ModifiedBlue Cross Blue Shield - MichiganPolicy N/A

Billing chart and policy clarifications for musculoskeletal orthopedic procedures

Summarizes Blue Cross Blue Shield of Michigan billing chart updates and medical policy clarifications for selected orthopedic/musculoskeletal procedures (including osteochondral grafting, microfracture, femoroacetabular impingement surgery and related coding/billing guidance) and indicates who is affected (providers billing BCBSM).

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyBilling chart and policy clarifications for musculoskeletal orthopedic procedures

Policy CodePolicy N/A

Change TypeCriteria and coverage updates (multiple services)

Effective DateNov. 1, 2024

Next Review DateN/A

Key ActionDocument and submit prior authorization and clinical documentation showing failed non-operative therapy, imaging findings, and lesion measurements when requesting coverage for osteochondral procedures or FAI surgery.

SourceLink

POLICY UPDATE CHANGES

The medical policy statement, and inclusionary and exclusionary criteria have been updated, effective Nov. 1, 2024.

Specific inclusion and exclusion criteria for osteochondral allografting, osteochondral autografting, and microfracture for OCD were specified (age ranges, lesion size, degenerative change limits, prior treatment requirements).

Imaging and clinical criteria for open or arthroscopic treatment of femoroacetabular impingement (FAI) were added, including alpha angle >55° for cam lesions and Center Edge angle >39° (and other pincer findings).

The inclusionary and exclusionary criteria for facet joint denervation and related procedures have been updated, effective Nov. 1, 2024.

Donor screening, MDRO testing and consent requirements for fecal microbiota transplantation align with FDA protections.

New or updated coverage criteria for Piasky (crovalimab-akkz) including required documentation, prior trials, and renewal criteria.

The medical policy statements for multiple services (e.g., fecal microbiota transplantation, ultrafiltration, telemedicine, elemental formula, pneumatic compression pumps) have been updated, effective Nov. 1, 2024.

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Nov. 1, 2024effective date for multiple policy inclusion/exclusion updates

1–2.5 cm2knee lesion size range

>35BMI exclusion consideration

alpha >55°FAI cam threshold

≥3 monthsnon-operative therapy minimum

4 weekslymphedema conservative trial

Coverage Criteria and Medical Necessity

inv-01: Osteochondral allografting — Covered when ALL of the following are met

Osteochondral allografting — Covered when ALL of the following are met:

Individual age: adolescent individuals should be skeletally mature with documented closure of growth plates (for example, ≥15 years); adult individuals should be too young to be considered an appropriate candidate for total knee arthroplasty or other reconstructive knee surgery (for example, younger than 55 years).

Lesion location and size: focal, full-thickness cartilage defects on the weight-bearing surface of the femoral condyles, trochlea or patella between 1 and 2.5 cm2 in size, confirmed by MRI or prior arthroscopic report.

Minimal surrounding degeneration: documented minimal to absent degenerative changes in surrounding articular cartilage (Outerbridge grade II or less) and normal-appearing hyaline cartilage surrounding the border of the defect.

Knee biomechanics/alignment: normal knee biomechanics or alignment and stability achieved concurrently with osteochondral grafting.

Talus indications: large (area ≥1.5 cm2) or cystic (volume >3.0 cm3) osteochondral lesions of the talus, or revision surgery after failed marrow stimulation for osteochondral lesion of the talus.

Symptoms and conservative care: persistent symptoms of disabling localized knee pain limiting ambulation for at least six months that have failed to respond to non-operative treatment (see note) and patient willing to comply with postoperative weight-bearing restrictions and rehabilitation.

inv-02: Osteochondral autografting — Covered when ALL of the following are met

Osteochondral autografting — Covered when ALL of the following are met:

Focal, full-thickness (grade III or IV) unipolar lesions on the weight-bearing surface of the femoral condyles, trochlea or patella between 1 and 2.5 cm2 in size, confirmed by MRI or prior arthroscopic report.

