ModifiedKaiser PermanentePolicy N/A

Clinical Review Criteria — Knee Arthroscopy Procedures (ACI, MACI, Meniscal Transplant, OATS/Mosaicplasty)

Clinical review criteria governing medical necessity review and utilization management for various knee arthroscopy procedures for Kaiser Foundation Health Plan of Washington members; applies to providers requesting these services.

Policy Summary

PayerKaiser Permanente

PolicyKnee Arthroscopy Procedures (ACI, MACI, Meniscal Transplant, OATS/Mosaicplasty)

Policy CodePolicy N/A

Change TypeMerged criteriaadopted MCG KP-S-705 for determinations

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the last 6 months of clinical notes with prior authorization requests to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Merged knee surgical procedures into one criteria set (OATS/Mosaicplasty, ACI, MACI, Allogeneic Meniscal Transplant, Meniscal Allograft Transplant).

Adopted MPC approval to use KP-S-705 criteria set for medical necessity determinations effective Jan 1, 2025.

MCGMCG referenced

MultipleProcedures listed

No RCT superiorityACI finding

6 mos notesDocumentation

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Coverage and Medical Necessity Criteria

MCG-guided Coverage Logic

Coverage decisions are made using the listed MCG clinical guidelines and internal MTAC conclusions.

MCG-based determination: Medical necessity determinations for knee arthroscopy procedures will be made using the referenced MCG guideline(s).

Kaiser Permanente has elected to use MCG Knee Arthroscopy KP-S-705 (effective 01/01/2025) and MCG Meniscal Allograft Transplant (A-0216) for determinations; providers may request the specific MCG criteria or access them via the provider portal.

Procedure-specific stance: Meniscal Allograft Transplant (allogeneic meniscal transplant) is not covered per MCG guidelines; microfracture is the standard first-line surgical treatment for smaller cartilage defects while ACI/MACI and OATS/mosaicplasty are considered for larger defects per MCG criteria and clinical judgment.

Historical MTAC reviews found insufficient evidence that ACI provides clear clinical advantage over alternatives.

Knee cartilage/meniscal procedures - Medically Necessary WHEN criteria met

Considered medically necessary when the specific criteria in the applicable policy statements (MCG KP-S-705 or referenced statements listed above) are satisfied.

Group inclusion: Procedures grouped in this criteria set (for example: arthroscopic osteochondral allograft, OATS/mosaicplasty, microfracture, ACI/MACI, and related arthroscopic knee procedures) are considered medically necessary only when the specific applicable policy criteria are met.

Detailed, procedure-specific medical necessity criteria reside in the referenced applicable policy statements (MCG KP-S-705 and A-0216 as applicable).

Per adopted MCG guidance, Meniscal Allograft Transplant is designated as not covered. Kaiser Permanente uses the MCG Meniscal Allograft Transplant (A-0216) criteria for medical-necessity determinations and will follow MCG direction when MCG indicates noncoverage; providers may request the specific MCG criteria used for an individual member review via the provider portal or by contacting Clinical Review staff.

Allogeneic meniscal transplant performed as arthroscopic or open meniscal transplantation (CPT 29868) is considered not covered. Billing or authorization requests for CPT 29868 will be reviewed consistent with this policy stance and may be denied when submitted for coverage.

Autologous chondrocyte implantation (ACI, including matrix-assisted ACI/MACI) was reviewed by Kaiser Permanente’s Medical Technology Assessment Committee (MTAC) across multiple assessments. MTAC concluded that the existing evidence base—composed primarily of small case series and a limited number of controlled trials—was insufficient to determine a clear effect of ACI on health outcomes and that the intervention did not meet Kaiser Permanente Medical Technology Assessment Criteria.

Across randomized and controlled trials reviewed by MTAC, ACI did not demonstrate consistent superiority to alternative surgical procedures (such as microfracture or mosaicplasty) for cartilage repair. Some trials found no significant differences in clinical outcomes at 1–2 years, and the strongest methodologic studies suggested that ACI may not provide a clear clinical advantage and could be inferior to microfracture on selected outcomes.

