Description
General Information

• It is an expectation that all patients receive care/services from a licensed clinician. All appropriate supporting documentation, including recent pertinent office visit notes, laboratory data, and results of any special testing must be provided. If applicable: All prior relevant imaging results and the reason that alternative imaging cannot be performed must be included in the documentation submitted.
• The guideline criteria in the following sections were developed utilizing evidence-based and peer-reviewed resources from medical publications and societal organization guidelines as well as from widely accepted standard of care, best practice recommendations.

Purpose
This guideline addresses elective, non-emergent knee arthroplasty (knee replacement) procedures including total knee arthroplasty (TKA), unicompartmental/unicondylar knee arthroplasty (UKA) or hemiarthroplasty (partial knee replacement), and revision arthroplasty procedures.

Scope
Surgical indications are based on relevant subjective clinical symptoms, objective physical exam & radiologic findings, and response to previous non-operative treatments when medically appropriate.

Special Note
In order for surgeries to be considered medically necessary there must be clear medical records that demonstrate a clear surgical plan that matches the request for surgery.
 

General Requirements

• Elective knee arthroplasty may be considered if the following general criteria are met:
  • Knee pain with documented loss of function, which may include painful weight bearing, painful or inadequate range of motion to accomplish age appropriate activities of daily living (ADLs) and/or employment, and painful mechanical catching, locking, or popping
  • Individual is medically stable and optimized for surgery, and any treatable comorbidities are adequately medically managed such as diabetes, nicotine addiction, or an excessively high BMI. There should also be a shared decision between the patient and physician to proceed with a total joint replacement when comorbidities exist as it pertains to the increased risk of complications ⁽¹⁾
  • Individual does not have an active local or systemic infection ⁽²⁾
  • Individual does not have active, untreated drug dependency (including but not limited to narcotics, opioids, muscle relaxants, nicotine) unless engaged in treatment program
  • Individual has good oral hygiene and does not have major dental work scheduled or anticipated (ideally within one year of joint replacement), due to increased post-surgical infection risk
• Clinical notes should address:
  • Symptom onset, duration, and severity
  • Loss of function and/or limitations
  • Type and duration of non-operative management modalities
  • Discussion with patient regarding decision making and timing

•  Non-operative management must include at least TWO or more of the following unless otherwise specified in clinical indications below ^(3,4):
  • Rest or activity modifications/limitations
  • Weight reduction for individual with elevated BMI
  • Protected weight-bearing with cane, walker, or crutches
  • Brace/orthosis
  • Physical therapy modalities
  • Physician-supervised exercise program (including home exercise program)
  • Application of heat or ice
  • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
  • Intra-articular injection(s)

Policy
INDICATIONS
Total Knee Arthroplasty (TKA)
There is no medical necessity to perform TKA in individuals with severe radiological disease and no symptoms. If medical records indicate that possibly either a TKA or a UKA will be performed, based on the findings at the time of surgery, separate requests are to be submitted.

TKA may be necessary as indicated in either Section One or Section Two ⁽²⁾:

• Section One
  • There is persistent pain and documented loss of function with radiographic evidence of disease from any of the following
    • Rheumatoid arthritis
    • Post-traumatic arthritis (i.e., previous proximal tibia or distal femur fracture causing subsequent arthritis)
    • Fracture
    • Avascular necrosis ⁽⁶⁾ confirmed by imaging (radiographs, MRI, or other advanced imaging)
    • Radiographs (X-rays) demonstrate bone-on-bone articulation
    • Malignancy ⁽⁷⁾ 

