CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Autologous Chrondrocyte Implantation for Focal Articular Cartilage Lesions

Defines medical coverage positions for autologous chondrocyte implantation (ACI/MACI), osteochondral allografting and autografting, and autologous minced/particulated cartilage for focal articular cartilage lesions (primarily knee and talus), including coding and prior authorization statements for Blue Cross Blue Shield - Rhode Island products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Autologous Chrondrocyte Implantation for Focal Articular Cartilage Lesions

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider should document lesion size (area/volume), depth, location, Outerbridge grade of surrounding cartilage, and skeletal maturity/alignment/biomechanics to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

No material changes to clinical coverage in this update.

CoveredCovered indications: knee and select talus lesions

ExcludedNot covered: other joints; autologous minced/particulated cartilage

Not requiredPrior Authorization

5Procedure codes listed

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.

Coverage Summary

This policy defines coverage positions for autologous chondrocyte implantation (ACI/MACI) and related osteochondral grafting procedures for focal articular cartilage lesions, primarily of the knee and select talus lesions. ACI/MACI (including second-generation matrix-applied techniques that seed chondrocytes onto bioresorbable collagen sponges) is an established option for large, disabling full-thickness cartilage lesions of the knee when alternatives are limited. Osteochondral allografting and autografting are covered for the knee; large (area > 1.5 cm2) or cystic (volume > 3.0 cm3) talar lesions and talar lesions inadequate for autografting are covered. Prior authorization is not required for these procedures. Techniques using autologous minced or particulated cartilage are considered not covered because evidence is insufficient, and osteochondral grafting for joints other than the knee or talus is also not covered for the same reason.

Surface thresholds / key facts

Osteochondral lesion area threshold> 1.5 cm2

Osteochondral cystic lesion volume threshold> 3.0 cm3

Minimum lesion size for ACI candidacy≥ 1.5 cm2

Adolescent skeletal maturityDocumented closure of growth plates (eg, ≥15 years)

Adult age considerationTypically <55 years to be considered not a candidate for arthroplasty

Prior authorization requirementPrior Authorization is not required

Medical-Necessity Criteria

Osteochondral allografting - Medically necessary vs Not covered

Covered when ALL of the following are met:

ALL of the following

Full-thickness osteochondral defect of the knee (unipolar, weight-bearing surface of the femoral condyles, trochlea) or osteochondral lesion of the talus where autografting would be inadequate due to lesion size, depth, or location.
Lesion size appropriate for allograft (eg, large lesions > 1.5 cm2 or cystic lesions with volume > 3.0 cm3 for talus).
Documented minimal to absent degenerative changes in surrounding articular cartilage (eg, Outerbridge grade I or less).
Normal knee biomechanics or alignment and stability, or corrective procedures performed concurrently to achieve this.

Background and Clinical Context

Autologous chondrocyte implantation (ACI) involves harvesting chondrocytes, expanding them in vitro, and implanting them into full-thickness chondral defects; second-generation (matrix-assisted) techniques seed chondrocytes onto a bioresorbable collagen scaffold. Typical patient selection considerations include skeletally mature adolescents (documented physeal closure, eg, ≥15 years), adults who are generally too young for arthroplasty (eg, <55 years), focal full-thickness (grade III or IV) unipolar lesions of the femoral condyles, trochlea, or patella with lesion area at least 1.5 cm2, minimal surrounding degenerative change (Outerbridge I or less), and restored knee alignment/biomechanics at the time of implantation. The evidence base is largest for the knee, where ACI has become an established treatment for large lesions; however, evidence is limited for joints other than the knee (the talus has the greatest literature outside the knee), and comparative trials are needed to determine effectiveness in other joints.

Definitions

Full-thickness lesionGrade III or IV unipolar lesion involving weight-bearing surface with depth through cartilage to subchondral bone

Large lesionLesion area >1.5 cm2 or cystic lesion volume >3.0 cm3

Coding

Covered / Medically Necessary Procedure Codes (BlueCHiP Medicare and Commercial)CPTCovered

27415	Osteochondral allograft; knee, open
27416	Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s])
29867	Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

Not covered / Not medically necessary procedure codeCPTNot Covered

28446

Open osteochondral autograft; talus (includes obtaining graft[s])

Approved diagnosis codes (when filing for medical necessity)ICD-10

M17.0	Osteoarthritis of knee, unspecified (range start)
M17.1	Osteoarthritis of knee (range)
M17.2	Osteoarthritis of knee (range)
M17.3	Osteoarthritis of knee (range)
M17.4	Osteoarthritis of knee (range)
M17.5	Osteoarthritis of knee (range end)
M17.9	Osteoarthritis of knee, unspecified
M12.561	Traumatic arthropathy, knee (range start)
M12.569	Traumatic arthropathy, knee (range end)
M23.90	Unspecified internal derangement of knee (range start)

1–10 of 23

1/3

Provider Actions

Prior Authorization

Prior authorization

Prior Authorization is not required for these procedures.

