CurrentBlue Cross Blue Shield of VermontPolicy 7.01.VT48

Autologous Chondrocyte Transplantation or Implantation Corporate Medical Policy

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This policy governs coverage, prior approval, documentation, and coding for autologous chondrocyte implantation and related osteochondral autograft procedures. Coverage may be available for selected disabling full-thickness cartilage defects of the knee when all medical-necessity criteria are met; ACI for other joints or other indications is investigational.

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAutologous Chondrocyte Transplantation or Implantation Corporate Medical Policy

Policy CodePolicy 7.01.VT48

Change TypeMaterial coding revision

Effective DateDecember 1, 2026

Last ReviewAug 1, 2026

Next Review DateAugust 1, 2027

Key ActionPrior approval is required for the listed procedures and products.

SourceLink

POLICY UPDATE CHANGES

The 2026 review removed CPT code 29870 from the coding table.

The 2026 review added CPT code 29866 to the coding table as requiring prior approval.

The 2026 review removed coding language from the body of the policy.

4Required criteria for covered knee ACI

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CurrentBlue Cross Blue Shield of VermontPolicy 7.01.VT48

Autologous Chondrocyte Transplantation or Implantation Corporate Medical Policy

Customize your policy alerts

Sign up for bcbsvermont Policy 7.01.VT48 alerts

Get alerted when Policy 7.01.VT48 changes without checking for updates manually.

Monitor payer policy activity

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Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAutologous Chondrocyte Transplantation or Implantation Corporate Medical Policy

Policy CodePolicy 7.01.VT48

Change TypeMaterial coding revision

Effective DateDecember 1, 2026

Last ReviewAug 1, 2026

Next Review DateAugust 1, 2027

Key ActionPrior approval is required for the listed procedures and products.

SourceLink

POLICY UPDATE CHANGES

The 2026 review removed CPT code 29870 from the coding table.

The 2026 review added CPT code 29866 to the coding table as requiring prior approval.

The 2026 review removed coding language from the body of the policy.

4Required criteria for covered knee ACI

<55 yearsExample adult age threshold

4Steps for matrix-induced ACI

5 cm²Approximate average defect size

5Codes listed in Attachment I

Medical Necessity and Investigational Indications

Medically Necessary Knee ACI

Autologous chondrocyte implantation may be considered medically necessary for disabling full-thickness articular cartilage defects of the knee caused by acute or repetitive trauma when ALL of the following criteria are met:

ALL of the following

Adolescent patients are skeletally mature with documented closure of growth plates (e.g., ≥ 15 years); adult patients are too young to be considered an appropriate candidate for total knee arthroplasty or other reconstructive knee surgery (e.g., < 55 years).
The lesion is a focal, full-thickness (grade III or IV) unipolar lesion of the weightbearing surface of the femoral condyles, trochlea, or patella, measuring at least 1.5 cm².
There are minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge Grade II or less), with normal-appearing hyaline cartilage surrounding the border of the defect.
Knee biomechanics and alignment are normal, and knee stability is normal or achieved concurrently with autologous chondrocyte implantation.

Investigational ACI

Autologous chondrocyte implantation is considered investigational when any of the following applies:

ANY of the following

The procedure is performed on a joint other than the knee, including the talar joint.
The indication is not otherwise listed under the medically necessary knee criteria.

Autologous chondrocyte implantation for all other joints, including the talar joint, and for any indications other than those listed under the medically necessary knee criteria is considered investigational.

Misalignment and instability of the joint are contraindications to autologous chondrocyte implantation. Additional procedures, such as repair of ligaments or tendons or creation of an osteotomy for joint realignment, may be performed concurrently so that normal biomechanics, alignment, and stability are achieved.

Coding and Clinical Thresholds

CPT codes considered medically necessary when applicableCPTCovered

27412	Autologous chondrocyte implantation, knee.
27416	Osteochondral autograft(s), knee open (e.g. Mosaicplasty) (Includes harvesting of autograft[s]).
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting.

HCPCS codes considered medically necessary when applicableHCPCSCovered

J7330	Autologous cultured chondrocytes, implant.
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells).

Minimum Cartilage Defect Size

Minimum defect sizeAt least 1.5 cm²

Lesion typeFocal, full-thickness grade III or IV, unipolar lesion

Eligible locationWeightbearing surface of the femoral condyles, trochlea, or patella

Adolescent Skeletal Maturity

Skeletal maturityDocumented closure of the growth plates is required

Example ageAt least 15 years

Applicable patients

Authorization, Documentation, and Approval Risks

Prior Authorization

Prior Authorization Required

Prior approval is required before autologous chondrocyte implantation (ACI). Benefits remain subject to the member’s subscriber contract, applicable limitations, exclusions, and benefit conditions.

Incomplete authorization requests may delay the decision until missing information is submitted.
Verify benefits before providing services; NEHP/ABNE, Federal Employee Program, ASO, and other group or individual contracts may have different coverage.
Member contract and applicable employer benefit-plan language take precedence over this medical policy when there is a conflict.

Step Therapy

Consider Marrow Stimulation for Smaller Lesions

For smaller lesions, particularly those measuring < 4 cm², consider marrow-stimulating techniques before proceeding with ACI when debridement is the only prior surgical treatment.

Document whether prior debridement was performed and whether marrow stimulation was considered or completed.

Clinical Background

Autologous chondrocyte implantation is a cartilage-repair procedure in which chondrocytes are harvested from healthy cartilage, expanded in vitro, and implanted into a chondral defect. Matrix-induced ACI generally involves an initial arthroscopy and cartilage biopsy, chondrocyte culturing, a separate arthrotomy to create a periosteal flap and implant the cells, and postsurgical rehabilitation. The policy supports ACI as an option for selected large, disabling, full-thickness cartilage lesions of the knee; evidence is insufficient for lesions in joints other than the knee.