• Section Two
  • There is persistent pain and documented loss of function for at least 12 weeks including all of the following ^(2,8):
    • •  
    • Physical exam (PE) findings demonstrate one or more of the following:
      • Tenderness
      • Swelling/effusion
      • Limited range of motion (decreased from uninvolved side or as compared to a normal joint)
      • Flexion contracture, palpable or audible crepitus, instability and/or angular deformity (PE is not required if bone-on-bone narrowing is present on X-ray)
    • Radiographic findings show evidence of advanced arthritic changes, described as Kellgren-Lawrence grade 3 or grade 4 degeneration or described as X-rays demonstrating advanced changes such as severe narrowing or bone-on-bone compartment collapse, subchondral sclerosis or cysts, osteophyte formation and/or bony deformity. ⁽⁹⁾ X-rays described only as showing 'severe', 'advanced' or 'end-stage' arthritis require more definitive descriptions as stated above. The severity of knee osteoarthritis is commonly determined with weight-bearing radiographs, however, if severe arthritic changes (e.g., bone on bone joint space narrowing) are noted on non-weightbearing images, further weight-bearing radiographs are not required.

NOTE: MRI should not be the primary radiographic test used to determine the presence or severity of arthritic changes in the joint ⁽⁹⁾; likewise, determinations as to the degree of arthritis should not routinely be determined by findings described from prior arthroscopic surgery of the knee

• • • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following ^(4,5):
      • Rest or activity modifications/limitations
      • Weight reduction for individual with elevated BMI
      • Protected weight-bearing with cane, walker, or crutches
      • Brace/orthosis
      • Physical therapy modalities
      • Physician-supervised exercise program (including home exercise program)
      • Application of heat or ice
      • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
      • Injections: corticosteroid or viscosupplementation
    • No corticosteroid injection into the joint within 12 weeks of surgery ^(1,10-13)
    • No prior arthroscopic knee surgery within 6 months of surgery ^(14-16)

Simultaneous Bilateral TKA

• ALL requests for simultaneous bilateral total knee replacements should clearly indicate why simultaneous TKA is preferable to staged procedures.
• Associated risks with simultaneous bilateral total knee replacements should also be discussed with the patient and documented in the medical record ^(17,18)

May be medically necessary when ALL of the criteria are met within ONE of the following two sections:

• Section One:
  • Failure of prior patellofemoral unloading procedures (i.e., Maquet or Fulkerson)⁽²³⁾
  • Unless patellofemoral bone-on-bone articulation is present, failure of at least 12 weeks of non-operative treatment, including at least TWO of the following:
    • Rest or activity modifications/limitations
    • Weight reduction for individual with elevated BMI
    • Protected weight-bearing with cane, walker, or crutches
    • Brace/orthosis
    • Physical therapy modalities
    • Physician-supervised exercise program (including home exercise program)

• • • Application of heat or ice

• • • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
    • Injections: corticosteroid or viscosupplementation
  • Standing, AP, or PA weight-bearing x-rays demonstrate only unicompartmental disease of the patellofemoral joint, described as Kellgren-Lawrence grade 3 or grade 4 degeneration (joint space narrowing, osteophyte formation, sclerosis and/or subchondral cystic changes), with no evidence of medial or lateral compartment arthritis⁽²⁴⁾
• Section Two:
  • At least 6 months of isolated patellar/anterior knee pain⁽²⁴⁾
  • Patellar/anterior knee pain that is exacerbated by stairs, inclines, transfers, or prolonged sitting
  • Reproducible patellofemoral pain upon physical exam 
  • No ligamentous instability upon physical exam⁽²³⁾
  • Failure of at least 12 weeks of non-operative treatment, including at least TWO of the following:
    • Rest or activity modifications/limitations
    • Weight reduction for individual with elevated BMI
    • Protected weight-bearing with cane, walker, or crutches
    • Brace/orthosis
    • Physical therapy modalities
    • Physician-supervised exercise program (including home exercise program)
    • Application of heat or ice
    • Pharmacologic treatment: oral/topical NSAIDS, acetaminophen, or analgesics
    • Injections: corticosteroid or viscosupplementation
  • Standing, AP, or PA weight-bearing radiographs demonstrate only unicompartmental disease of the patellofemoral joint, described as Kellgren-Lawrence grade 3 or grade 4 degeneration, with no evidence of medial or lateral compartment arthritis⁽²⁴⁾
  • No cortisone injection into the joint within 12 weeks of surgery ^(1,10-13)

