CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Medical Coverage Policy Meniscal Allografts and Other Meniscal Implants

Defines medical coverage and medical necessity criteria for meniscal allograft transplantation (MAT) and the coverage position for collagen meniscal implants (CMI) for Medicare Advantage and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Meniscal Allografts and Other Meniscal Implants

Policy CodePolicy N/A

Change TypeClarified

Effective DateOct 2, 2003

Next Review Date

Key ActionProvide imaging or surgical documentation establishing absence or near absence (>50%) of the meniscus to support medical necessity for MAT.

SourceLink

POLICY UPDATE CHANGES

Policy states collagen meniscal implants are not covered for Medicare Advantage and not medically necessary for Commercial products due to insufficient evidence.

1Covered Procedure CPT listed

1Not Covered HCPCS listed

3ICD-10 diagnosis code ranges supporting medical necessity

5Major medical necessity criteria (AND conditions)

Overview: This policy (effective 10|02|2003, last reviewed 05|07|2025) addresses coverage for Meniscal Allograft Transplantation (MAT) and Collagen Meniscal Implants (CMI). Meniscal allografts and meniscal implants are intended to improve symptoms and reduce joint degeneration in individuals after total or partial meniscectomy.

Coverage stance: The policy takes a mixed stance. MAT may be considered medically necessary when specific anatomic, symptom, age, and cartilage criteria are met (see criteria), and is supported by systematic reviews and limited RCT data showing improvements in symptoms and function. In contrast, CMIs (collagen meniscal implants/scaffolds, e.g., Menaflex/CMI/RejuvaKnee) are not covered for Medicare Advantage and not medically necessary for Commercial products because the evidence is insufficient to determine a net health benefit.

MAT eligibility thresholds and coverage stance

Residual meniscusAbsence or near absence (>50%) of the meniscus (established by imaging or surgery)

Articular cartilage degenerationOuterbridge II or less; ≤50% joint space narrowing (minimal to absent diffuse degenerative changes)

Age considerationPatient considered too young for total knee arthroplasty (e.g., <55 years)

Coverage stanceMAT: may be medically necessary when criteria met; CMI: not covered for Medicare Advantage and not medically necessary for Commercial products (insufficient evidence)

Medical Necessity Criteria

Meniscal Allograft Transplantation - Medically Necessary Criteria

May be considered medically necessary when ALL of the following are met:

ALL of the following

Disabling pain refractory to conservative treatment: Disabling knee pain with activity that is refractory to conservative treatment
Age consideration: Patient is considered too young to be an appropriate candidate for total knee arthroplasty or other reconstructive knee surgery<55 years
Residual meniscus: Absence or near absence of the meniscus, established by imaging or surgery>50% meniscus absent
Knee biomechanics: Normal knee biomechanics, or alignment and stability achieved concurrently with meniscal transplantation
Cartilage status: Documented minimal to absent diffuse degenerative changes in the surrounding articular cartilage (e.g., Outerbridge II or less; ≤50% joint space narrowing)Outerbridge II or less; ≤50% joint space narrowing

Meniscal Allograft Transplantation - Concomitant Procedures

May be considered medically necessary when performed in combination (concurrently or sequentially) with treatment of focal articular cartilage lesions using ANY of the following:

ANY of the following

Autologous chondrocyte implantation
Osteochondral autografting
Osteochondral allograft or grafting

Collagen Meniscal Implants (CMI)

Coverage stance

Not covered / Not medically necessary: Collagen meniscal implants are NOT covered for Medicare Advantage Plans and are NOT medically necessary for Commercial products because the evidence is insufficient to determine that the technology results in an improvement in the net health outcome

Coding

Covered CPT (when medical necessity met)CPTCovered

29868

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

Supporting ICD-10-CM Diagnosis CodesICD-10

M23.000-M23.92	Internal derangement of knee (range of codes noted in policy)
S83.200-S83.289	Sprain/strain and other meniscal injury codes (range noted)
S83.30-S83.32	Specific meniscal tear codes (range noted)

Not Covered / Not Medically Necessary HCPCSHCPCSNot Covered

G0428

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

Provider Actions & Billing Impact

Documentation Required

Document imaging or surgical confirmation of meniscal deficiency

Provide imaging (e.g., MRI, radiograph) or operative reports that confirm absence or near absence of the native meniscus (>50% meniscal loss). Documentation should clearly state the extent of meniscal deficiency to support medical necessity for meniscal allograft transplantation.

