CurrentMass General Brigham Health PlanPolicy 007

Medical Necessity Guidelines Autologous Chondrocyte Implantation in the Knee

Defines medical necessity criteria, prior authorization requirements, covered indications and exclusions for autologous chondrocyte implantation (MACI) of the knee for Mass General Brigham Health Plan members across Commercial, Medicare Advantage, Mass General Brigham ACO, One Care/SCO lines.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines Autologous Chondrocyte Implantation in the Knee

Policy CodePolicy 007

Change TypeAd hoc and annual updates (most recent: March 2026)

Effective Date

Next Review Date

Key ActionTreating specialist must request prior authorization for autologous chondrocyte implantation for applicable lines of business.

SourceLink

POLICY UPDATE CHANGES

March 2026: Ad hoc update. Reformatted policy. Removed reference to retired custom InterQual® subset. Fixed typo in previous effective date. Clarified criteria hierarchy in One Care and SCO section.

January 2026: Ad hoc update. Updated prior authorization table and added variation for One Care and SCO members.

August 2025: Annual update. Fixed wording in MassHealth variation. Fixed typos. Updated code disclaimer.

March 2025: Ad hoc update. Summary of evidence added.

November 2024: Ad hoc update. Medicare Variation language clarified. Added language to coverage guidelines pointing to custom subset in InterQual™. MassHealth Variation language added. Codes updated.

August 2024: Annual update. Added BMI restriction.

August 2023: Annual update. Medicare Advantage added to table. Minor editorial refinement to coverage guidelines; intent unchanged.

1Procedure type covered (knee only)

4Core numeric thresholds (age, BMI, duration, size)

Primary exclusions listed

4Codes listed (CPT/HCPCS)

Coverage Summary

Defines medical necessity criteria and prior authorization requirements for autologous chondrocyte implantation (ACI), including FDA‑approved matrix‑induced ACI (MACI), for Mass General Brigham Health Plan members across Commercial, Medicare Advantage, Mass General Brigham ACO, and One Care/SCO lines. The policy covers ACI/MACI of the knee with criteria-based coverage (covered_with_criteria) and requires prior authorization for all applicable lines of business. When present, CMS and MassHealth guidance are applied to Medicare Advantage, One Care/SCO, and ACO determinations; when CMS/MassHealth guidance is absent, the Commercial criteria apply.

Core numeric thresholds

Age15 - 55 years (adolescents must be ≥15 and skeletally mature with documented growth plate closure)

Skeletal maturityDocumented closure of growth plates; adolescent must be ≥15 on date of service

BMILess than 35 kg/m2

Symptom durationSymptoms interfering with ADLs for ≥6 months

Cartilage defect sizeSingle or multiple full-thickness defects each ≥2.0 cm2

Medical Necessity Criteria (Commercial and Variations)

Commercial and Qualified Health Plans — Coverage Criteria (Medical Necessity)

Covered when ALL of the following are met:

ALL of the following

Age: Member age 15 to 55 years15 - 55 years
If adolescent evaluated, member should be ≥15 on date of service and skeletally mature with documented closure of growth plates
BMI: Body mass index (BMI) less than 35 kg/m2< 35 kg/m2
Duration:

Provider Actions & Documentation Requirements

Prior Authorization

Prior Authorization Required

Treating specialist must request prior authorization for ACI for applicable lines of business.

Commercial
Medicare Advantage
Mass General Brigham ACO
One Care/SCO

Documentation Required

Document growth plate status for adolescents

For adolescent members, document skeletal maturity and growth plate closure; member must be ≥15 on date of service.

Must be ≥15 and skeletally mature; document closure of growth plates

Coding

Informational procedural and drug codes listed in policymixed

27412	Autologous chondrocyte implantation, knee.
27416	Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft[s]).
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft[s]).
J7330	Autologous cultured chondrocytes, implant.

Informational procedural and drug codes listed in policymixed

27412	Autologous chondrocyte implantation, knee.
27416	Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft[s]).
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g., mosaicplasty) (includes harvesting of the autograft[s]).
J7330	Autologous cultured chondrocytes, implant.

Background, Evidence, and Definitions

This policy describes medical appropriateness for autologous chondrocyte implantation (ACI), specifically FDA‑approved matrix‑induced autologous chondrocyte implantation (MACI), for repair of symptomatic, full‑thickness cartilage defects of the knee. It applies to knee procedures only and lists informational CPT/HCPCS codes. The treating specialist must request prior authorization for the procedure, and Mass General Brigham Health Plan uses CMS and MassHealth guidance where applicable; when such guidance is not available, the plan's commercial medical policy criteria are used.

