CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Meniscal allograft transplantation and meniscal implants — coverage criteria

This policy addresses coverage and medical necessity criteria for meniscal allograft transplantation and collagen meniscal implants for knee meniscal deficiency following meniscectomy, and specifies coding and coverage stance for BlueCHP for Medicare and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMeniscal allograft transplantation and meniscal implants — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 2, 2003

Next Review DateN/A

Key ActionVerify member benefits and eligibility and obtain any required authorizations per participation agreements prior to providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Covered CPT code listed

1HCPCS not covered

<55Age guidance

Outerbridge IIMax cartilage damage

MultipleEvidence syntheses cited

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Coverage and Medical Necessity Criteria

Meniscal allograft transplantation - primary

Covered when ALL of the following are met

Primary medical necessity criteria: Patient has had meniscectomy and has symptoms related to the affected side; disabling knee pain refractory to conservative treatment; adult patient considered too young to be an appropriate candidate for total knee arthroplasty (e.g., younger than 55 years); absence or near absence (>50%) of the meniscus established by imaging or surgery; normal knee biomechanics, or alignment and stability achieved concurrently with transplantation; documented minimal to absent diffuse degenerative changes in surrounding articular cartilage (eg, Outerbridge II or <50% joint space narrowing)as stated

From policy medical necessity criteria

Meniscal allograft transplantation with cartilage procedures

Covered when performed in combination with treatment of focal articular cartilage lesions

Allowed concurrent or sequential procedures: Meniscal allograft transplantation may be considered medically necessary when performed concurrently or sequentially with osteochondral allografting, autologous chondrocyte implantation, or osteochondral autografting.

Combination therapy allowed

Collagen meniscal implants are not covered for BlueCHP for Medicare and are considered not medically necessary for Commercial products due to insufficient evidence demonstrating meaningful improvements in health outcomes. The policy specifically identifies HCPCS G0428 (Collagen Meniscus Implant procedure) as not covered and not medically necessary for Commercial plans. Providers should use the coding and coverage guidance in this policy when submitting claims for meniscal implant procedures.

The rationale for this stance is limited and low-quality evidence: systematic reviews and case series report mixed results, with some symptomatic and functional improvements but inconsistent durability and radiologic evidence of implant size reduction in some patients. Because available studies are primarily case series and the overall quality is uncertain, collagen meniscal implants are excluded from coverage for BlueCHP for Medicare and deemed not medically necessary for Commercial products.

Services that are identified as non-covered in a member's certificate, subscriber agreement, or employer agreement are excluded from coverage under the member's benefit. Coverage and payment are governed by those benefit documents, which supersede this medical policy.

Providers must verify member benefits and eligibility prior to providing services. If a service is a non-covered benefit under the member's contract, providers may not bill the member for the non-covered service unless the provider first informed the member and obtained a written agreement in advance authorizing the member to be responsible for payment. Refer to applicable participation agreements for additional billing rules.

In summary, collagen meniscal implants are not covered for BlueCHP for Medicare and are not medically necessary for Commercial products. The policy lists HCPCS G0428 as the specific non-covered code for collagen meniscal implant procedures.

This concise restatement reflects the policy determination based on available evidence and applies to claims and prior billing decisions for collagen scaffold/CMI procedures.

Billing Codes and Diagnosis Codes

Covered CPT CodesCPTCovered

29868

Arthroscopy, knee, surgical; Meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral

Not covered HCPCSHCPCSNot Covered

G0428

Collagen Meniscus Implant procedure for meniscal defects (e:g , CMI, collagen scaffold, Menaflex) filling

ICD-10 Diagnosis Codes that may support medical necessityICD-10

M23.000-M23.92	Internal derangement of knee (ICD-10 range listed)
S83.200-S83.289	Dislocation/ligament/meniscal knee injury range (ICD-10 range listed)
S83.30-S83.32	Other meniscal tears (ICD-10 range listed)

Provider Requirements and Billing Actions

Prior Authorization

Prior authorization is not applicable according to this policy. However, providers should confirm any plan-specific requirements prior to scheduling services.

