Autologous Chondrocyte Implantation
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This policy governs coverage and prior authorization requirements for autologous chondrocyte implantation (ACI) procedures for Geisinger Health Plan members across applicable lines of business.
No material clinical or coverage changes in this revision.
Coverage and Medical Necessity Criteria
General coverage and authorization framing
Covered when ALL of the following are met:
Prior authorization through Cohere is required; eligibility and contract-specific benefits, limitations, and exclusions supersede this policy.
Case-by-case evaluation applies to Medicaid as described in policy materials.
Requests that do not meet Cohere's criteria and decision‑support tools may be denied.
Line-of-business benefit documents and Medicare LCD/NCD supersede policy statements.
A revision on 8/19 added an exclusion specific to hybrid ACI/OATS procedures. The policy document notes this change in its revision history but does not reproduce the exclusion language within the body of the current document.
The procedure and device codes listed in this policy are provided for informational purposes only and do not alone determine coverage or guarantee reimbursement. Coverage is determined by the member’s specific benefit plan document, applicable laws, and, for Medicare members, applicable LCDs/NCDs; line-of-business benefit documents supersede this policy.
Associated Procedure and Billing Codes (Informational)
| 29866 | Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty) (includes harvesting of the autograft[s]) |
| 29867 | Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty) |
| 27412 | Osteochondral allograft, knee, open |
| 27415 | Osteochondral allograft, knee, open |
| 27416 | Osteochondral autograft(s), knee, open (eg, mosaicplasty) (includes harvesting of autograft[s]) |
Prior Authorization and Provider Requirements
Prior authorization required through Cohere; verify member benefits
Prior authorization is required through Cohere for members in applicable lines of business; eligibility and contract-specific benefits, limitations, and exclusions apply and line-of-business benefit documents supersede this policy.
- Prior authorization requirement applies to Commercial HMO/PPO, Medicare Advantage, GHP Family Medicaid and CHIP products as noted.
- For Medicare, applicable LCDs and NCDs supersede this policy; for PA Medicaid Business Segment, this policy applies as written.
Medicaid requests may be evaluated case‑by‑case
For the Medicaid Business Segment, any requests that do not meet the criteria set in the PARP may be evaluated on a case‑by‑case basis.
- Submit such requests for individualized review under the Medicaid case‑by‑case process when PARP criteria are not met.
Submit PA requests via Cohere; coding list is informational
Providers must submit prior authorization requests through Cohere for applicable Commercial HMO/PPO, Medicare Advantage, GHP Family Medicaid and CHIP products; coding information is provided for informational purposes and does not guarantee coverage or reimbursement.
- Inclusion of CPT/HCPCS procedure codes in the policy is informational only; coverage is determined by the member‑specific benefit plan and applicable laws.
- For Medicare, consult LCD/NCD and CMS/MAC guidance for coverage and coding requirements.
Denial risk if Cohere criteria or prior authorization not met
Requests for services that do not meet Cohere's clinical criteria and Utilization Management decision‑support tools may be denied; failure to obtain required prior authorization can affect claim adjudication.
- Cohere applies proprietary clinical criteria and UM decision‑support tools when reviewing prior authorization requests.
- Verify prior authorization is approved before performing the service to reduce risk of denial or non‑payment.
Key Definitions
Clinical Background
Autologous chondrocyte implantation (ACI) of the knee uses the patient’s own cartilage cells to repair focal articular cartilage defects with the intent of restoring the joint surface, improving function, and reducing pain. The procedure involves harvesting cartilage, producing an ex vivo, FDA‑approved chondrocyte matrix or culture product, and implanting the cultured chondrocytes into the defect to promote regeneration of the articular surface.
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