Documented minimal to absent degenerative changes in surrounding articular cartilage (Outerbridge grade II or less) and normal-appearing hyaline cartilage surrounding the border of the defect.

Normal knee biomechanics or alignment and stability achieved concurrently with osteochondral grafting.

Talus indications: large (area ≥1.5 cm2) or cystic (volume >3.0 cm3) osteochondral lesions of the talus, or revision surgery after failed marrow stimulation for osteochondral lesion of the talus.

inv-03: Microfracture for OCD — Covered when ANY of the following criteria are met

Microfracture for osteochondritis dissecans (OCD) — Covered when ANY of the following are met:

Displaced lesion.

Nondisplaced lesion in skeletally immature individuals (growth plates open) after failure of at least 12 weeks of non-operative treatment.

Acute nondisplaced lesion in skeletally mature individuals (closed growth plates).

Chronic nondisplaced lesion in skeletally mature individuals (closed growth plates) after failure of at least six weeks of non-operative treatment.

inv-04: FAI surgery — May be appropriate when ALL of the following are met

Femoroacetabular impingement (FAI) surgery — May be appropriate when ALL of the following are met:

Age: patient between 15 years (skeletally mature with documented closure of growth plates) and 55 years (not considered a candidate for hip replacement). Note: age is not an absolute cutoff for individuals >55 who have minimal hip arthritis and meet other criteria.

Symptoms and prior therapy: significant hip pain worsened by flexion activities that limits daily activities and has failed non-operative therapy for at least three months, including activity modification, pharmacologic therapy (NSAIDs or acetaminophen), physical therapy focused on core hip musculature with documentation of dates/duration/response, and intra-articular injection(s).

Other causes ruled out: all other reasonable causes of pain have been excluded.

Physical exam: positive FADIR or FABER test.

Imaging evidence of impingement — one of the following: cam impingement with alpha angle >55 degrees; or pincer impingement demonstrated by center edge angle >39 degrees, positive cross-over sign, acetabular retroversion or overcoverage, coxa profunda, Tönnis angle <0 degrees, or rim fracture/ossified labrum.

Coding — CPT/HCPCS/Drug Codes and Thresholds

Highlighted/clarified orthopedic procedure codesCPT

20932
20933
20934
27412
27415
27416
28446
29866
29867
29879

1–10 of 11

1/2

Experimental / unlisted orthopedic-related codesCPTExperimental

27299

Unlisted procedure (noted as experimental in chart)

Codes listed as experimentalCPT|HCPCSExperimental

32850
32851
32852
32853
32854
32855
32856
S2060
S2061

Mixed codes referenced in excerptsmixed

47133
47135
47140
47141
47142
47143
47144
47145
47146
47147

1–10 of 66

1/7

Pneumatic compression HCPCS referencedHCPCS

E0650	Pneumatic compression device, single compartment
E0651	Pneumatic compression device, multichambered nonprogrammable
E0660	Pneumatic compression device, trunk/chest
E0666	Pneumatic compression device (other)
E0667	Pneumatic compression device (other)
E0669	Pneumatic compression device (other)

Experimental / unlisted HCPCS referencedHCPCSNot Covered

E0652	Pneumatic compression device - experimental list
E0671	Pneumatic compression device - experimental list
E0672	Pneumatic compression device - experimental list
E0673	Pneumatic compression device - experimental list
E0676	Non-established/experimental device code
E0678	Experimental device code
E0679	Experimental device code
E0680	Experimental device code
E0681	Experimental device code
E0682	Experimental device code

1–10 of 11

1/2

Drug J-codes referencedHCPCS

J1413	Drug code referenced (Mircera context)
J1747	Injection code referenced
J3490	Unclassified drug or biological
J3590	Unclassified biologic

Specific drug HCPCS/CPT codesHCPCS

J9039	Drug administration code referenced (Yesafili not benefit for URMBT)
J9271	Blinatumomab-related code