NOTE: MRI should not be the primary radiographic test used to determine the presence or severity of arthritic changes in the joint ⁽⁹⁾

• Local or systemic active infection
• Inflammatory arthritis
• Presence of tibiofemoral osteoarthritis ⁽²³⁾
• Patellofemoral malalignment with an increased Q angle  ⁽²³⁾
• Limb malalignment including severe uncorrected coronal plane deformity (valgus > 8 or varus > 5 degree alignment) or sagittal plane deformity (120 degree flexion with < 10 degree flexion contracture) ⁽²³⁾
• Angular deformity or contracture greater than indicated range
• Knee instability (ligaments and/or menisci injuries) ⁽²³⁾
• Poor bone quality or significant osteoporosis or osteopenia
• Stiffness greater than indicated range of motion
• Any corticosteroid injection into the joint within 12 weeks of surgery ^(1,10–13)

Revision TKA may be considered medically necessary when the following criteria in either section one or section two are met:

• Section One
  • Previous removal of infected knee prosthesis⁽²⁵⁾
  • No evidence of current, ongoing, or inadequately treated knee infection (ruled out by normal inflammatory markers (ESR and CRP) or significant improvement in these markers. If these inflammatory markers are elevated, further evaluation is required, including an aspiration with synovial fluid WBC count, gram stain and cultures, or an intraoperative frozen biopsy^(25,26)
  • A clear statement by the treating surgeon that infection has been adequately treated
  • Patient is off antibiotics for two weeks⁽²⁵⁾
• Section Two
  • When ALL of the following criteria are met:
    • Symptomatic UKA/PKA or TKA as evidenced by persistent, severe, disabling pain, complaints of instability, mechanical abnormalities ('clunking' or audible crepitus), any of which result in a loss of function
    • Any of the following findings upon physical exam: tenderness to palpation objectively attributable to the implant, swelling or effusion, pain on weight-bearing or motion, instability on stress-testing, abnormal or limited motion (compared to usual function), palpable or audible crepitus or 'clunking' associated with reproducible pain
    • Aseptic loosening, instability, osteolysis, progressive bone loss, or mechanical failure confirmed on radiographic or advanced imaging (bone scan, CT scan, or MRI)⁽²⁵⁾
    • For implant loosening seen on routine X-rays or advanced imaging, documentation of no current, ongoing, or inadequately treated knee infection, ruled out by normal inflammatory markers (ESR and CRP). If these markers are elevated, a clear statement by the treating surgeon is required regarding the surgical plan to rule out infection^(25,26)
    • If the revision is for obvious radiographic evidence of hardware failure or there is a history of instability, inflammatory markers are not required
    • Cases that do not demonstrate any radiographic abnormalities yet show findings of gross instability on physical examination will be evaluated on a case-by-case basis
  • No corticosteroid injection into the joint within 12 weeks of surgery ^(1,10-13)

Prosthesis Removal

• Removal of infected knee prosthesis and subsequent insertion of antibiotic spacer is not considered a revision knee arthroplasty

Absolute Contraindication

• Active infection (local or remote). If a local or remote infection is documented in the patient’s history, records should clearly demonstrate that the previous infection has been treated and symptoms have resolved or that the individual has no clinical signs or symptoms of the previous infection at the time of the operation
• Any corticosteroid injection into the joint within 12 weeks of surgery ^(1,10-13)

• Unstable or poorly controlled comorbidities
• Severe peripheral vascular disease
• Compromised soft-tissue envelope (revision may be performed in conjunction with plastic surgical consultation for soft tissue coverage via pedicle flaps or other acceptable procedure)

• Manipulation following total knee arthroplasty:
  • See CAM 776 Knee Arthroscopy for specific Manipulation indications

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline ⁽¹⁾

Study Design: This study is a clinical practice guideline developed by the American College of Rheumatology and the American Association of Hip and Knee Surgeons. It uses a systematic literature review and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to rate the quality of evidence and develop recommendations.

