CurrentConnectiCarePolicy MG.MM.SU.37

Autologous Chondrocyte Implantation for Knee Cartilage Defects

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This policy governs ConnectiCare coverage and prior authorization for autologous chondrocyte implantation (ACI), including MACI, to repair symptomatic focal articular cartilage defects of the knee for commercial members, subject to the member’s benefit plan and applicable coverage requirements.

Policy Summary

PayerConnectiCare

PolicyAutologous Chondrocyte Implantation for Knee Cartilage Defects

Policy CodePolicy MG.MM.SU.37

Change TypeMaterial revision

Effective DateSeptember 11, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization with clinical evidence supporting medical necessity for all ACI requests.

SourceLink

POLICY UPDATE CHANGES

The indication for articular cartilage loss was revised to remove the trochlear aspect as a component of the femoral condyle.

ConnectiCare replaced prior MCG criteria with the clinical criteria of its parent corporation, EmblemHealth.

The policy replaced Carticel with MACI after Carticel was removed from the market.

The policy was transferred to an individual company-branded template.

7Required criteria for initial medically necessary ACI

15–55Age range for the covered indication

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CurrentConnectiCarePolicy MG.MM.SU.37

Autologous Chondrocyte Implantation for Knee Cartilage Defects

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Policy Summary

PayerConnectiCare

PolicyAutologous Chondrocyte Implantation for Knee Cartilage Defects

Policy CodePolicy MG.MM.SU.37

Change TypeMaterial revision

Effective DateSeptember 11, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization with clinical evidence supporting medical necessity for all ACI requests.

SourceLink

POLICY UPDATE CHANGES

The indication for articular cartilage loss was revised to remove the trochlear aspect as a component of the femoral condyle.

ConnectiCare replaced prior MCG criteria with the clinical criteria of its parent corporation, EmblemHealth.

The policy replaced Carticel with MACI after Carticel was removed from the market.

The policy was transferred to an individual company-branded template.

7Required criteria for initial medically necessary ACI

15–55Age range for the covered indication

1–10 cmRequired focal chondral defect size

6 monthsMinimum interval before a second procedure

3Listed procedure codes

6Listed diagnosis codes

Medical Necessity Criteria

Initial ACI

ACI is considered medically necessary when ALL of the following criteria are met:

Initial ACI medical necessity criteria

Patient and lesion eligibility: The member is 15-55 years of age; has Grade III or Grade IV full-thickness articular cartilage loss on a weight-bearing surface of the medial or lateral femoral condyle; has a symptomatic lesion defined by lesion-related pain, swelling, or catching/locking that limits activities of daily living; and has a focal chondral defect measuring 1-10 cm.Age 15-55 years; Grade III or IV; defect size 1-10 cm
The defect must be associated with acute or repetitive trauma.
Prior treatment and joint status: There has been an inadequate response to a prior arthroscopic or other surgical repair procedure, and the knee is stable and aligned.Prior repair may include debridement, microfracture, drilling/abrasion arthroplasty, or osteochondral allograft/autograft
A corrective procedure may be performed in combination with or before ACI to ensure stability, alignment, and normal weight distribution within the joint.
Rehabilitation readiness: Before the procedure, there is an expectation that the member will be able to fully participate in the prescribed postoperative rehabilitation program necessary to ensure an optimal outcome.
This expectation must be documented.

Subsequent ACI

A subsequent or second procedure for a different cartilage defect in the same knee may be considered medically necessary only when the following criteria are met:

Subsequent procedure for a different defect: A new injury has produced a different cartilage defect in the same knee, and the subsequent procedure is performed at least 6 months after the prior or initial procedure on that knee.At least 6 months

This provision does not establish medical necessity for repeat ACI of the same lesion.

ACI is not considered medically necessary for kissing lesions, including degeneration or disease involving both the femoral and tibial aspects of the joint.

Repeat ACI for the same lesion is not considered medically necessary because it has not been sufficiently studied.

ACI is not considered reasonable and medically necessary as initial or first-line surgical therapy.

ACI is not considered reasonable and medically necessary for a member who has had a previous total meniscectomy. An unstable or torn meniscus requires partial resection, repair, or replacement before or concurrent with MACI implantation.

ACI is not considered reasonable and medically necessary for a member with a known history of anaphylaxis to gentamicin or sensitivities to materials of bovine origin.

ACI is not considered reasonable and medically necessary for a member with infection at any proposed operative site.

ACI is not considered reasonable and medically necessary for a cartilaginous defect associated with osteoarthritis or inflammatory disease, or when an osteoarthritic or inflammatory process significantly and adversely affects the quality of the perilesional cartilage.

ACI is not considered reasonable and medically necessary for members over 55 years of age.

Procedure, Diagnosis, and Clinical Parameters

Procedure CodesHCPCS

J7330	Autologous cultured chondrocytes, implant
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells) (Commercial only)
27412	Autologous chondrocyte implantation, knee

Diagnosis CodesICD-10

M24.10	Other articular cartilage disorders, unspecified site
M25.861	Other specified joint disorders, right knee
M25.862	Other specified joint disorders, left knee
M25.869	Other specified joint disorders, unspecified knee
M94.8X8	Other specified disorders of cartilage, other site
M94.9	Disorder of cartilage, unspecified

Member age

Covered age range15-55 years

Minimum age15 years

Maximum age55 years

Cartilage loss grade

Required cartilage lossGrade III or Grade IV

Defect typeFull-thickness articular cartilage loss

Required locationA weight-bearing surface of the medial or lateral femoral condyle

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for ACI. The treating physician or primary care provider must submit clinical evidence showing that the member meets the medical-necessity criteria; without this information, ConnectiCare cannot properly review the request.