Definitions

Unsupported block type: definition

Evidence summary

Unsupported block type: paragraph

Medicare Determinations

At the time of the most recent policy review there are no National Coverage Determinations (NCDs) or Local Coverage Determinations (LCDs) for ACI in the knee. Medicare Advantage and One Care/SCO plan determinations use CMS guidance when available and otherwise reference the commercial criteria; Medicare Advantage members follow CMS guidance for medical necessity and Medicare Advantage prior authorization requirements (with commercial criteria referenced when no CMS guidance exists).

Revision History

August 2023revised

Annual update. Medicare Advantage added to table. Minor editorial refinement to coverage guidelines; intent unchanged. Medicare Variation language added.

August 2024revised

Annual update. Added BMI restriction. (material change; Added BMI restriction)

November 2024revised

Ad hoc update. Medicare Variation language clarified. Added language to coverage guidelines pointing to custom subset in InterQual™. MassHealth Variation language added. Codes updated.

Policy Summary

PayerMass General Brigham Health Plan

PolicyMedical Necessity Guidelines Autologous Chondrocyte Implantation in the Knee

Policy CodePolicy 007

Change TypeAd hoc and annual updates (most recent: March 2026)

Effective Date

Next Review Date

Key ActionTreating specialist must request prior authorization for autologous chondrocyte implantation for applicable lines of business.

SourceLink

On This Page

Symptoms of knee pain interfere with activities of daily living and have persisted for at least six months

Size: Single or multiple full-thickness cartilage defects each measuring greater than or equal to 2.0 cm2>= 2.0 cm2

Location: Cartilage defect involves the weight-bearing areas of the femoral condyle (medial, lateral, or trochlear) or the patella

Based on documentation from prior arthroscopic procedures

Etiology: Femoral condyle defects are the result of acute or repetitive trauma

Conservative therapy: Prior conservative treatment including physical therapy, nonsteroidal medications, and steroid injections have failed to offer relief

Rehabilitation willingness: Member is willing to comply with a vigorous rehabilitation program post ACI procedure

Anatomic / Biomechanical Considerations (recommended/corrective)

Conditions that should be corrected to optimize success:

ALL of the following

Instability correction: Knee instability should be corrected; anterior and posterior cruciate ligaments should be free of laxity, stable and intact; cruciate deficiencies recommended to be corrected
Alignment correction: Abnormal weight distribution within the joint should be corrected; tibial/femoral joint should be properly aligned

Medicare Advantage / MassHealth / One Care / SCO

Prior authorization required; coverage determinations follow CMS and MassHealth guidance when present. When no CMS/MassHealth guidance exists, the Commercial criteria apply.

ANY of the following

Medicare Advantage: Prior authorization required; no NCD or LCD for ACI at time of review; commercial criteria referenced for medical necessity
Mass General Brigham Health Plan uses CMS guidance when available; when none exists commercial criteria apply
Mass General Brigham ACO (MassHealth): Mass General Brigham ACO: Prior authorization required; MassHealth guidance used when available; otherwise plan medical policies apply
When MassHealth guidance unavailable, commercial criteria apply
One Care and SCO: Prior authorization required; CMS guidance used when available; if Medicare criteria not met then MassHealth criteria applied
Hierarchy: use CMS guidance first; if none or criteria not met then apply MassHealth criteria

Documentation Required

Document defect characteristics and prior treatments

Provide prior arthroscopic and clinical documentation of the cartilage defect and prior conservative treatments.

Location (weight-bearing femoral condyle or patella)
Size (≥2.0 cm2)
Full-thickness nature
Traumatic etiology for femoral condyle defects
Failure of conservative therapies (PT, NSAIDs, steroid injections)

Documentation Required

Document willingness to comply with rehabilitation

Document that the member is willing to comply with and has a plan for vigorous post-ACI rehabilitation.

Include post-ACI rehab plan and adherence expectations

Documentation Required

Document correction of instability or malalignment

Document corrective plans or confirmation that instability or malalignment issues have been resolved prior to ACI.

Document corrective plans or confirmation issues resolved prior to ACI

March 2025revised

Ad hoc update. Summary of evidence added.

August 2025revised

Annual update. Fixed wording in MassHealth variation. Fixed typos. Updated code disclaimer.

January 2026revised

Ad hoc update. Updated prior authorization table and added variation for One Care and SCO members.

March 2026revisedLatest

Ad hoc update. Reformatted policy. Removed reference to retired custom InterQual® subset. Fixed typo in previous effective date. Clarified criteria hierarchy in One Care and SCO section.