


Unlisted procedure, arthroscopy [when specified as arthroscopic knee lavage as a separate procedure]






Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage (chondroplasty) at the time of other surgical knee arthroscopy in a different compartment of the same knee



ICD-10 Diagnosis



All diagnoses

Discussion/General Information


An arthroscopy is a surgical procedure in which a joint is viewed using a small camera. Arthroscopy provides a view inside the knee to better diagnose and treat knee problems. The arthroscope (a small camera instrument about the size of a pencil) is inserted into the knee joint through a small incision. Using a monitor, the surgeon can see the structures of the knee in great detail. The arthroscopy can also be used to repair or remove damaged tissue.

A study by Vermesan and colleagues (2013) followed 120 participants with non-traumatic symptomatic knee pain who had degenerative lesions of the cartilage and meniscus. The participants were randomized to receive either intra-articular steroid injections or arthroscopic debridement. At the 1-month follow-up, 79% of the participants in the arthroscopic group and 61% in the intra-articular steroid group showed improvement in knee symptoms. At 1-year follow-up, 48 participants from the injection group and 50 participants from the arthroscopy group were available and 5 participants (42%) had been converted to a total knee replacement. This particular study did not take into account the influence of physical therapy or the amount of oral non-steroidal anti-inflammatory drugs from the 1-month to 1-year follow-up.

Katz and colleagues (2013) reported on a multicenter, randomized, controlled trial of 351 participants who had knee symptoms consistent with a meniscus tear. The participants were randomized to receive either arthroscopic surgery and post-operative physical therapy or standard physical therapy regimen. Evaluations were done at 6 and 12 months. The primary outcome used the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score 6 months after randomization. At the 6 month follow-up, the surgical group had a mean improvement WOMAC score of 20.9 points and the physical therapy group had an 18.5 point score. At 6 months, 51 participants who initially were randomized to the physical therapy group only had undergone surgery and 9 participants assigned to surgery had not undergone surgery. Results at 12 months were similar to the 6 month results. This study has several limitations including potential for bias, it was unblended, and the trial was conducted as academic referral centers so the findings may not be generalized to community settings.

Herrlin and colleagues (2013) reported on a prospective randomized trial which evaluated the outcome of a 2-year and 5-year follow-up in which arthroscopic knee surgery followed by exercise therapy was superior to exercise therapy alone when treating meniscal tears. A total of 96 participants were included. All participants had x-rays before randomization and after 5 years. Both groups showed significant clinical improvements from baseline at the 24 and 60 months follow-up. The authors reported that while arthroscopic surgery followed by exercise therapy was not superior to exercise therapy alone, one-third of the participants from the exercise group still had disabling knee symptoms at the end of the study period and improved to the same level as the rest of the participants after arthroscopic surgery and partial menisectomy.

A study by Cho (2012) reported on the efficacy of arthroscopic excision of popliteal cysts. A total of 105 participants had direct arthroscopic excision and were followed up over 2 years. At the 2-year mark, participants had either an ultrasound or magnetic resonance imaging (MRI) exam to detect the recurrence of cysts. There were no complaints of pain, swelling or functional impairment more than 2 years after surgery. While the study is limited by the fact that there was no comparison group, there was no recurrence of cysts found on ultrasound or MRI.



Anterior cruciate ligament: One of the four ligaments that connect the femur and tibia and gives the knee joint stability. This ligament is in the center of the knee and limits rotation and the forward movement of the tibia.


Meniscus: Pads of connective tissue which separate the bones of the knee.


Popliteal cyst: A buildup of joint fluid that forms a cyst behind the knee.


Posterior cruciate ligament: One of the four ligaments that connect the femur and tibia and gives the knee joint stability. This ligament is in the center of the knee and limits backward movement of the tibia.



Peer Reviewed Publications:

  1. Barber-Westin SD, Noyes FR. Clinical healing rates of meniscus repairs of tears in the central-third (red-white) zone. Arthroscopy 2014; 30(1):134-146.
  2. Boughanem J, Riaz R, Patel RM, Sarwark JF. Functional and radiographic outcomes of juvenile osteochondritis dissecans of the knee treated with extra-articular retrograde drilling. Am J Sports Med. 2011; 39(10):2212-2217.
  3. Cho JH. Clinical results of direct arthroscopic excision of popliteal cyst using a posteromedial portal. Knee Surg Relat Res. 2012; 24(4):235-240.
  4. Herrlin SV, Wange PO, Lapidus G, et al. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surg Sports Traumatol Arthrosc. 2013; 21(2):358-364.
  5. Hwang YG, Kwoh CK The METEOR trial: no rush to repair a torn meniscus. Cleve Clin J Med. 2014; 81(4):226-232.
  6. Juyal A, Variyani A, Sharma SC, et al. Evaluation of clinical diagnosis by knee arthroscopy. J Indian Med Assoc. 2013; 111(2):86-88.
  7. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med. 2013; 368(18):1675-1684.
  8. Katz JN, Chaisson CE, Cole B, et al. The MeTeOR trial (Meniscal Tear in Osteoarthritis Research): rationale and design features. Contemp Clin Trials. 2012; 33(6):1189-1196.
  9. Levy BA, Stuart MJ. Treatment of PCL, ACL, and lateral-side knee injuries: acute and chronic. J Knee Surg. 2012; 25(4):295-305.
  10. Salzler MJ, Lin A, Miller CD, et al. Complications after arthroscopic knee surgery. Am J Sports Med. 2014; 42(2):292-296.
  11. Vermesan D, Prejbeanu R, Laitin S, et al. Arthroscopic debridement compared to intra-articular steroids in treating degenerative medial meniscal tears. Eur Rev Med Pharmacol Sci. 2013; 17(23):3192-3196.
Websites for Additional Information
  1. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Available at: Accessed on June 13, 2018.

Knee arthroscopy







Medical Policy & Technology Assessment Committee (MPTAC) review.



MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.”



MPTAC review. Clarification to MN and NMN indications.



MPTAC review. Clarification made to criteria for repair or excision of torn meniscus. Added note about conservative therapy in Clinical Indications.



MPTAC review. Clarification to MN criteria.



MPTAC review. Updated Background/Overview and References. Clarification to Clinical Indications. Coding section updated to add CPT 29888 and 29889; removed ICD-9 codes.



MPTAC review. Clarification to criteria for treatment of osteochondral defect; removed reference to age and changed to growth plate closure instead. Clarification to Not Medically Necessary statement, excluded mechanical symptoms. Updated References.



MPTAC review. Initial document development.