Documentation Required

Document lesion characteristics and cartilage status

Provider should document lesion size (area/volume), depth, location, Outerbridge grade of surrounding cartilage, and skeletal maturity/alignment/biomechanics to support medical necessity.

Lesion size (area) — e.g., >1.5 cm2 for large lesions
Cystic lesion volume — e.g., >3.0 cm3
Lesion depth — full-thickness (grade III or IV) involving subchondral bone
Lesion location — knee (femoral condyles, trochlea, patella) or talus as specified
Outerbridge grade of surrounding cartilage — minimal to absent degenerative changes (Outerbridge I or less)

Evidence Summary

Multiple systematic reviews and randomized trials report that ACI (including matrix-assisted ACI) can provide better outcomes than microfracture for larger knee lesions, particularly at mid-term follow-up. The literature includes randomized controlled trials and systematic reviews/meta-analyses comparing ACI/MACI with microfracture and other repair techniques; while mid-term outcomes of second-generation ACI approximate first-generation ACI, long-term data and larger comparative trials for joints other than the knee (eg, talus, patella) are limited, and evidence is insufficient to establish benefit outside the knee.

Revision History

05/07/2020policy updateLatest

Policy states second-generation ACI (matrix-assisted, chondrocytes seeded onto bioresorbable collagen sponge) may be considered medically necessary for large disabling full-thickness cartilage lesions of the knee; evidence shows ACI superior to microfracture for larger knee lesions and evidence is limited for joints other than the knee.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Autologous Chrondrocyte Implantation for Focal Articular Cartilage Lesions

Policy CodePolicy N/A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionProvider should document lesion size (area/volume), depth, location, Outerbridge grade of surrounding cartilage, and skeletal maturity/alignment/biomechanics to support medical necessity.

SourceLink

On This Page

Patient is an appropriate candidate for biological cartilage restoration (eg, skeletally mature; adult patients for whom joint replacement is not currently indicated).

Autologous minced or particulated cartilage

Covered when ALL of the following are met:

ALL of the following

Full-thickness cartilage defect of the knee (unipolar, weight-bearing surface of femoral condyles, trochlea) or osteochondral lesion of the talus appropriate for autografting.
Lesion size suitable for harvesting one or more osteochondral cores (mosaicplasty) without unacceptable donor-site morbidity.
Documented minimal to absent degenerative changes in surrounding articular cartilage (eg, Outerbridge grade I or less).
Normal knee biomechanics or alignment and stability, or corrective procedures performed concurrently to achieve this.
Patient is an appropriate candidate for biological cartilage restoration (eg, skeletally mature; adult patients for whom joint replacement is not currently indicated).

title":"Osteochondral autografting - Medically necessary vs Not covered

type":"criteria_group"},{

Skeletal maturity/alignment/biomechanics — documented growth plate closure and normal knee biomechanics or concurrent correction

Billing Rule

File with approved diagnosis codes

Procedures are considered medically necessary when filed with an approved diagnosis from the listed ICD-10 code ranges.

ICD-10 code group: M17.0-M17.12
ICD-10 code group: M17.4-M17.5
ICD-10 code group: M17.9
ICD-10 code group: M12.561-M12.569
ICD-10 code group: M23.90-M23.92
ICD-10 code group: M23.8x1-M23.8x9
ICD-10 code group: M25.861-M25.869
ICD-10 code group: M93.261-M93.269
ICD-10 code group: M89.8x6
ICD-10 code group: M94.8x6
ICD-10 code group: S89.90-S89.92
ICD-10 code group: S99.811-S99.929

Denial Risk

Not covered for other joints or techniques

Claims for osteochondral grafting in joints other than the knee/talus or for autologous minced/particulated cartilage may be denied as not covered due to insufficient evidence.