Breast reconstruction and implant codesmixed

11920	Breast reconstruction-related CPT (filleting/reduction?)
11921	Breast reconstruction-related CPT
11922	Breast reconstruction-related CPT
19301	Partial mastectomy
19302	Mastectomy
19303	Mastectomy
19305	Mastectomy
19306	Mastectomy
19307	Mastectomy reconstruction-related
19316	Breast reconstruction-related CPT

1–10 of 33

1/4

Lesion size thresholds (knee, talus)

Knee lesion sizeUnipolar weight-bearing femoral condyle/trochlea/patella lesions between 1 and 2.5 cm2 (confirmed by MRI or arthroscopy)

Talar large lesionArea ≥ 1.5 cm2

Talar cystic lesionCystic volume > 3.0 cm3

FAI radiographic thresholds (alpha angle, Center Edge angle)

Cam-type thresholdAlpha angle > 55 degrees

Provider Requirements, Prior Authorization and Documentation

Prior Authorization

Prior Authorization and Where to Check

Prior authorization is required for many procedures and services. Check Availity Benefit Explainer (Commercial Policy tab) or the payer's prior authorization and step therapy documents for specific guidance and code-level requirements before scheduling services.

How to check: Availity.com > Payer Spaces > BCBSM and BCN > Benefit Explainer > Commercial Policy > Topic (search by HCPCS/CPT).
Prior authorization portals and step therapy lists may specify preferred agents, required trials, and quantity limits.

Prior Authorization

Transplant Prior Authorization

All transplants require prior authorization through the Human Organ Transplant Program. Transplant candidates and hospitals must maintain complete documentation of imaging, lesion assessments, and other transplant-specific criteria in the medical record.

All transplants: prior authorization through the Human Organ Transplant program is mandatory.
Transplant documentation: radiologic images and OPTN Class 5 lesion assessments must be maintained; if growth criteria used, radiology reports must include prior and current imaging dates, modality and lesion measurements.

Background and Scope

Osteochondral grafting (allograft or autograft) and microfracture are therapeutic options for carefully selected patients with full‑thickness cartilage defects of the knee or talus when strict clinical and imaging criteria are met. Covered indications include symptomatic, focal, full‑thickness defects on weight‑bearing surfaces of the femoral condyles, trochlea or patella with lesion area for knee unipolar defects between 1 and 2.5 cm2, minimal surrounding degenerative change (Outerbridge II or less), and confirmation by MRI or arthroscopy.

For talar lesions, coverage considerations include large lesions (≥1.5 cm2) or cystic lesions (volume >3.0 cm3), revision after failed marrow stimulation, or persistent disabling localized knee pain limiting ambulation for ≥6 months despite nonoperative care. Candidates should be skeletally mature (documented growth plate closure, e.g., ≥15 years) or adults too young for arthroplasty (commonly <55 years), and willing to comply with postoperative weight‑bearing restrictions and rehabilitation.

Skeletally mature — definition and example age/closure guidance

Skeletal maturity criterionAdolescents should have documented closure of growth plates (for example, 15 years or older)

Adult age guidanceAdults considered 'too young' for arthroplasty typically younger than 55 years for grafting candidacy

Documentation required

Policy Revision History

2024-11-01policy_revisionLatest

Medical policy statements, inclusionary and exclusionary criteria were updated for multiple services including osteochondral grafting, FAI surgery, facet procedures, elemental formula, pneumatic compression pumps, and others; effective Nov. 1, 2024.

2024-05-20policy_addition

Aflibercept biosimilars (Opuviz and Yesafili) dosing and indications were added as established when criteria are met (effective May 20, 2024).

2024-11-01

Policy Summary

PayerBlue Cross Blue Shield - Michigan

PolicyBilling chart and policy clarifications for musculoskeletal orthopedic procedures

Policy CodePolicy N/A

Change TypeCriteria and coverage updates (multiple services)

Effective DateNov. 1, 2024

Next Review DateN/A

SourceLink

On This Page

Persistent symptoms of disabling localized knee pain that limit ambulation for at least six months and have failed to respond to non-operative treatment (see note).