Procedure Definitions

Autologous Chondrocyte Implantation (ACI)

Cell sourceChondrocytes are harvested from healthy tissue

Cell expansionThe harvested cells are expanded in vitro

ImplantationThe expanded cells are implanted into the chondral defect

Matrix-Induced ACI

Step 1Initial arthroscopy and biopsy of normal cartilage

Step 2Culturing of chondrocytes

Step 3Separate arthrotomy to create a periosteal flap and implant the chondrocytes

Policy Summary

PayerBlue Cross Blue Shield of Vermont

PolicyAutologous Chondrocyte Transplantation or Implantation Corporate Medical Policy

Policy CodePolicy 7.01.VT48

Change TypeMaterial coding revision

Effective DateDecember 1, 2026

Last ReviewAug 1, 2026

Next Review DateAugust 1, 2027

Key ActionPrior approval is required for the listed procedures and products.

SourceLink

On This Page

Adolescent patients being considered for knee autologous chondrocyte implantation

Adult Candidate Suitability

Example age thresholdYounger than 55 years

Candidate suitabilityThe adult should be too young to be an appropriate candidate for total knee arthroplasty or other reconstructive knee surgery

Coverage contextApplies to adult patients with disabling full-thickness articular cartilage defects of the knee caused by acute or repetitive trauma

Surrounding Cartilage

Maximum surrounding-cartilage gradeOuterbridge Grade II or less

Degenerative changesMinimal to absent degenerative changes in the surrounding articular cartilage

Defect borderNormal-appearing hyaline cartilage must surround the border of the defect

Smaller Lesions and Marrow Stimulation

Smaller lesion thresholdLess than 4 cm²

Prior surgical treatmentDebridement is the only prior surgical treatment

Recommended considerationConsider marrow-stimulating techniques before performing autologous chondrocyte implantation

Severe Obesity

Severe obesity thresholdBody mass index greater than 35 kg/m²

Potential concernSevere obesity may affect outcomes

Reason identified in the policyIncreased stress on the weightbearing surfaces of the joint

Explain the clinical rationale when proceeding directly to ACI.

Documentation Required

Required Medical-Necessity Documentation

The request must include supporting documentation of medical necessity sufficient for review of the proposed ACI procedure.

Member’s name and age.
Symptoms and duration.
Previous conservative treatments and outcomes.
Results of prior arthroscopic or surgical repairs, including photographs of the defect when available or obtained during chondrocyte harvesting.
Grade and size of the cartilage defect.
Patient’s ability to comply with postsurgical rehabilitation.

Documentation Required

Clinical Eligibility Support

Submit clinical records that substantiate every eligibility requirement for ACI of the knee, including patient maturity or age, lesion characteristics, surrounding cartilage, and knee biomechanics.

Adolescents should be skeletally mature with documented closure of growth plates; adults should be too young to be appropriate candidates for total knee arthroplasty or other reconstructive knee surgery.
Document a focal, full-thickness grade III or IV unipolar lesion on the weightbearing femoral condyle, trochlea, or patella measuring at least 1.5 cm².
Document minimal to absent surrounding degenerative changes (Outerbridge grade II or less) and normal-appearing hyaline cartilage at the defect border.
Document normal knee biomechanics or alignment and stability achieved concurrently with ACI.
Include relevant imaging, operative findings, photographs, and measurements needed to verify these criteria.

Denial Risk

Investigational Joint or Indication

ACI for all other joints, including the talar joint, and for indications not listed in the policy is considered investigational and is not eligible under the described knee indication.

Confirm that the requested treatment is for a qualifying knee cartilage defect caused by acute or repetitive trauma.
Do not assume coverage for another joint or an indication outside the stated criteria.

Denial Risk

Failure to Meet Knee Eligibility Criteria

Failure to satisfy the knee eligibility criteria creates a denial risk. The defect, surrounding cartilage, patient age or skeletal maturity, and ability to undergo rehabilitation must be documented before submission.

Lesion must be focal, full-thickness (grade III or IV), unipolar, and located on the weightbearing femoral condyle, trochlea, or patella.
Lesion must measure at least 1.5 cm²; surrounding articular cartilage must show minimal to absent degeneration, with Outerbridge grade II or less.
Severe obesity (for example, BMI > 35 kg/m²) may adversely affect outcomes because of increased stress on weightbearing joint surfaces; address its clinical relevance in the request.
The patient must be able to comply with postsurgical rehabilitation.

Denial Risk

Correct Instability or Malalignment

Uncorrected instability or malalignment is a contraindication and may prevent approval. Knee biomechanics and alignment must be normal, or instability and malalignment must be corrected concurrently with ACI.

Document stability and alignment in the clinical evaluation.
When indicated, coordinate concurrent procedures such as ligament or tendon repair or osteotomy for realignment.
Do not submit the request without documenting correction or planned concurrent correction of the instability or malalignment.

Prior Authorization

Complete the Request and Verify Benefits

Authorization review may be delayed when required information is missing, and benefit availability depends on the member’s contract. Confirm that the request is complete and verify member-specific coverage before treatment.

Use the policy guidelines and documentation requirements to complete the authorization request.
Contact the applicable health-plan customer service department for benefit questions, including NEHP/ABNE, FEP, or ASO coverage.
Coverage varies by group or individual contract; not all groups are subject to Vermont legislative mandates.
Administrative Services Only benefits may vary or not apply, and employer benefit-plan documents may control.

Step 4Postsurgical rehabilitation