CurrentColorado Rocky Mountain Health PlansPolicy CS068.AC

Surgery of the Knee (including cartilage repair techniques and meniscal implants)

Defines UnitedHealthcare's medical policy for surgery of the knee including indications for arthroscopy, arthrotomy, total and partial knee arthroplasty, and states which specific cartilage repair and meniscal implant procedures are considered unproven/not medically necessary. Cross-references InterQual® criteria for medical necessity determinations and lists applicable CPT/HCPCS/CPT-related codes.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicySurgery of the Knee (including cartilage repair techniques and meniscal implants)

Policy CodePolicy CS068.AC

Change TypeDefinitions added; template update

Effective DateMar 1, 2026

Next Review Date

Key ActionRefer to the InterQual® CP procedures (listed in the policy) to assess whether a specific knee surgery meets medical necessity criteria; medical records documentation may be required to assess member eligibility.

POLICY UPDATE CHANGES

Definitions added for Disabling Pain, Functional Disability, Outerbridge Grades, Radiographic Findings of Osteoarthritis, and WOMAC.

Template update removed content/language pertaining to the state of Louisiana.

8InterQual® referenced knee procedures

7Unproven cartilage/meniscal techniques

~50Procedure/HCPCS/CPT codes listed

Coverage Summary

Defines UnitedHealthcare's medical policy for surgery of the knee, including indications for arthroscopy, arthrotomy, total and partial knee arthroplasty, and cross-references InterQual® clinical criteria for medical necessity determinations. Effective March 1, 2026; last reviewed March 1, 2026.

Policy status: CURRENT (material revision 03/01/2026 added definitions and updated applicable CPT codes; 04/01/2026 template update removed state-specific language).

Thresholds

Radiographic Findings of OsteoarthritisThree or more moderate to severe radiographic findings (narrowing of joint space; osteophyte formation; subchondral sclerosis; subchondral cysts; deformity of bony end-plates; thinning or complete loss of articular cartilage)

Disabling PainWOMAC pain domain > 40

Functional DisabilityWOMAC functional limitation domain > 40

Medically Necessary and Unproven Procedures

Medically Necessary Procedures (general)

Surgery of the knee is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures listed below.

Arthroscopy or Arthroscopically Assisted Surgery, Knee (adult)
Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric)
Arthroscopy, Diagnostic, +/- Synovial Biopsy, Knee
Arthrotomy, Knee
Arthrotomy, Knee (Pediatric)
Removal and Replacement, Total Joint Replacement (TJR), Knee
Total Joint Replacement (TJR), Knee
Unicondylar or Patellofemoral Knee Replacement

Not Medically Necessary / Unproven Procedures

Articular cartilage repair procedures are considered unproven and not medically necessary due to insufficient evidence of efficacy for the following techniques/devices.

Autologous minced or particulated cartilage procedures (examples: Cartilage Autograft Implantation System (CAIS), Reveille Cartilage Processor)
Insufficient high-quality evidence; early case series only
Allogeneic minced or particulated cartilage (examples: BioCartilage®, DeNovo Natural Tissue (NT) Graft, DeNovo ET)
Very low/insufficient quality evidence; case series and reports
Collagen meniscus implant (CMI) / collagen scaffolds
Insufficient evidence; mixed small studies, high heterogeneity
Decellularized osteochondral allografts (examples: Chondrofix)
Reported high failure rates in case series (examples: up to 72% failure within 2 years; 29% revision rate)

Applicable CPT / HCPCS Codes (informational)

Referenced/Applicable procedure and HCPCS codes (informational only)mixed

0737T	Xenograft implantation into the articular surface
27412	Autologous chondrocyte implantation, knee
27415	Osteochondral allograft, knee, open
27416	Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft[s])
27418	Anterior tibial tubercleplasty (e.g., Maquet type procedure)
27437	Arthroplasty, patella; without prosthesis
27438	Arthroplasty, patella; with prosthesis
27440	Arthroplasty, knee, tibial plateau
27441	Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy
27442	Arthroplasty, femoral condyles or tibial plateau(s), knee

1–10 of 43

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Provider Actions & Billing Notes

Documentation Required

Use InterQual® criteria for medical necessity determinations

Refer to the InterQual® CP procedures listed in this policy to determine whether a specific knee surgery meets medical necessity criteria. Medical records documentation may be required to assess member eligibility and determine whether the clinical criteria are met; see the Medical Records Documentation Used for Reviews guidance and the InterQual® CP.

Medical records/documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the InterQual® CP.

Billing Rule

Applicable procedure codes are informational

The CPT/HCPCS/procedure codes listed are provided for reference/informational purposes only. Inclusion of a code in this policy does not guarantee coverage or reimbursement; verify applicable federal, state, and contractual terms for benefit coverage and payment.

0737T
27412
27415
27416
27418
27437
27438
27440
27441
27442
27443
27446
27447
27486
27487
27658
27659
27664
27665
29866
29867
29868
29870
29871
29873
29874
29875
29876
29877

Background, Evidence Summary, and Definitions

Conventional knee surgeries (arthroscopy, arthrotomy, unicompartmental/total knee replacement, and related procedures) are considered proven and medically necessary when they meet InterQual® clinical criteria; the policy directs reviewers to use InterQual® for specific medical necessity determinations.

Several articular cartilage repair techniques and meniscal implants— including autologous and allogeneic minced/particulated cartilage (e.g., CAIS, Reveille, BioCartilage, DeNovo NT/ET), collagen meniscus implants, decellularized osteochondral allografts (e.g., Chondrofix), reduced osteochondral discs (e.g., ProChondrix, Cartiform), synthetic resorbable polymers (e.g., TruFit, TruGraft, PolyGraft BGS), and xenograft implantation—have insufficient high-quality evidence of efficacy (primarily small case series, case reports, or animal studies) and are therefore considered unproven / not medically necessary.

label	value
Decellularized osteochondral allograft failure rate	Case series reported up to 72% failure within first 2 years (Farr et al. 2016) and 29% revision rate (Johnson et al. 2017)
Quality of evidence for DeNovo NT and BioCartilage	Very low/insufficient quality; mostly small case series and case reports (Hayes, ECRI assessments)
CMI outcomes	Mixed small studies; limited evidence with variable outcomes and high heterogeneity (systematic reviews and cohort studies)

term	definition
BioCartilage®	Dehydrated, micronized allograft articular cartilage matrix intended to provide a scaffold for microfracture; mixed with blood to create paste-like consistency applied over cartilage defect.
Cartilage Autograft Implantation System (CAIS)	Harvests minced autograft cartilage and disperses chondrocytes on a scaffold in a single-stage treatment.
Collagen Meniscus Implants	Implantable porous meniscus scaffolds composed of collagen fibers enriched with glycosaminoglycan, used as template/support to generate new tissue to replace lost menisci.
Decellularized Osteochondral Allograft Plugs	Cylinder-shaped plug of healthy cartilage tissue and subchondral bone taken from non-weightbearing area and matched to defect; used to leave smooth cartilage surface.
Disabling Pain	WOMAC pain domain > 40
Functional Disability	WOMAC functional limitation domain > 40
Outerbridge Grades	Grade 0 normal; Grade I softening/swelling; Grade II partial-thickness defect <=1.5 cm; Grade III fissuring to subchondral bone >1.5 cm; Grade IV exposed subchondral bone
Radiographic Findings of Osteoarthritis	Narrowing of joint space, osteophyte formation, subchondral sclerosis, subchondral cysts, deformity of bony end-plates, and thinning or complete loss of articular cartilage; UnitedHealthcare will accept three or more moderate to severe findings to support diagnosis of severe osteoarthritis.