Patient is willing to comply with postoperative weight-bearing restrictions and rehabilitation.

Minimal degeneration: minimal degeneration of the hip (Tönnis grade 1 or less), absence of joint space narrowing on weight-bearing X-rays, and minimal cartilage injury (Outerbridge grade II or less).

Documentation: medical record must contain documentation of risk/benefit discussion and address significant/uncontrolled comorbid conditions or complications.

Pincer-type thresholdCenter Edge angle > 39 degrees

Other pincer findingsPositive crossover sign, acetabular retroversion/overcoverage, coxa profunda, Tönnis angle < 0°, rim fracture/ossified labrum

Diagnostic medial branch block success threshold

Diagnostic MBB success>= 80% reduction in pain with improved function for the expected duration of the anesthetic

Timing for repeat MBBRepeat MBB >= 2 weeks after first when criteria met

Session limitsNo more than 4 sessions within a rolling 12 months per spinal region

Repeat RF ablation response threshold

Repeat RF response requirementDocumentation of >= 50% reduction in pain and improved function lasting at least 6 months

Procedure frequency limitPlanned procedures do not exceed two per region within a rolling 12 months

Ongoing therapyContinued participation in concurrent non-operative regimen required

FMT recurrence definition

Definition of recurrence (FMT)A recurrence occurs within eight weeks of completion of a course of C. difficile infection therapy

Recurrence requirement for treatmentAt least two recurrences refractory to standard antibiotic treatment required for FMT consideration

Repeat FMTA repeat FMT is considered established for recurrence within eight weeks of an initial FMT

LDH threshold for Piasky coverage

LDH threshold for Piasky coverageLactic dehydrogenase (LDH) ≥ 1.5 × upper limit of normal (with qualifying symptoms)

Additional Piasky requirementsFDA-approved indication and age, flow cytometric confirmation of PNH type III red cells, prior transfusion in past 12 months, history of major thrombotic events

Minimum compression pressure for garments

Minimum distal compressionGarment must provide a minimum of 30 mmHg distally

Graduated compression requirementAdequate graduated compression across the gradient without tourniquet effect

Garment typeMay be prefabricated or custom-fabricated but must meet pressure requirement

Conservative measures (lymphedema and CVI) — definition and required trial elements

Lymphedema conservative trial durationFour-week trial of conservative therapy required before pump coverage

Required trial elementsRegular/compliant use of appropriate compression bandage system or garment (minimum 30 mmHg distally), regular exercise, limb elevation

Additional elements for comprehensive trialManual lymphatic drainage (where available) or self-MLD for ≥30 minutes/day, technician fitting/training and supervised home usage

Denial Risk

FAI Surgery Exclusions

Femoroacetabular impingement (FAI) surgery is excluded when there is advanced osteoarthritis or advanced chondral damage. Ensure imaging and clinical exams document Tonnis grade and Outerbridge grade to confirm eligibility.

Exclusions: Evidence of advanced osteoarthritis (Tonnis grade 2 or 3, or joint space < 2 mm).
Exclusions: Evidence of advanced chondral damage (Outerbridge grade III or IV).
Required: Documented risk/benefit discussion and assessment of comorbid conditions in the medical record.

Denial Risk

Device Exclusion Triggers

Certain devices and device models trigger exclusions — verify device type and anatomic indication against policy. Non-lower-extremity wound devices and some home model devices with segmental calibrated gradient pressure are considered experimental or excluded.

Excluded: Devices used to treat ulcers in locations other than the lower extremity.
Experimental/excluded: Segmental home model pneumatic compression devices with calibrated gradient pressure for CVI and many non-pneumatic compression devices.
Check specific HCPCS/CPT or E-code guidance in the policy (examples: E1399 and listed E-codes).

