Implants for Joint Pain
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This policy governs coverage of cartilage and synthetic cartilage implants used to treat articular cartilage damage, including first metatarsophalangeal joint arthritis and knee cartilage or osteochondral defects, for Medicare Advantage and commercial products in Rhode Island.
No material clinical or coverage changes in this revision.
Coverage Criteria
Medicare Advantage Cartilage Implant Coverage
For Medicare Advantage Plans:
The evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Cartilage Implant Medical Necessity
For Commercial Products:
The evidence is insufficient to determine the effects of the technology on health outcomes.
For the Cartiva first metatarsophalangeal (MTP) implant, contraindications include lesions greater than 10 mm and insufficient bone quality or quantity.
For Commercial Products, cartilage implants used to treat articular cartilage damage are considered not medically necessary because the evidence is insufficient to determine their effects on health outcomes or improvement in net health outcomes.
For cartilage and osteochondral defects of the knee treated with a cartilage repair implant, the evidence is insufficient to determine improvement in net health outcomes. Although an Agili-C trial reported favorable results, independent replication and head-to-head comparisons with alternative cartilage repair procedures are needed.
For synthetic cartilage implants used in early-stage or advanced first MTP osteoarthritis, the evidence is insufficient to determine improvement in net health outcomes.
Coding and Product Parameters
| L8699 | Prosthetic Implant, not otherwise specified |
| 28291 | Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant |
Provider and Claims Actions
Medicare Advantage: cartilage implants are not covered
For Medicare Advantage Plans, cartilage implants used to treat articular cartilage damage are considered not covered because the evidence is insufficient to determine the effects of the technology on health outcomes.
Commercial Products: medical-necessity denial
For Commercial Products, cartilage implants used to treat articular cartilage damage are considered not medically necessary because the evidence is insufficient to determine the effects of the technology on health outcomes.
Policy-listed implant codes are not covered
Claims for the referenced cartilage implants are not covered for Medicare Advantage Plans and are not medically necessary for Commercial Products when submitted under the policy-listed unlisted implant or implantation procedure codes.
Clinical Background
Articular cartilage damage may occur as a focal lesion or as diffuse osteoarthritis. It can cause pain, loss of function, and disability. Treatment options include debridement, microfracture, osteochondral grafting, autologous chondrocyte implantation, and joint replacement. Synthetic cartilage implants have been studied as motion-preserving alternatives, particularly for first MTP arthritis and knee cartilage or osteochondral defects; however, the policy concludes that evidence is insufficient to establish improvement in net health outcomes.
Definitions and Products
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