CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

This policy governs coverage for autologous and allogeneic osteochondral grafting and related cartilage repair technologies for focal full-thickness articular cartilage lesions, primarily of the knee and talus, for members of Blue Cross Blue Shield - Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyAutografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateOct 1, 2022

Next Review Date

Key ActionVerify member benefits and eligibility prior to scheduling surgery.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2022-10-01Effective date

2024-10-02Policy last reviewed

Knee, talusCovered joints

>1.5 cm2 / >3.0 cm3Lesion threshold

6 listedSurgery codes

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Coverage Determinations

Coverage determinations

Covered when ALL of the following apply as specified below:

Fresh osteochondral allograft - knee/talus: Fresh osteochondral allografting is covered to repair full-thickness chondral defects of the knee; covered for large (area >1.5 cm2) or cystic (volume >3.0 cm3) osteochondral lesions of the talus, or for talus lesions when autografting would be inadequate due to lesion size, depth, or location.area >1.5 cm2; volume >3.0 cm3

Intended as a salvage option when autograft or other techniques are inadequate.

Osteochondral autograft - knee/talus: Osteochondral autografting (one or more osteochondral cores / mosaicplasty) is covered for full-thickness cartilage defects of the knee and for osteochondral lesions of the talus.

Includes harvesting of autograft(s) and mosaicplasty techniques.

Other joints - allograft/autograft: Osteochondral allografting or autografting for joints other than the knee and talus are not covered for Medicare Advantage Plans and are considered not medically necessary for Commercial Products due to insufficient evidence.

Not covered / not medically necessary for non-knee, non-talus joints.

Experimental / insufficient evidence techniques: Autologous minced or particulated cartilage, allogeneic minced or particulated cartilage, decellularized osteochondral allograft plugs (e.g., Chondrofix), and reduced osteochondral allograft discs (e.g., ProChondrix, Cartiform) are not covered / not medically necessary because evidence is insufficient to determine health outcomes.

These techniques are considered experimental or unproven.

Coding — medically necessary procedures: The following surgery codes are considered medically necessary when filed with an appropriate ICD-10 diagnosis: 27415, 27416, 28446, 29866, 29867.

See coding section for full code descriptions.

The following procedures and products are not covered / not medically necessary due to insufficient evidence: autologous minced or particulated cartilage, allogeneic minced or particulated cartilage, decellularized osteochondral allograft plugs (eg, Chondrofix), and reduced osteochondral allograft discs (eg, ProChondrix, Cartiform).

Osteochondral autografting and fresh osteochondral allografting are covered for focal, full-thickness cartilage defects of the knee and for osteochondral lesions of the talus. For lesions of the talus, fresh allograft may be covered when lesions are large (area >1.5 cm2) or cystic (volume >3.0 cm3), or when autografting would be inadequate because of lesion size, depth, or location. Osteochondral autografting or allografting for joints other than the knee and talus are not covered for Medicare Advantage Plans and are considered not medically necessary for Commercial Products because the evidence is insufficient to determine health outcomes.

The following procedures/products are explicitly considered insufficient evidence / experimental or investigational and are not covered or are not medically necessary: autologous minced/particulated cartilage, allogeneic minced/particulated cartilage, decellularized osteochondral allograft plugs (eg, Chondrofix), and reduced osteochondral allograft discs (eg, ProChondrix, Cartiform).

This policy is informational and not a guarantee of payment. Services determined to be not medically necessary (or medically necessary services that are non‑covered benefits) may result in nonpayment. Providers may not charge the member for such services unless the member has been informed in advance and has provided written consent to accept financial responsibility.

Relevant Codes and Lesion Thresholds

Medically necessary surgery codesCPTCovered

27415	Osteochondral allograft, knee, open
27416	Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s])
28446	Open osteochondral autograft, talus (includes obtaining graft[s])
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) includes harvesting of the autograft[s])
29867	Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)

Associated ICD-10 Diagnosis CodesICD-10

M12.561-M12.569	ICD-10 diagnosis range listed
M17.0-M17.9	ICD-10 diagnosis range listed
M23.8x1-M23.92	ICD-10 diagnosis range listed
M25.861-M25.869	ICD-10 diagnosis range listed
M85.671-M85.679	ICD-10 diagnosis range listed
M89.8x6	ICD-10 diagnosis code listed
M93.261-M93.269	ICD-10 diagnosis range listed
M93.271-M93.279	ICD-10 diagnosis range listed
M94.261-M94.269	ICD-10 diagnosis range listed
M94.8x6	ICD-10 diagnosis code listed

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Allograft lesion size/volume thresholds

Area threshold (talus)Lesions with area >1.5 cm2

Volume threshold (cystic talus lesions)Cystic lesion volume >3.0 cm3

Clinical intentThresholds apply when determining coverage of fresh osteochondral allograft for large or cystic talar osteochondral lesions

Prior Authorization, Verification, and Provider Guidance

Prior Authorization

Prior Authorization / Benefit Verification Required

Verify member benefits and obtain prior authorization when required. Benefits and authorization requirements vary by contract; confirm surgery coverage, inpatient vs outpatient setting, and specific benefit limits before scheduling.

Prior authorization may be required for surgical cartilage repair procedures — check the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement.
Contact the provider call center for member-specific eligibility and authorization details.

Note

Verify Coverage and Authorization — Informational

Verification of coverage and authorization is informational and does not guarantee payment. Payment determinations are made at claim adjudication based on the member's subscriber agreement, employer contract, and submitted documentation.

Confirm any required authorizations are in place prior to the procedure date.
Document authorization numbers and retain prior-authorization correspondence in the medical record.

Clinical Background

Osteochondral autografting (mosaicplasty) involves harvesting one or more small osteochondral plugs from non‑weight‑bearing donor sites—commonly within the ipsilateral knee—and press‑fitting those grafts into the prepared full‑thickness cartilage lesion. Autografting is typically used for medium‑sized focal defects where donor tissue is adequate; when lesion size, depth, or location exceed autograft feasibility, fresh osteochondral allograft transplantation is used as a salvage option.

Key Definitions

Osteochondral autograft (mosaicplasty) — definition and brief description

DefinitionHarvesting one or more small osteochondral plugs from non-weight-bearing sites (usually the knee) and press‑fitting them into the prepared lesion site.

Typical indicationRepair of focal full‑thickness chondral defects of the knee and osteochondral lesions of the talus.

Technique noteIncludes mosaicplasty (multiple plugs) and harvesting as part of the same procedure.

Osteochondral allograft — definition and clinical use

DefinitionTransplantation of fresh osteochondral tissue from a donor to replace damaged osteochondral lesions.

Typical useUsed for larger or cystic lesions or when autografting would be inadequate due to lesion size, depth, or location.