Prior Authorization Request Form Member Name: DOB: HPHC ID#: Requesting Provider #: Requesting Provider Phone #: Requesting Provider NPI #: Facility Name/Location: Requested Setting: Surgical day care Other (describe): Planned Date of Service: Facility NPI: Knee arthroscopy is authorized for conditions listed below when specific criteria are met. Supporting documentation including results of office evaluation, imaging report(s), and evidence of failed conservative management (when appropriate) is required. Conservative management typically includes anti-inflammatory medication (NSAIDs), at least one corticosteroid injection, and at least 8 PT visits over an 8-week period. Condition Intra-Articular Joint Pathology Osteochondral Defect, includes Osteochondral Dissecans Symptomatic Acute Meniscal Tear Knee Osteoarthitis with Concomitant Meniscal Tear Check all that apply Need for fracture treatment Loose bodies or foreign body on imaging study Locked knee (i.e., knee will flex but not fully extend) Failure of > 8 weeks of conservative management (i.e., NSAIDS, PT, corticosteroid injection), and compliance with home exercise program and activity restriction(s) Suspected Plica Syndrome with persistent symptoms after >8 weeks of conservative management Osteochondral defect on imaging studies Osteochondral lesion displacement or unstable fragment Presence of loose body/bodies Nondisplaced osteochondral lesion in an adult with closed growth plates Nondisplaced osteochondral lesion in a child with an open growth plate, including: Stable lesion < 2 cm that has not responded to at least 3 months of conservative care (physical therapy, immobilization, and partial weight-bearing progressing to gradual weight-bearing as tolerated); and/or Radiographic evidence of healing Bucket handle tear, symptomatic horizontal cleavage tear, radial tear, posterior horn tear, complex tear on exam or MRI Displaced/unstable meniscal fragment on MRI Symptomatic meniscal tear on exam with catching, locking or instability Continued symptoms and/or disability following failure of conservative treatment including 8 weeks of NSAIDs, and >8 PT visits over the 8-week period Symptomatic bucket handle tear with catching or locking (on exam or MRI) Displaced or unstable symptomatic meniscal fragment on MRI Acute traumatic tear, and failure of conservative treatment including 8 weeks of NSAIDs, and >8 PT visits over the 8-week period Age >45 years with: Osteoarthritis Kellgren-Lawrence Scale Grade 1 or 2 Completion of >8 PT visits and >3 weeks of anti-inflammatory medications (unless contraindicated) Kellgren-Lawrence Grading Scale Grade 1: Doubtful narrowing of joint space and possible osteophytic lipping Grade 2: Definite osteophytes, definite narrowing of joint space Grade 3: Moderate multiple osteophytes, definite narrowing of joint space, some sclerosis and possible deformity of bone contour Grade 4: Large osteophytes, marked narrowing of joint space, severe sclerosis and definite deformity of bone contour Harvard Pilgrim Health Care Provider Manual D.75 September 2015
PRIOR AUTHORIZATION REQUEST FORM (CON'T) Condition Torn ACL Arthroscopy for Debridement, Drainage, or Lavage Torn PCL Popliteal/Baker s Cyst Synovectomy Lateral Retinacular Release for Patellar Pathology Check all that apply Torn ACL (on clinical exam or imaging) with: Anterior drawer sign is positive for ACL laxity Positive pivot shift test Positive Lachman test Additional major ligamentous injury (i.e., medial or posterior collateral ligament, posterior cruciate ligament, or posterolateral corner ligamentous injury) Failure of at least 8 weeks of conservative management including immobilization, knee brace, PT Patient has physically demanding occupation (e.g., law enforcement, firefighter or other safety personnel, construction) Patient s activity level includes participation in athletic activities that include cutting, jumping, and/or pivoting (e.g., skiing, tennis, basketball, football). Rheumatoid arthritis Septic joint or osteomyelitis Septic prosthetic joint Postoperative arthrofibrosis (s/p ACL repair or total knee replacement) with: Loss of range of motion Failure to respond to 2-4 weeks of PT and/or other nonoperative care (e.g., manipulation under anesthesia) Torn PCL on clinical exam with: Posterior drawer sign positive for laxity of PCL Positive reversed pivot shift test Positive posterior sag sign Diagnostic imaging demonstrates PCL tear PCL tear occurred with other injuries (e.g., injury to the posterolateral