Submit the request before treatment with clinical evidence supporting the diagnosis, indication, and medical necessity.
Applicable procedure codes include J7330, S2112 (commercial only), and 27412.
Applicable diagnosis codes include M24.10, M25.861, M25.862, M25.869, M94.8X8, and M94.9.

Denial Risk

Prior Surgical Repair Required

ACI requires an inadequate response to prior arthroscopic or other surgical repair; it is not appropriate as initial or first-line surgical therapy.

Policy Background

Autologous chondrocyte implantation (ACI) is a cartilage-repair procedure that uses the member’s cultured chondrocytes to treat focal articular cartilage defects. The policy describes MACI as autologous cultured chondrocytes seeded on a resorbable porcine Type I/III collagen membrane, with coverage focused on symptomatic, full-thickness focal defects of the knee after an inadequate response to prior surgical repair.

Key Terms and Products

MACI

Product typeAutologous cellularized scaffold product

IndicationRepair of symptomatic single or multiple full-thickness cartilage defects of the knee, with or without bone involvement, in adults

CompositionAutologous chondrocytes seeded on a 3 x 5 cm resorbable porcine Type I/III collagen membrane

Autologous chondrocyte implantation (ACI)

DefinitionImplantation of autologous cultured chondrocytes

Clinical useRepair of symptomatic cartilaginous defects of the knee

Defect cause

Policy Summary

PayerConnectiCare

PolicyAutologous Chondrocyte Implantation for Knee Cartilage Defects

Policy CodePolicy MG.MM.SU.37

Change TypeMaterial revision

Effective DateSeptember 11, 2026

Next Review DateNot specified

Key ActionSubmit prior authorization with clinical evidence supporting medical necessity for all ACI requests.

SourceLink

On This Page

Focal chondral defect size

Required defect size1-10 cm

Minimum size1 cm

Maximum size10 cm

Interval for subsequent procedure

Minimum intervalAt least 6 months

Interval measured fromThe prior or initial procedure on that knee

Procedure eligibilityA subsequent or second procedure for a different cartilage defect in the same knee

Document the dates and outcomes of prior procedures, such as debridement, microfracture, drilling, abrasion arthroplasty, chondroplasty, or osteochondral allograft/autograft.
A request may be denied when the member has not first undergone an appropriate prior repair procedure or has not demonstrated inadequate response.

Documentation Required

Clinical Evidence to Submit

Submit the clinical records needed to verify the indication and the member’s ability to undergo ACI and rehabilitation. Documentation must establish the lesion characteristics, functional symptoms, prior treatment history, and knee status.

Record symptoms limiting activities of daily living, including lesion-related pain, swelling, locking, crepitus, catching, or giving-way.
Provide the lesion’s location, dimensions, grade, and depth, the condition of surrounding articular cartilage, and confirmation of Grade III or IV full-thickness loss on a weight-bearing femoral condyle.
Provide preoperative confirmation that the knee is stable and aligned with normal or optimal weight distribution.
Document the expectation that the member can fully participate in the prescribed postoperative rehabilitation program.

Denial Risk

Medical-Necessity Criteria Must Be Met

Failure to meet all medical-necessity criteria creates a denial risk. ACI is medically necessary only for symptomatic cartilaginous knee defects caused by acute or repetitive trauma when the required age, lesion, prior-treatment, knee, and rehabilitation criteria are satisfied.

Member is 15–55 years old.
Defect is Grade III or IV full-thickness articular cartilage loss on a weight-bearing surface of the medial or lateral femoral condyle.
Lesion is symptomatic and limits activities of daily living; focal chondral defect size is 1–10 cm.
Knee is stable and aligned; corrective treatment may be required before or with ACI.
Member is expected to fully participate in the required postoperative rehabilitation program.

Denial Risk

Excluded Clinical Circumstances

ACI is not medically necessary in specified excluded circumstances because evidence of therapeutic value is insufficient or the procedure has not been adequately studied. Review the member’s clinical history and operative plan for these exclusions before requesting authorization.

Kissing lesions, including degeneration or disease on both the femoral and tibial aspects of the joint; history of patellar or multiple defects; or defects in joints other than the knee.
Repeat ACI for the same lesion.
Previous total meniscectomy; infection at a proposed operative site; anaphylaxis to gentamicin or sensitivity to bovine-origin materials.
Defect associated with osteoarthritis or inflammatory disease, or a process that significantly adversely affects peri-lesional cartilage.
Member older than 55 years.

Denial Risk

Insufficient Supporting Documentation

Incomplete records can prevent ConnectiCare from confirming medical necessity and may result in denial or inability to complete prior-authorization review. Ensure the submission contains the required clinical history and objective knee findings.

Missing or insufficient documentation of symptoms and their effect on activities of daily living.
Missing dates and outcomes of all previous knee surgeries and repairs.
Missing confirmation of knee stability, alignment, and normal or optimal weight distribution.
Missing lesion location, dimensions, grade, depth, surrounding cartilage condition, or evidence supporting the rehabilitation expectation.

Acute or repetitive trauma