Note

Benefit Verification

Benefits and coverage may vary by contract. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement for applicable surgery coverage and benefits.

Prior Authorization

Verify Benefits and Eligibility

Providers should verify member-specific benefits and eligibility and obtain any required authorizations per the member subscriber agreement and participation agreements prior to providing services. Confirm coverage and any preauthorization requirements before scheduling procedures to avoid claim denials or member liability.

Clinical Background

Meniscal allograft transplantation and meniscal implants are intended to improve symptoms and reduce joint degeneration in patients who have previously undergone total or partial meniscectomy. Meniscal allograft transplantation is typically used as a salvage procedure for patients with disabling knee symptoms after meniscectomy who are considered too young for total knee arthroplasty or who have undergone near-total meniscectomy.

Outcomes evidence for meniscal allograft transplantation and implants is limited. Studies include case series, several systematic reviews, and a small randomized trial. Reports indicate improvements in pain and function for some patients, but prevention of osteoarthritis has not been demonstrated. Evidence for collagen meniscal implants shows some positive symptomatic results in selected series, but the overall quality of evidence is insufficient to confirm long-term benefits.

Key Terms and Definitions

Collagen Meniscus Implant (CMI) — definition entry

TermCollagen Meniscus Implant (CMI)

CompositionResorbable collagen matrix composed primarily of type I collagen derived from bovine Achilles tendon.

FormProvided in a semilunar shape and trimmed to size for suturing to the remaining meniscal rim.

Intended useDesigned as an absorbable scaffold to fill meniscal defects after meniscectomy; requires an existing meniscal rim for attachment.

Clinical roleReplaced by the patient’s soft tissue over time; not intended to replace normal meniscal structure permanently.

Types of meniscal allograft processing

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMeniscal allograft transplantation and meniscal implants — coverage criteria

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 2, 2003

Next Review DateN/A

Key ActionVerify member benefits and eligibility and obtain any required authorizations per participation agreements prior to providing services.

SourceLink

On This Page

Documentation Required

Coding and Documentation

Report the appropriate CPT code(s) with a supporting ICD-10 diagnosis from the ranges listed to substantiate medical necessity. Ensure documentation in the medical record supports the procedure, clinical indications, prior conservative treatment attempts, imaging or surgical confirmation of meniscal deficiency, and alignment/stability assessments when applicable.

Report CPT 29868 (arthroscopy, knee, meniscectomy) with an appropriate ICD-10 diagnosis to support medical necessity when applicable
Include operative reports, imaging results, and documentation of conservative management efforts in the medical record

Denial Risk

Not Covered HCPCS

The HCPCS code G0428 (Collagen Meniscus Implant procedure) is not covered for BlueCHiP for Medicare and is not considered medically necessary for Commercial products.

HCPCS G0428 — Not covered / Not medically necessary

Billing Rule

Benefit and Eligibility Limits

Coverage and payment are subject to member benefits, eligibility, and employer agreements. Services determined to be non-covered benefits may result in member liability; providers should obtain written agreement from the member if proceeding with non-covered services.

Harvested under sterile conditions and intended to be used within a short time window to maintain cell viability; used less frequently due to limited storage time.

Fresh frozenHarvested and frozen for storage until needed; widely used and commonly preferred by surgeons.

CryopreservedFrozen in glycerol to help preserve cell membrane integrity and donor fibrochondrocyte viability (commercial suppliers available).

Lyophilized (freeze-dried)Dehydrated for room-temperature storage but associated with reduced tensile strength, shrinkage, poor rehydration, posttransplantation effusion, and synovitis; no longer used clinically.

Irradiation/sterilization considerationsSecondary sterilization techniques such as gamma irradiation are used but radiation doses can alter mechanical structure; nonirradiated grafts from screened donors are most frequently preferred.