corner of the knee, medial collateral ligament tear, ACL tear, avulsion fracture of fibular head, or avulsion of the tibia distal to the lateral plateau) Visible or palpable bulge in popliteal fossa on clinical exam, or diagnostic imaging demonstrates presence of the cyst Failure of at least 8 weeks of conservative treatment (e.g., activity modification, anti-inflammatory medication Failed treatment of intra-articular pathology (e.g., Rheumatoid Arthritis) Significant functional impairment or pain referable to the cyst (documentation required) Rheumatoid arthritis Hemophiliac joint disease Localized pigmented villonodular synovitis Other chronic inflammatory conditions Lateral patellar compression syndrome, with positive patella glide or tilt test Planned procedure to be performed concurrent with other patellar realignment procedures Failure of conservative treatment including 8 weeks of NSAIDs and PT Procedure codes (include all that apply): Harvard Pilgrim Health Care Provider Manual D.76 September 2015
Diagnosis (check all that appy): Code PRIOR AUTHORIZATION REQUEST FORM (CON'T) L40.50 Arthropathic psoriasis, unspecified L40.52 Psoriatic arthritis mutilans L40.53 Psoriatic spondylitis L40.54 Psoriatic juvenile arthropathy L40.59 Other psoriatic arthropathy M66.0 Rupture of popliteal cyst M00.061 Staphylococcal arthritis, right knee M00.062 Staphylococcal arthritis, left knee M00.069 Staphylococcal arthritis, unspecified knee M00.161 Pneumococcal arthritis, right knee M00.162 Pneumococcal arthritis, left knee M00.169 Pneumococcal arthritis, unspecified knee M00.261 Other streptococcal arthritis, right knee M00.262 Other streptococcal arthritis, left knee M00.269 Other streptococcal arthritis, unspecified knee M00.861 Arthritis due to other bacteria, right knee M00.862 Arthritis due to other bacteria, left knee M00.869 Arthritis due to other bacteria, unspecified knee M05.461 Rheumatoid myopathy with rheumatoid arthritis of right knee M05.462 Rheumatoid myopathy with rheumatoid arthritis of left knee M05.469 Rheumatoid myopathy with rheumatoid arthritis of unspecified knee M05.561 Rheumatoid polyneuropathy with rheumatoid arthritis of right knee M05.562 Rheumatoid polyneuropathy with rheumatoid arthritis of left knee M05.569 Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified knee M05.761 Rheumatoid arthritis with rheumatoid factor of right knee without organ or systems involvement M05.762 Rheumatoid arthritis with rheumatoid factor of left knee without organ or systems involvement M05.769 Rheumatoid arthritis with rheumatoid factor of unspecified knee without organ or systems involvement M05.861 Other rheumatoid arthritis with rheumatoid factor of right knee M05.862 Other rheumatoid arthritis with rheumatoid factor of left knee M05.869 Other rheumatoid arthritis with rheumatoid factor of unspecified knee M06.061 Rheumatoid arthritis without rheumatoid factor, right knee M06.062 Rheumatoid arthritis without rheumatoid factor, left knee M06.069 Rheumatoid arthritis without rheumatoid factor, unspecified knee M06.261 Rheumatoid bursitis, right knee M06.262 Rheumatoid bursitis, left knee M06.269 Rheumatoid bursitis, unspecified knee M06.361 Rheumatoid nodule, right knee M06.362 Rheumatoid nodule, left knee M06.369 Rheumatoid nodule, unspecified knee M06.861 Other specified rheumatoid arthritis, right knee M06.862 Other specified rheumatoid arthritis, left knee M06.869 Other specified rheumatoid arthritis, unspecified knee M12.261 Villonodular synovitis (pigmented), right knee Harvard Pilgrim Health Care Provider Manual D.77 September 2015
Code PRIOR AUTHORIZATION REQUEST FORM (CON'T) M12.262 Villonodular synovitis (pigmented), left knee M12.269 Villonodular synovitis (pigmented), unspecified knee M17.0 primary osteoarthritis of knee M17.10 Unilateral primary osteoarthritis, unspecified knee M17.11 Unilateral primary osteoarthritis, right knee M17.12 Unilateral primary osteoarthritis, left knee M22.40 Chondromalacia patellae, unspecified knee M22.41 Chondromalacia patellae, right knee M22.42 Chondromalacia patellae, left knee M22.90 Unspecified disorder of patella, unspecified knee M22.91 Unspecified disorder of patella, right knee M22.92 Unspecified disorder of patella, left knee M23.000 Cystic meniscus, unspecified lateral meniscus, right knee M23.001 Cystic meniscus, unspecified lateral meniscus, left knee M23.002 Cystic meniscus, unspecified lateral meniscus, unspecified knee M23.003 Cystic meniscus, unspecified medial meniscus, right