Target Population: Patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, which was ineffective.

Key Factors:

• The guideline addresses the optimal timing of elective hip or knee arthroplasty (TJA) to improve patient-important outcomes such as pain, function, infection, hospitalization, and death at one year.
• It includes 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions.
• Recommendations are made based on the quality of evidence, with a focus on shared decision-making between patients and clinicians.

Management of Osteoarthritis of the Knee (Non-Arthroplasty) ⁽⁴⁾

Study Design: This is an evidence-based clinical practice guideline developed by the American Academy of Orthopaedic Surgeons for the management of osteoarthritis of the knee (non-arthroplasty). It is based on a systematic review of the available scientific and clinical information.

Target Population: Adults diagnosed with osteoarthritis of the knee undergoing non-arthroplasty treatment.

Key Factors:

• The guideline provides recommendations for various non-pharmacologic and pharmacologic interventions, including lateral wedge insoles, canes, braces, oral/dietary supplements, topical treatments, supervised exercise, and more.
• It emphasizes the importance of patient education, weight loss intervention, manual therapy, and other modalities to improve pain and function.
• The strength of recommendations is categorized as strong, moderate, limited, or consensus based on the quality of evidence.

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee ⁽⁵⁾

Study Design: This guideline, developed by the American College of Rheumatology and the Arthritis Foundation, updates the 2012 ACR recommendations for the management of osteoarthritis of the hand, hip, and knee. It uses the GRADE methodology to rate the quality of evidence and develop recommendations.

Target Population: Patients with osteoarthritis of the hand, hip, and knee.

Key Factors:

• The guideline provides strong recommendations for exercise, weight loss in overweight or obese patients, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal joint OA, tibiofemoral bracing for knee OA, topical NSAIDs for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA.
• Conditional recommendations are made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping, orthoses for hand joints other than the first CMC joint, patellofemoral bracing, acupuncture, thermal modalities, radiofrequency ablation, topical NSAIDs, intraarticular steroid injections, and chondroitin sulfate for hand OA.
• The guideline emphasizes shared decision-making between clinicians and patients, considering patients' values, preferences, and comorbidities.

Shared Findings ^(1,4,5) :

• Exercise and Weight Loss: All three articles emphasize the importance of exercise and weight loss in managing knee osteoarthritis (OA). They agree that these interventions can improve pain and function, and are strongly recommended for patients with knee OA.
• Use of NSAIDs: The use of nonsteroidal anti-inflammatory drugs (NSAIDs) is consistently recommended across all three articles for managing knee OA. They highlight that NSAIDs can effectively reduce pain and improve function.
• Intraarticular Glucocorticoid Injections: All three articles support the use of intraarticular glucocorticoid injections for short-term pain relief in knee OA. They note that these injections can provide significant pain relief, although the duration of effectiveness may vary.

Differing Findings:

• Timing of Arthroplasty:
  • 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline: This article provides detailed guidelines on the optimal timing of total joint arthroplasty (TJA), recommending against delaying surgery for additional nonoperative treatments like physical therapy, NSAIDs, or braces. It emphasizes proceeding directly to surgery without delay for patients with moderate-to-severe OA. ⁽¹⁾

• • Management of Osteoarthritis of the Knee (Non-Arthroplasty): This guideline focuses on non-arthroplasty management of knee OA and does not provide specific recommendations on the timing of arthroplasty. It emphasizes various nonoperative treatments and their effectiveness. ⁽⁴⁾
  • 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee: This guideline also does not provide specific recommendations on the timing of arthroplasty. It emphasizes a comprehensive management approach, including both nonoperative and pharmacologic treatments. ⁽⁵⁾
• Acupuncture:
  • 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline: Does not provide specific recommendations on acupuncture for knee OA. ⁽¹⁾
  • Management of Osteoarthritis of the Knee (Non-Arthroplasty): Provides a limited recommendation for acupuncture, noting that it may improve pain and function but the evidence is inconsistent. ⁽⁴⁾
  • 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee: Conditionally recommends acupuncture for knee OA, acknowledging the variability in trial results and the small effect size. ⁽⁵⁾

