CurrentEmblemHealthPolicy MG.MM.SU.68bC3

Osteochondral Grafting

Describes EmblemHealth clinical review criteria for osteochondral autograft and allograft procedures for focal, full-thickness cartilage defects of the knee and ankle, and lists coding and exclusions; applies to providers requesting coverage determinations for members.

Policy Summary

PayerEmblemHealth

PolicyOsteochondral Grafting

Policy CodePolicy MG.MM.SU.68bC3

Change TypeNo material clinical or coverage changes

Effective DateN/A

Next Review DateJan 23, 2026

Key ActionSubmit clinical evidence showing the member meets medical necessity criteria when requesting preauthorization.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

≥6 mopain duration

≥1 cm2defect size

Knee, Anklejoints covered

5 listedprocedure codes

Multiple ICD-10 groupsdiagnosis codes

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Medically Necessary Criteria

Osteochondral autografting and allografting are considered medically necessary when ALL of the following are met:

Main medical necessity criteria: 1. Presence of disabling, localized knee or ankle pain of ≥ 6 months duration that is refractory to conservative treatment, as well as abrasion arthroplasty and/or microfracture techniques.

2. Mature skeletal growth achieved, or not a suitable candidate for total joint replacement.

3. Cartilage defect ≥ 1 cm^2.

4. Focal, full-thickness isolated defect of the weight-bearing surface of one of the following: a) Talus; b) Medial or lateral femoral condyles; c) Trochlear region of the knee; d) Patellar chondral defect.

5. Defect is unipolar.

6. Lesion is largely contained with near-normal surrounding articular cartilage (grades 0-2).

7. In the knee, the meniscus is intact or has stable partial tears (partial meniscectomy may be indicated and does not preclude osteochondral grafting).

8. Normal or near-normal joint space with no > 15% joint space narrowing.

9. No presence of active infection.

10. No inflammation or osteoarthritis in the joint.

11. Joint is stable with normal alignment (a procedure to correct alignment may be performed in combination with, or prior to, grafting).

12. Member is willing and able to comply with post-operative weight-bearing restrictions and rehabilitation.

All listed conditions must be met for the procedure to be considered medically necessary.

Use in joints other than the knee and ankle (for example, shoulder, elbow, hip) is not considered medically necessary due to insufficient evidence of therapeutic value.

The use of minced articular cartilage products (autologous or allogeneic) — examples include CAIS, BioCartilage, DeNovo NT — is not considered medically necessary because available evidence does not demonstrate therapeutic benefit.

Decellularized osteochondral allograft plugs (for example, Chondrofix) and reduced allograft discs (for example, ProChondrix, Cartiform) are not considered medically necessary and are listed in the policy limitations/exclusions due to insufficient evidence of therapeutic value.

Per the policy revision history, decellularized osteochondral allograft plugs and reduced allograft discs were added to the Limitations/Exclusions section as investigational (revision entry dated Jan. 11, 2019), and this change is retained in subsequent EmblemHealth template transfers.

The products and indications listed in the Limitations/Exclusions section — including use outside the knee/ankle, minced articular cartilage products, decellularized osteochondral plugs, and reduced allograft discs — are considered not medically necessary because of insufficient evidence of therapeutic value.

Procedure and Diagnosis Codes, and Key Criteria Values

Covered Procedure CodesCPTCovered

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

Primary Diagnosis Codes (ICD-10)ICD-10Covered

M22.40	Chondromalacia patellae, unspecified knee
M22.41	Chondromalacia patellae, right knee
M22.42	Chondromalacia patellae, left knee
M23.000	Cystic meniscus, unspecified lateral meniscus, right knee
M23.001	Cystic meniscus, unspecified lateral meniscus, left knee
M23.002	Cystic meniscus, unspecified lateral meniscus, unspecified knee
M23.003	Cystic meniscus, unspecified medial meniscus, right knee
M23.004	Cystic meniscus, unspecified medial meniscus, left knee
M23.005	Cystic meniscus, unspecified medial meniscus, unspecified knee
M23.006	Cystic meniscus, unspecified meniscus, right knee

1–10 of 149

1/15

Additional Diagnosis Codes (ICD-10)ICD-10Covered

No codes listed

Key Criteria Values

Pain duration≥ 6 months

Cartilage defect size≥ 1 cm²

Joint space narrowingNo > 15% joint space narrowing

Provider Requirements and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. The treating physician or primary care provider must submit clinical evidence that the member meets EmblemHealth criteria for the requested osteochondral grafting procedure. Without the required documentation, EmblemHealth cannot properly review the preauthorization request or perform post-payment review.

Affected CPT codes: 27415, 27416, 28446, 29866, 29867.
Diagnosis linkage: document covered diagnostic coding for chondromalacia/osteochondral disorders (e.g., M94.261–M94.279 and related codes).

Prior Authorization

Prior Authorization per EmblemHealth Criteria

Preauthorization requests will be reviewed against EmblemHealth clinical criteria which follow the parent corporation's sequencing and coverage logic (MCG retired). Requests must demonstrate that conservative therapy prerequisites and other medical necessity criteria are met.