knee M23.004 Cystic meniscus, unspecified medial meniscus, left knee M23.005 Cystic meniscus, unspecified medial meniscus, unspecified knee M23.006 Cystic meniscus, unspecified meniscus, right knee M23.007 Cystic meniscus, unspecified meniscus, left knee M23.009 Cystic meniscus, unspecified meniscus, unspecified knee M23.011 Cystic meniscus, anterior horn of medial meniscus, right knee M23.012 Cystic meniscus, anterior horn of medial meniscus, left knee M23.019 Cystic meniscus, anterior horn of medial meniscus, unspecified knee M23.021 Cystic meniscus, posterior horn of medial meniscus, right knee M23.022 Cystic meniscus, posterior horn of medial meniscus, left knee M23.029 Cystic meniscus, posterior horn of medial meniscus, unspecified knee M23.031 Cystic meniscus, other medial meniscus, right knee M23.032 Cystic meniscus, other medial meniscus, left knee M23.039 Cystic meniscus, other medial meniscus, unspecified knee M23.041 Cystic meniscus, anterior horn of lateral meniscus, right knee M23.042 Cystic meniscus, anterior horn of lateral meniscus, left knee M23.049 Cystic meniscus, anterior horn of lateral meniscus, unspecified knee M23.051 Cystic meniscus, posterior horn of lateral meniscus, right knee M23.052 Cystic meniscus, posterior horn of lateral meniscus, left knee M23.059 Cystic meniscus, posterior horn of lateral meniscus, unspecified knee M23.061 Cystic meniscus, other lateral meniscus, right knee M23.062 Cystic meniscus, other lateral meniscus, left knee M23.069 Cystic meniscus, other lateral meniscus, unspecified knee M23.200 Derangement of unspecified lateral meniscus due to old tear or injury, right knee M23.201 Derangement of unspecified lateral meniscus due to old tear or injury, left knee M23.202 Derangement of unspecified lateral meniscus due to old tear or injury, unspecified knee M23.203 Derangement of unspecified medial meniscus due to old tear or injury, right knee M23.204 Derangement of unspecified medial meniscus due to old tear or injury, left knee Harvard Pilgrim Health Care Provider Manual D.78 September 2015
Code PRIOR AUTHORIZATION REQUEST FORM (CON'T) M23.205 Derangement of unspecified medial meniscus due to old tear or injury, unspecified knee M23.206 Derangement of unspecified meniscus due to old tear or injury, right knee M23.207 Derangement of unspecified meniscus due to old tear or injury, left knee M23.209 Derangement of unspecified meniscus due to old tear or injury, unspecified knee M23.211 Derangement of anterior horn of medial meniscus due to old tear or injury, right knee M23.212 Derangement of anterior horn of medial meniscus due to old tear or injury, left knee M23.219 Derangement of anterior horn of medial meniscus due to old tear or injury, unspecified knee M23.221 Derangement of posterior horn of medial meniscus due to old tear or injury, right knee M23.222 Derangement of posterior horn of medial meniscus due to old tear or injury, left knee M23.229 Derangement of posterior horn of medial meniscus due to old tear or injury, unspecified knee M23.231 Derangement of other medial meniscus due to old tear or injury, right knee M23.232 Derangement of other medial meniscus due to old tear or injury, left knee M23.239 Derangement of other medial meniscus due to old tear or injury, unspecified knee M23.241 Derangement of anterior horn of lateral meniscus due to old tear or injury, right knee M23.242 Derangement of anterior horn of lateral meniscus due to old tear or injury, left knee M23.249 Derangement of anterior horn of lateral meniscus due to old tear or injury, unspecified knee M23.251 Derangement of posterior horn of lateral meniscus due to old tear or injury, right knee M23.252 Derangement of posterior horn of lateral meniscus due to old tear or injury, left knee M23.259 Derangement of posterior horn of lateral meniscus due to old tear or injury, unspecified knee M23.261 Derangement of other lateral meniscus due to old tear or injury, right knee M23.262 Derangement of other lateral meniscus due to old tear or injury, left knee M23.269 Derangement of other lateral meniscus due to old tear or injury, unspecified knee M23.300 Other meniscus derangements, unspecified lateral meniscus, right knee M23.301 Other meniscus derangements, unspecified lateral meniscus, left knee M23.302 Other meniscus derangements, unspecified lateral meniscus, unspecified knee M23.303 Other meniscus derangements, unspecified medial meniscus, right knee M23.304 Other meniscus derangements, unspecified medial meniscus, left knee