In summary, the three articles share common ground on the importance of exercise, weight loss, NSAIDs, and intraarticular glucocorticoid injections in managing knee OA. However, they differ in their recommendations on the timing of arthroplasty, the use of hyaluronic acid injections, and acupuncture. "2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline" provides specific guidelines on the timing of arthroplasty, ⁽¹⁾ while the other two articles focus more on nonoperative treatments. ^(4,5) The evidence for hyaluronic acid injections and acupuncture remains inconsistent, leading to varying recommendations across the articles.

References

1.           Hannon CP, Goodman SM, Austin MS, et al. 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate‐to‐Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective. Arthritis Care Res (Hoboken). 2023;75(11):2227-2238. doi:10.1002/acr.25175

2.           Hsu H, Siwiec RM. Knee Arthroplasty. StatPearls. Published online July 24, 2023. https://www.ncbi.nlm.nih.gov/books/NBK507914/

3.           Young JR, Bannon AL, Anoushiravani AA, Posner AD, Adams CT, DiCaprio MR. Oral health implications in total hip and knee arthroplasty patients: A review. J Orthop. 2021;24:126-130. doi:10.1016/j.jor.2021.02.021

4.           American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline. American Academy of Orthopaedic Surgeons. August 31, 2021. https://www.aaos.org/oak3cpg

5.           Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). 2020;72(2):149-162. doi:10.1002/acr.24131

6.           Wilson C, Marappa-Ganeshan R. Secondary Osteonecrosis of the Knee. StatPearls. Published online July 24, 2023. https://www.ncbi.nlm.nih.gov/books/NBK562286/

7.           Gibbons JAB, Kahlenberg CA, Jannat-Khah DP, et al. Tumors Constitute a Majority of Total Knee Arthroplasty in Patients <21 Years Old: A United States Nationwide Analysis. Journal of Arthroplasty. 2023;38(5):836-842. doi:10.1016/j.arth.2022.11.018

8.           Rehman Y, Lindberg MF, Arnljot K, Gay CL, Lerdal A, Aamodt A. More Severe Radiographic Osteoarthritis Is Associated With Increased Improvement in Patients’ Health State Following a Total Knee Arthroplasty. J Arthroplasty. 2020;35(11):3131-3137. doi:10.1016/j.arth.2020.06.025

9.           Newman S, Ahmed H, Rehmatullah N. Radiographic vs. MRI vs. arthroscopic assessment and grading of knee osteoarthritis - are we using appropriate imaging? J Exp Orthop. 2022;9(1):2. doi:10.1186/s40634-021-00442-y

10.        Baums MH, Aquilina J, Pérez-Prieto D, Sleiman O, Geropoulos G, Totlis T. Risk analysis of periprosthetic knee joint infection (PJI) in total knee arthroplasty after preoperative corticosteroid injection: a systematic review. Arch Orthop Trauma Surg. 2022;143(5):2683-2691. doi:10.1007/s00402-022-04532-z

11.        Cancienne JM, Werner BC, Luetkemeyer LM, Browne JA. Does Timing of Previous Intra-Articular Steroid Injection Affect the Post-Operative Rate of Infection in Total Knee Arthroplasty? J Arthroplasty. 2015;30(11):1879-1882. doi:10.1016/j.arth.2015.05.027

12.        Kim YM, Joo YB, Song JH. Preoperative intra-articular steroid injections within 3 months increase the risk of periprosthetic joint infection in total knee arthroplasty: a systematic review and meta-analysis. J Orthop Surg Res. 2023;18(1):148. doi:10.1186/s13018-023-03637-4

