CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Osteochondral Grafting (Autograft and Allograft) Coverage Criteria

Defines coverage and medical necessity for osteochondral autografts and allografts (and related cartilage treatments) for focal full-thickness articular cartilage lesions of the knee, talus, and other joints for Medicare Advantage and Commercial products.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyOsteochondral Grafting (Autograft and Allograft) Coverage Criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionVerify member benefits/eligibility and file claims with listed ICD-10 diagnosis codes when using the listed surgery codes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

>1.5 cm2lesion area threshold

>3.0 cm3lesion volume threshold

5 codescovered surgery codes

85+references

Coverage and Medical Necessity Criteria

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Coverage determinations

Coverage varies by product and joint; statements below reflect Medicare Advantage Plans and Commercial Products distinctions.

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

Osteochondral allografting for all other joints is not covered for Medicare Advantage Plans and not medically necessary for Commercial Products due to insufficient evidence.

Osteochondral autograft - Knee and Talus: Osteochondral autografting, using one or more cores of osteochondral tissue, is covered for full-thickness cartilage defects of the knee and for osteochondral lesions of the talus.

Autografting for all other joints is not covered for Medicare Advantage Plans and not medically necessary for Commercial Products due to insufficient evidence.

Other cartilage treatments - Not covered / Not medically necessary: The following treatments of focal articular cartilage lesions are considered not covered for Medicare Advantage Plans and not medically necessary for Commercial Products: autologous minced or particulated cartilage; allogeneic minced or particulated cartilage; decellularized osteochondral allograft plugs; reduced osteochondral allograft discs (eg, ProChondrix, Cartiform).

These techniques are considered not covered / not medically necessary based on insufficient evidence of benefit.

The policy explicitly lists several cartilage-derived products and techniques that are not covered for Medicare Advantage Plans and considered not medically necessary for Commercial Products. These include autologous minced/particulated cartilage, allogeneic minced/particulated cartilage, decellularized osteochondral allograft plugs, and reduced osteochondral allograft discs (examples: ProChondrix, Cartiform).

Benefits and coverage are determined by the member's subscriber agreement, member certificate, or employer agreement. This policy is provided for informational purposes and is not a guarantee of payment. Providers should verify member-specific benefits via the provider call center and follow any applicable participation or provider agreements.

Osteochondral allografting and osteochondral autografting are covered for the knee and talus under the conditions described in this policy. For joints other than the knee and talus, these procedures are not covered for Medicare Advantage Plans and are not medically necessary for Commercial Products due to insufficient evidence of benefit.

If a service is determined to be not medically necessary (or is medically necessary but is a non-covered benefit), the provider may be unable to bill the member unless the member was informed and provided written agreement in advance. Providers should consult the applicable participation agreement(s) and obtain informed, written member consent when appropriate.

CPT/ICD-10 Codes and Clinical Thresholds

Surgery codes considered medically necessaryCPTCovered

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 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 listed

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inv-08: Large lesion area threshold — key clinical threshold (>1.5 cm2)

Large lesion area threshold>1.5 cm2 (lesion area qualifying as 'large' for talus/knee allograft coverage)

Applies toFresh osteochondral allografting for talus (and knee) lesions

Coverage implicationArea >1.5 cm2 supports coverage of allograft for Medicare Advantage and Commercial Products as specified

inv-09: Cystic lesion volume threshold — key clinical threshold (>3.0 cm3)

Cystic lesion volume threshold>3.0 cm3 (lesion volume qualifying as 'cystic' for talus allograft coverage)

Applies toFresh osteochondral allografting for talus lesions

Coverage implicationVolume >3.0 cm3 supports coverage of allograft for Medicare Advantage and Commercial Products as specified

Prior Auth, Billing, and Provider Responsibilities

Prior Authorization

Prior authorization / Benefits verification

Prior authorization: Not applicable to this policy. However, coverage and prior authorization requirements may vary by group, contract, and product. Providers must verify member-specific benefits, eligibility, and any prior authorization requirements with the member’s plan (refer to the Benefit Booklet, Evidence of Coverage, Subscriber Agreement, or employer contract) before scheduling services.