M23.305 Other meniscus derangements, unspecified medial meniscus, unspecified knee M23.306 Other meniscus derangements, unspecified meniscus, right knee M23.307 Other meniscus derangements, unspecified meniscus, left knee M23.309 Other meniscus derangements, unspecified meniscus, unspecified knee M23.311 Other meniscus derangements, anterior horn of medial meniscus, right knee M23.312 Other meniscus derangements, anterior horn of medial meniscus, left knee M23.319 Other meniscus derangements, anterior horn of medial meniscus, unspecified knee M23.321 Other meniscus derangements, posterior horn of medial meniscus, right knee M23.322 Other meniscus derangements, posterior horn of medial meniscus, left knee M23.329 Other meniscus derangements, posterior horn of medial meniscus, unspecified knee M23.331 Other meniscus derangements, other medial meniscus, right knee M23.332 Other meniscus derangements, other medial meniscus, left knee M23.339 Other meniscus derangements, other medial meniscus, unspecified knee M23.341 Other meniscus derangements, anterior horn of lateral meniscus, right knee M23.342 Other meniscus derangements, anterior horn of lateral meniscus, left knee M23.349 Other meniscus derangements, anterior horn of lateral meniscus, unspecified knee M23.351 Other meniscus derangements, posterior horn of lateral meniscus, right knee Harvard Pilgrim Health Care Provider Manual D.79 September 2015
Code PRIOR AUTHORIZATION REQUEST FORM (CON'T) M23.352 Other meniscus derangements, posterior horn of lateral meniscus, left knee M23.359 Other meniscus derangements, posterior horn of lateral meniscus, unspecified knee M23.361 Other meniscus derangements, other lateral meniscus, right knee M23.362 Other meniscus derangements, other lateral meniscus, left knee M23.369 Other meniscus derangements, other lateral meniscus, unspecified knee M23.40 Loose body in knee, unspecified knee M23.41 Loose body in knee, right knee M23.42 Loose body in knee, left knee M23.90 Unspecified internal derangement of unspecified knee M23.91 Unspecified internal derangement of right knee M23.92 Unspecified internal derangement of left knee M25.561 Pain in right knee M25.562 Pain in left knee M25.569 Pain in unspecified knee M25.661 Stiffness of right knee, not elsewhere classified M25.662 Stiffness of left knee, not elsewhere classified M25.669 Stiffness of unspecified knee, not elsewhere classified M67.50 Plica syndrome, unspecified knee M67.51 Plica syndrome, right knee M67.52 Plica syndrome, left knee M71.20 Synovial cyst of popliteal space [Baker], unspecified knee M71.21 Synovial cyst of popliteal space [Baker], right knee M71.22 Synovial cyst of popliteal space [Baker], left knee M79.604 Pain in right leg M79.605 Pain in left leg M79.606 Pain in leg, unspecified M79.609 Pain in unspecified limb M79.651 Pain in right thigh M79.652 Pain in left thigh M79.659 Pain in unspecified thigh M79.661 Pain in right lower leg M79.662 Pain in left lower leg M79.669 Pain in unspecified lower leg M93.20 Osteochondritis dissecans of unspecified site M93.261 Osteochondritis dissecans, right knee M93.262 Osteochondritis dissecans, left knee M93.269 Osteochondritis dissecans, unspecified knee M93.28 Osteochondritis dissecans other site M93.29 Osteochondritis dissecans multiple sites Q68.6 Discoid meniscus R29.898 Other symptoms and signs involving the musculoskeletal system S83.001A Unspecified subluxation of right patella, initial encounter S83.002A Unspecified subluxation of left patella, initial encounter S83.003A Unspecified subluxation of unspecified patella, initial encounter Harvard Pilgrim Health Care Provider Manual D.80 September 2015
PRIOR AUTHORIZATION REQUEST FORM (CON'T) Code S83.004A S83.005A S83.006A S83.011A S83.012A S83.013A S83.014A S83.015A S83.016A S83.091A S83.092A S83.093A S83.094A S83.095A S83.096A S83.200A S83.201A S83.202A S83.203A S83.204A S83.205A S83.206A S83.207A S83.209A S83.211A S83.212A S83.219A S83.221A S83.222A S83.229A S83.231A S83.232A S83.239A S83.241A S83.242A S83.249A S83.251A S83.252A S83.259A S83.261A S83.262A S83.269A S83.271A S83.272A Unspecified dislocation of right patella, initial encounter Unspecified dislocation of left patella, initial encounter Unspecified dislocation of unspecified patella, initial encounter Lateral subluxation of right patella, initial encounter Lateral subluxation of left patella, initial encounter Lateral subluxation of unspecified patella, initial encounter Lateral dislocation of right patella, initial encounter Lateral