13.        Lai Q, Cai K, Lin T, Zhou C, Chen Z, Zhang Q. Prior Intra-articular Corticosteroid Injection Within 3 Months May Increase the Risk of Deep Infection in Subsequent Joint Arthroplasty: A Meta-analysis. Clin Orthop Relat Res. 2022;480(5):971-979. doi:10.1097/CORR.0000000000002055

14.        Liu Q, Tian Z, Pian K, et al. The influence of prior arthroscopy on outcomes of primary total lower extremity arthroplasty: A systematic review and meta-analysis. International Journal of Surgery. 2022;98:106218. doi:10.1016/j.ijsu.2021.106218

15.        Goyal T, Tripathy SK, Schuh A, Paul S. Total knee arthroplasty after a prior knee arthroscopy has higher complication rates: a systematic review. Arch Orthop Trauma Surg. 2021;142(11):3415-3425. doi:10.1007/s00402-021-04175-6

16.        Ma JN, Li XL, Liang P, Yu SL. When can total knee arthroplasty be safely performed following prior arthroscopy? BMC Musculoskelet Disord. 2021;22(1):2. doi:10.1186/s12891-020-03859-1

17.        Liu L, Liu H, Zhang H, Song J, Zhang L. Bilateral total knee arthroplasty. Medicine. 2019;98(22):e15931. doi:10.1097/MD.0000000000015931

18.        Richardson MK, Liu KC, Mayfield CK, Kistler NM, Christ AB, Heckmann ND. Complications and Safety of Simultaneous Bilateral Total Knee Arthroplasty. Journal of Bone and Joint Surgery. 2023;105(14):1072-1079. doi:10.2106/JBJS.23.00112

19.        Varacallo M, Luo TD, Mabrouk A, Johanson NA. Total Knee Arthroplasty Techniques. StatPearls. Published online May 6, 2024. https://www.ncbi.nlm.nih.gov/books/NBK499896/

20.        Luo TD, Hubbard JB. Arthroplasty Knee Unicompartmental. StatPearls. Published online July 3, 2023. https://www.ncbi.nlm.nih.gov/books/NBK538267/

21.        Jaber A, Kim C min, Barié A, et al. Combined treatment with medial unicompartmental knee arthroplasty and anterior cruciate ligament reconstruction is effective on long-term follow-up. Knee Surgery, Sports Traumatology, Arthroscopy. 2023;31(4):1382-1387. doi:10.1007/s00167-022-07102-3

22.        Purcell RL, Cody JP, Ammeen DJ, Goyal N, Engh GA. Elimination of Preoperative Flexion Contracture as a Contraindication for Unicompartmental Knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. 2018;26(7):e158-e163. doi:10.5435/JAAOS-D-16-00802

23.        Pisanu G, Rosso F, Bertolo C, et al. Patellofemoral Arthroplasty: Current Concepts and Review of the Literature. Joints. 2017;05(04):237-245. doi:10.1055/s-0037-1606618

24.        Vasso M, Antoniadis A, Helmy N. Update on unicompartmental knee arthroplasty. EFORT Open Rev. 2018;3(8):442-448. doi:10.1302/2058-5241.3.170060

25.        Ayoade F, Li DD, Mabrouk A, Todd JR. Periprosthetic Joint Infection. Published online October 14, 2023. https://www.ncbi.nlm.nih.gov/books/NBK448131/

26.        Salari P, Baldini A. Revision knee surgery: the practical approach. EFORT Open Rev. 2021;6(6):495-500. doi:10.1302/2058-5241.6.210018

27.        Kellgren JH, Lawrence JS. Radiological Assessment of Osteo-Arthrosis. Ann Rheum Dis. 1957;16(4):494-502. doi:10.1136/ard.16.4.494

BACKGROUND
Grading Appendix
Kellgren-Lawrence Grading System (Standing/weight-bearing X-rays) ⁽²⁷⁾

Coding Section

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each Policy. They may not be all-inclusive.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, and other nonaffiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

History From 2026 Forward