Documentation Required

Required Clinical Documentation

The medical record must document required clinical information for coverage determinations: non-operative therapy attempts, imaging, lesion measurements, dates and duration of treatments, response to therapy, and risk/benefit discussions when applicable.

Non-operative therapy: document dates, duration, modalities (activity modification, injections, physical therapy/home exercise), and patient's response.
Imaging and lesion measurements: include modality, prior and current dates, and numeric lesion measurements when used for staging or transplant candidacy.
Procedure documentation: document risk/benefit discussion, comorbidities, contraindications, and rationale for proceeding.

Documentation Required

Imaging Documentation for Transplant Candidates

For transplant candidates, maintain radiologic images and detailed OPTN Class 5 lesion assessments in the candidate's medical record. If lesion growth is used for classification, include prior and current imaging dates, imaging type, and precise measurements.

Radiology reports must include prior and current imaging dates and modalities when growth criteria are applied.
Document OPTN Class 5 lesion size(s) and measurements to support MELD/PELD exception requests.

Documentation Required

Procedure and Conservative Therapy Documentation

The medical record must document procedural rationale and conservative care. For procedures consider: risk/benefit, comorbid conditions, dates and duration of prior conservative therapies, and objective response to those therapies.

Document risk/benefit discussion and any significant/uncontrolled comorbid conditions or bleeding disorders.
List dates/duration of conservative treatments and objective improvement or failure.
Anesthesia note: general anesthesia, conscious sedation and MAC are generally not medically necessary for pain injections/ablations unless justified.

Documentation Required

Non-operative Therapy Prerequisites

Many musculoskeletal procedures require documented trials of specific non-operative therapies before surgery. For osteochondral procedures and FAI surgery, document the required course of non-operative care including activity modification, injections, and physical therapy with dates and response.

Osteochondral lesions: document non-operative treatments (activity modification, immobilization, corticosteroid injection, physical therapy/home exercise) and dates/duration; some indications require 6–12 weeks of failure prior to surgery depending on lesion and skeletal maturity.
FAI surgery: document at least three months of non-operative therapy including activity modification, NSAIDs/acetaminophen, targeted physical therapy (dates, duration, response), and intra-articular injection attempts.
Physical therapy documentation must include dates, duration and patient's response.

Prior Authorization

Conservative Therapy Before Lymphedema Pump

Pneumatic compression pumps for lymphedema require failure of conservative therapies first. A documented four-week trial of conservative therapy demonstrating failure is required and must include compliant use of appropriate compression bandaging or garments and other standard measures.

Required four-week conservative trial: regular compliant use of appropriate compression bandage system or compression garment providing graduated compression.
Conservative measures may also include exercise, elevation, wound care and management of contributory conditions; document dates, duration and response.

Medical record should document growth plate status or imaging confirmation of physeal closure when used to establish maturity

Recurrence — definition used in FMT context

Recurrence definition (general)Recurrence defined as occurring within eight weeks of completion of a course of C. difficile infection therapy

Use in FMT criteriaAt least two recurrences refractory to standard antibiotic treatment required for FMT candidacy

Oslo score — definition reference

Oslo score referenceOslo score used as part of selection criteria for colorectal liver metastases (example: Oslo score 0–2 for CRCLM inclusions)

Context of useApplied when evaluating candidates for liver transplant with colorectal metastases as part of institutional protocol requirements

Elemental formula medical policy statement and exclusionary criteria updated; elemental formula for infants considered established when clinical criteria are met (reimbursed up to 12 months); exclusions clarified; effective Nov. 1, 2024.

2024-11-01policy_revision

Pneumatic compression pumps/appliances policy updated: lymphedema and trunk/chest pumps established when criteria met; head/neck pumps listed as experimental; conservative trial requirements specified; effective Nov. 1, 2024.

2024-11-01policy_revision

Fecal microbiota transplantation criteria clarified to require at least two recurrences refractory to standard antibiotic treatment, donor screening and safety-mitigating procedures, and age criteria for FDA-approved products; effective Nov. 1, 2024.