EmblemHealth adopted parent corporation clinical criteria (see revision history).
Verify that conservative measures were attempted and documented prior to grafting.
Failure to show criteria met may result in denial.

Documentation Required

Documentation Required for Review

Clinical documentation required for review must be submitted by the treating physician or PCP and should include sufficient evidence to confirm all coverage criteria are satisfied. Failure to submit required clinical evidence will prevent EmblemHealth from authorizing the procedure.

History and physical exam notes, symptom duration and severity.
Documentation of prior conservative therapy and any prior abrasion arthroplasty and/or microfracture procedures.
Imaging reports (MRI, radiographs) showing defect size, location, and containment.
Operative reports if prior relevant procedures were performed.
Plan for postoperative rehabilitation and patient ability to comply.

Step Therapy

Conservative Therapy and Clinical Sequencing

EmblemHealth follows a clinical sequencing that requires conservative therapy and procedural stepwise treatment prior to authorizing osteochondral grafting. Ensure records document at minimum 6 months of refractory pain despite conservative care and that abrasion arthroplasty and/or microfracture were attempted where applicable.

Conservative therapy prerequisite: ≥6 months of disabling localized knee or ankle pain refractory to conservative treatment.
Include evidence of abrasion arthroplasty and/or microfracture attempted when applicable.
Confirm skeletal maturity or documented reason not a candidate for total joint replacement.

Denial Risk

Investigational Product Denial Risk

Investigational products and specified graft types listed as investigational are not covered and may be denied. EmblemHealth has added decellularized osteochondral allograft plugs and reduced allograft discs to the investigational/denial list.

Examples added to exclusion list: decellularized osteochondral allograft plugs (e.g., Chondrofix) and reduced allograft discs (e.g., ProChondrix, Cartiform).
Use of these products risks investigational/denial determination.

Definitions and Technique Notes

inv-22: Autograft — graft harvested from patient's own tissue; single-stage, donor-site considerations

DefinitionGraft of bone and cartilage harvested from the patient’s own less weight-bearing surfaces and implanted into the defect

Procedure characteristicsTypically a single-stage procedure; limited available graft volume and potential donor-site morbidity (may require harvest from multiple sites)

Clinical useTypically used to repair smaller defects; systems such as COR/COR2 may be used for autograft transplantation

inv-23: Allograft — graft from cadaver tissue; used for larger defects, availability considerations

DefinitionGraft of bone and cartilage harvested from a cadaver joint (fresh or cryopreserved) and implanted into the defect

IndicationsTypically used to repair larger defects (e.g., up to ~10 cm^2 in the knee)

Practical considerationsAvailability may be limited; fresh allografts must often be implanted within a short window and there are concerns about cartilage cell viability and disease transmission

inv-24: Mosaicplasty / OATS — description of mosaicplasty and OATS techniques

Technique overviewMosaicplasty uses multiple small cylindrical osteochondral plugs harvested from less weight-bearing areas and inserted into the defect; OATS uses larger plugs and may fill the defect with a single plug

ApproachMay be performed open or arthroscopically

Systems/examplesMosaicplasty System and Osteochondral Autograft Transfer System (OATS) are described as tools for these techniques

inv-25: Mosaicplasty / Osteochondral autograft transfer — transfer of cylindrical osteochondral plugs; outcomes summary

Procedure descriptionTransfer of cylindrical osteochondral autograft plugs harvested from less weight-bearing areas to repair focal full-thickness cartilage defects

Outcomes evidenceMultiple outcome studies and randomized trials are cited supporting mosaicplasty/OATS for focal lesions (references include randomized and long-term follow-ups)

Typical indicationsUsed for focal, full-thickness, unipolar defects of weight-bearing surfaces in appropriate patients

inv-26: Fresh osteochondral allograft — transplantation of size-matched fresh donor tissue; outcomes and indications

Definition and indicationTransplantation of size-matched fresh donor osteochondral tissue for larger or posttraumatic defects of the knee or talus

Evidence baseMultiple outcomes studies and systematic reviews cited (including long-term follow-up and comparative studies) support use in selected patients

Clinical/practical noteFresh allografts may be limited by donor availability and concerns about cartilage viability; cited literature includes series on fresh talar and femoral allografts

Policy Revision History

2025-02-14template_transferLatest

Policy content was transferred to an individual company branded template for EmblemHealth.

2023-02-10coverage_update

Patellar chondral defect indication was added to align with covered diagnostic coding listed in the policy.

2022-01-14criteria_adoption

Retired MCG criteria for this service and adopted the clinical criteria of parent corporation EmblemHealth.

2019-01-11exclusion_addition

Decellularized osteochondral allograft plugs (e.g., Chondrofix) and reduced allograft discs (e.g., ProChondrix, Cartiform) were added to Limitations/Exclusions as investigational.

OpenPayer

Osteochondral Grafting

Coverage Criteria for Osteochondral Grafting

Procedure and Diagnosis Codes, and Key Criteria Values

Provider Requirements and Prior Authorization

Background on Osteochondral Grafting

Definitions and Technique Notes

Policy Revision History