Procedure and Billing Codes

Referenced Procedure CodesCPT

27416	Osteochondral autograft transfer (OATS) / Mosaicplasty (as cited)
29866	Arthroscopy procedure code referenced with OATS/mosaicplasty (as cited)
29879	Microfracture (MFX)

Considered Medically Necessary when criteria metCPTCovered

29867	Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty).
29870	Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure).
29871	Arthroscopy, knee, surgical; for infection, lavage and drainage.
29874	Arthroscopy, knee, surgical; for removal of loose body or foreign body (eg, osteochondritis dissecans fragment/chondral fragmentation).
29875	Arthroscopy, knee, surgical; (unspecified in source).
29876	Arthroscopy, knee, surgical; synovectomy, limited (eg, plica or shelf resection) (separate procedure).
29877	Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (eg, medial or lateral).
29881	Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral, including any meniscal shaving) (including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s) when performed).
29882	Arthroscopy, knee, surgical; with meniscus repair (medial OR lateral).
29883	Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral).

1–10 of 15

1/2

Allogeneic Meniscal TransplantCPTNot Covered

29868

Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral.

OATS / Mosaicplasty / MicrofracturemixedCovered

27416	Osteochondral autograft transfer system (OATS) / mosaicplasty (as listed).
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (eg, mosaicplasty).
29879	Microfracture (MFX).

ACI / MACI related HCPCS and S codesHCPCSCovered

J7330	Autologous cultured chondrocytes, implant.
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells).

Prior Authorization, Documentation, and Billing Guidance

Prior Authorization

Prior Authorization Required; Documentation; Code Verification

Kaiser Permanente requires prior authorization for listed knee arthroscopy procedures and applies MCG guidance for determinations. Providers must verify authorization requirements and applicable CPT/HCPCS codes using the plan's Pre-authorization Code Check tool.

Verify prior authorization for listed knee procedure CPT/HCPCS codes via Pre-authorization Code Check.
Kaiser uses MCG KP-S-705 (Knee Arthroscopy) and A-0216 (Meniscal Allograft Transplant) for utilization decisions.
Requesting providers should submit the last 6 months of clinical notes to support medical necessity.

Denial Risk

Allogeneic Meniscal Transplant Not Covered (Denial Risk)

Allogeneic meniscal transplant (meniscal allograft transplant) is considered not covered per the MCG Meniscal Allograft Transplant (A-0216) guidance. Submissions for this service are subject to denial; providers should not expect coverage and should discuss alternative treatment options with the member prior to performing or billing for this procedure.

Clinical Background and Evidence Summary

Knee arthroscopy is a minimally invasive, typically outpatient procedure used to diagnose and treat intra-articular pathology of the knee. Articular cartilage has limited intrinsic repair capacity; surgical treatment options described in the literature and considered in this policy include microfracture (marrow stimulation) for smaller focal defects and reconstructive approaches such as osteochondral autograft transfer (OATS/mosaicplasty) or cell-based procedures like ACI/MACI for larger lesions. Providers should consider lesion size, patient factors, and applicable guideline criteria when selecting the appropriate intervention.

Procedure Definitions

inv-21: Microfracture (marrow stimulation)

DefinitionSingle-stage arthroscopic marrow-stimulation technique that penetrates the subchondral bone plate to produce bleeding and a marrow clot that matures into repair tissue (fibrocartilage or hyaline-like), typically used for smaller focal cartilage defects.

Typical lesion size/useCommonly used as first-line treatment for smaller cartilage defects (investigators cite effectiveness for defects <100 mm2).

Procedure characteristicsMinimally invasive, technically simple, low morbidity; repair tissue is fibrocartilaginous and mechanically inferior to native hyaline cartilage, with potential deterioration over time.

Clinical considerationsMore effective for new injuries, small focal defects, and younger patients with lower BMI; marrow-derived cells and growth factors are released into the joint rather than contained at the defect site.

inv-22: Autologous Chondrocyte Implantation (ACI/MACI)

Policy Revision History

08/06/2024policy_approvalLatest

Medical Policy Committee approved adoption of MCG Knee Arthroscopy KP-S-705 for medical necessity determinations, effective 2025-01-01 with a 60-day notice requirement.

08/02/2024content_revision

Merged knee surgical procedures into a single criteria set (OATS/Mosaicplasty, ACI, MACI, Allogeneic Meniscal Transplant, Meniscal Allograft Transplant).

06/05/2006evidence_review

MTAC review concluded ACI did not demonstrate clear clinical advantage over alternatives and does not meet Kaiser Permanente Medical Technology Assessment Criteria.