Examples: MRI report describing >50% meniscal resection; operative note documenting prior subtotal or total meniscectomy.

Documentation Required

Document prior conservative management

Document disabling knee pain with activity that has persisted despite conservative management (e.g., physical therapy, activity modification, medications). Records should note prior conservative therapies attempted and the persistence of symptoms despite these treatments.

Examples: physical therapy records, medication trials, activity modification documentation, and clinician notes describing refractory symptoms.

Documentation Required

Document cartilage status and knee biomechanics

Document the status of articular cartilage and knee biomechanics: report Outerbridge grade II or less and radiographic joint space narrowing of ≤50%. Also document knee alignment and ligamentous stability or plans to correct alignment/stability concurrently with the meniscal transplantation.

Examples: arthroscopy findings describing Outerbridge grade, radiograph measurements of joint space narrowing, and notes regarding alignment/ligamentous stability or planned corrective procedures.

Billing Rule

CPT 29868 requires supporting diagnosis codes

CPT 29868 (meniscal transplantation) may be considered medically necessary only when reported with an appropriate supporting ICD-10 diagnosis from the listed ranges.

Affected codes: 29868, M23.000-M23.92, S83.200-S83.289, S83.30-S83.32

Denial Risk

CMI procedures are not covered

Claims for HCPCS G0428 (Collagen Meniscus Implant procedure) are not covered for Medicare Advantage Plans and are considered not medically necessary for Commercial products; such claims may be denied.

G0428

Background & Evidence Summary

Background: MAT is a surgical procedure that transplants donor meniscal tissue to replace an absent or deficient native meniscus and is intended to improve pain, function, and potentially reduce progression of joint degeneration in patients after meniscectomy. It is considered a salvage procedure reserved for patients with disabling knee pain after meniscectomy who are considered too young for total knee arthroplasty (commonly <55 years) and who meet specific anatomic and cartilage criteria.

Purpose and policy interpretation: Collagen meniscal implants (CMIs) are resorbable semilunar collagen scaffolds intended to fill meniscal defects after meniscectomy and be replaced by the patient’s soft tissue. The policy interprets available evidence as sufficient to support MAT in appropriately selected patients but finds the evidence for CMIs insufficient; therefore CMIs are not covered for Medicare Advantage and are not medically necessary for Commercial products.

Evidence

Evidence level for MATSystematic reviews of case series and limited RCT data; sufficient to determine improvement in net health outcome

Evidence level for CMISystematic reviews primarily of case series; insufficient to determine improvement in net health outcome

Glossary:

Meniscal Allograft Transplantation (MAT): Transplantation of donor meniscal tissue to replace absent or deficient native meniscus.

Collagen Meniscal Implant (CMI): A resorbable semilunar collagen scaffold intended to fill meniscal defects and be replaced by the patient’s soft tissue (examples: CMI, RejuvaKnee, Menaflex).

Outerbridge grade: A classification of articular cartilage degeneration; the policy considers Outerbridge II or less acceptable for MAT.

Year	Name	Number	Type
2010	CMS Decision Memo for COLLAGEN MENISCUS IMPLANT	CAG-00414N	NCD

Revision History

2003-10-02effective_date

Policy effective date established (Medical Coverage Policy Meniscal Allografts and Other Meniscal Implants).

2003-10-02change

Policy text includes position that collagen meniscal implants are not covered for Medicare Advantage and not medically necessary for Commercial products due to insufficient evidence.

2025-05-07last_reviewLatest

Policy last reviewed; position reiterated that collagen meniscal implants are not covered for Medicare Advantage and not medically necessary for Commercial products and criteria for meniscal allograft transplantation specified.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyMedical Coverage Policy Meniscal Allografts and Other Meniscal Implants

Policy CodePolicy N/A

Change TypeClarified

Effective DateOct 2, 2003

Next Review Date

Key ActionProvide imaging or surgical documentation establishing absence or near absence (>50%) of the meniscus to support medical necessity for MAT.

SourceLink

On This Page

OpenPayer

Medical Coverage Policy Meniscal Allografts and Other Meniscal Implants

Coverage Summary

Medical Necessity Criteria

Coding

Provider Actions & Billing Impact

Background & Evidence Summary

Medicare Determinations

Revision History