dislocation of left patella, initial encounter Lateral dislocation of unspecified patella, initial encounter Other subluxation of right patella, initial encounter Other subluxation of left patella, initial encounter Other subluxation of unspecified patella, initial encounter Other dislocation of right patella, initial encounter Other dislocation of left patella, initial encounter Other dislocation of unspecified patella, initial encounter Bucket-handle tear of unspecified meniscus, current injury, right knee, initial encounter Bucket-handle tear of unspecified meniscus, current injury, left knee, initial encounter Bucket-handle tear of unspecified meniscus, current injury, unspecified knee, initial encounter Other tear of unspecified meniscus, current injury, right knee, initial encounter Other tear of unspecified meniscus, current injury, left knee, initial encounter Other tear of unspecified meniscus, current injury, unspecified knee, initial encounter Unspecified tear of unspecified meniscus, current injury, right knee, initial encounter Unspecified tear of unspecified meniscus, current injury, left knee, initial encounter Unspecified tear of unspecified meniscus, current injury, unspecified knee, initial encounter Bucket-handle tear of medial meniscus, current injury, right knee, initial encounter Bucket-handle tear of medial meniscus, current injury, left knee, initial encounter Bucket-handle tear of medial meniscus, current injury, unspecified knee, initial encounter Peripheral tear of medial meniscus, current injury, right knee, initial encounter Peripheral tear of medial meniscus, current injury, left knee, initial encounter Peripheral tear of medial meniscus, current injury, unspecified knee, initial encounter Complex tear of medial meniscus, current injury, right knee, initial encounter Complex tear of medial meniscus, current injury, left knee, initial encounter Complex tear of medial meniscus, current injury, unspecified knee, initial encounter Other tear of medial meniscus, current injury, right knee, initial encounter Other tear of medial meniscus, current injury, left knee, initial encounter Other tear of medial meniscus, current injury, unspecified knee, initial encounter Bucket-handle tear of lateral meniscus, current injury, right knee, initial encounter Bucket-handle tear of lateral meniscus, current injury, left knee, initial encounter Bucket-handle tear of lateral meniscus, current injury, unspecified knee, initial encounter Peripheral tear of lateral meniscus, current injury, right knee, initial encounter Peripheral tear of lateral meniscus, current injury, left knee, initial encounter Peripheral tear of lateral meniscus, current injury, unspecified knee, initial encounter Complex tear of lateral meniscus, current injury, right knee, initial encounter Complex tear of lateral meniscus, current injury, left knee, initial encounter Harvard Pilgrim Health Care Provider Manual D.81 September 2015
PRIOR AUTHORIZATION REQUEST FORM (CON'T) Code S83.279A S83.281A S83.282A S83.289A S83.30xA S83.31xA S83.32xA S83.501A S83.502A S83.509A S83.511A S83.512A S83.519A S83.521A S83.522A S83.529A Complex tear of lateral meniscus, current injury, unspecified knee, initial encounter Other tear of lateral meniscus, current injury, right knee, initial encounter Other tear of lateral meniscus, current injury, left knee, initial encounter Other tear of lateral meniscus, current injury, unspecified knee, initial encounter Tear of articular cartilage of unspecified knee, current, initial encounter Tear of articular cartilage of right knee, current, initial encounter Tear of articular cartilage of left knee, current, initial encounter Sprain of unspecified cruciate ligament of right knee, initial encounter Sprain of unspecified cruciate ligament of left knee, initial encounter Sprain of unspecified cruciate ligament of unspecified knee, initial encounter Sprain of anterior cruciate ligament of right knee, initial encounter Sprain of anterior cruciate ligament of left knee, initial encounter Sprain of anterior cruciate ligament of unspecified knee, initial encounter Sprain of posterior cruciate ligament of right knee, initial encounter Sprain of posterior cruciate ligament of left knee, initial encounter Sprain of posterior cruciate ligament of unspecified knee, initial encounter Describe previous treatment(s), outcome(s) and duration: Completed by (please print): Name: Fax: Phone: Date: Harvard Pilgrim Health Care Provider Manual D.82 September 2015