Confirm benefits and any prior authorization requirements with the payer and document verification in the medical record.
If treating a member covered by Medicare Advantage or a commercial product, contact the provider call center for member-specific information.

Denial Risk

Financial liability and denial risk

When services are rendered that the payer determines to be not medically necessary or otherwise non-covered under the member’s benefit plan, the provider may be financially liable and the member may be balance billed only if the provider has informed the member and obtained written agreement in advance per the participation agreement. Providers should review participation agreements and the member’s subscriber/employer documents for applicable billing rules.

Services determined not medically necessary or non-covered may result in denial and provider financial liability.
Obtain documented member consent before performing services that are non-covered if you intend to bill the member.
Refer to your participation agreement for billing and balance-billing provisions.

Documentation Required

Claims coding and documentation requirements

Claims for surgery codes listed as medically necessary must be filed with one of the listed ICD-10 diagnosis codes and supported by appropriate clinical documentation that demonstrates medical necessity.

Affected surgery CPT/HCPCS codes: 27415, 27416, 28446, 29866, 29867 (see policy for code descriptions).
Required diagnosis codes: use one of the ICD-10 codes listed in the policy (see ICD-10 ranges in policy).
Ensure operative notes, imaging, prior treatments, lesion size/location, and rationale for chosen procedure are included in the record to support claims.

Note

Treatment sequence and not-covered techniques

Treatment sequencing and clinical context: osteochondral autograft and allograft procedures are generally considered in the context of alternative cartilage repair techniques. Treatments such as microfracture, drilling, and autologous chondrocyte implantation may be appropriate alternatives depending on lesion size, location, patient age, and prior treatments; fresh osteochondral allograft is often reserved as a salvage option when autografting or other techniques are inadequate due to lesion size, depth, or location. Correction of malalignment and appropriate patient selection are important for successful outcomes.

Osteochondral autografting is an option for moderate-size, symptomatic full-thickness chondral lesions (eg, ~2–6 cm2), especially on the femoral condyles; outcomes are generally better than abrasion techniques for these lesions.
Fresh osteochondral allograft may be used as a salvage procedure when autograft is inadequate because of lesion size, location, or depth.
The following treatments are considered not covered / not medically necessary due to insufficient evidence: autologous or allogeneic minced/particulated cartilage, decellularized osteochondral allograft plugs, and reduced osteochondral allograft discs (eg, ProChondrix, Cartiform).

Definitions

inv-19: Osteochondral autograft — definition (one or more small plugs harvested from non-weight-bearing sites)

DefinitionOne or more small osteochondral plugs harvested from non-weight-bearing sites (usually the knee) and press-fit into the lesion.

Typical donor siteNon-weight-bearing regions of the knee

IndicationUsed to repair full-thickness chondral defects when autografting is appropriate

inv-20: Osteochondral allograft — definition (donor-derived tissue for larger lesions; fresh allografting for large or cystic lesions)

DefinitionDonor-derived osteochondral tissue used for larger lesions; fresh allografting may be used for large or cystic lesions or when autografting would be inadequate.

Typical usePreferred for larger or deep osteochondral lesions and for cystic talus lesions exceeding volume/area thresholds

Coverage noteFresh osteochondral allografting is covered for large (area >1.5 cm2) or cystic (volume >3.0 cm3) talus lesions and for knee full-thickness defects as specified

OpenPayer

Osteochondral Grafting (Autograft and Allograft) Coverage Criteria

Coverage and Medical Necessity Criteria

CPT/ICD-10 Codes and Clinical Thresholds

Prior Auth, Billing, and Provider Responsibilities

Clinical Background and Rationale

Definitions

Policy Revision History