CurrentPremera BluecrossPolicy 7.01.48

Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

Defines medical necessity criteria, site-of-service rules, documentation and coding for autologous chondrocyte implantation (including MACI) of the knee; states ACI is investigational for non-knee joints.

Policy Summary

PayerPremera Bluecross

PolicyAutologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

Policy CodePolicy 7.01.48

Change TypeCoding updatesdocumentation correctionASC site-of-service addition

Effective Date

Next Review Date

Key ActionSubmit office visit notes with lesion size, age, Outerbridge grade and surrounding cartilage description; obtain prior authorization and follow current coding.

SourceLink

POLICY UPDATE CHANGES

Policy reinstated and may be considered medically necessary when criteria are met; investigational when criteria not met.

Coding update removed CPT code 29870 (04/01/26 entry).

Correction to Documentation Requirements removed BMI and MRI requirement (09/08/23).

Related policy renumberings and replacements (multiple dates).

Added related policy 11.01.525 Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures effective 2025-11-07.

>=1.5 cm2Minimum Lesion Size for Consideration

15-55 yrsTypical Age Consideration

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knee: covered; other joints: investigational

J7330, 27412, 29877-29883Key Codes

SeveralCode removals/renumberings since 2018

Coverage Summary

Scope: This policy defines medical necessity criteria, site-of-service rules, documentation, and coding for autologous chondrocyte implantation (ACI), including matrix-induced ACI (MACI), primarily for focal full-thickness cartilage defects of the knee. Coverage stance: knee: covered with criteria; other joints: investigational.

Minimum lesion size: lesion >= 1.5 cm2 for covered knee indications (full-thickness Outerbridge grade III or IV lesions of the femoral condyles, trochlea, or patella).

Typical age considerations: skeletally mature adolescents (documented growth plate closure, e.g., >= 15 years) or adults who are generally considered too young for total knee arthroplasty (< 55 years).

Key codes and status (CURRENT): CPT 27412 (ACI, knee) and arthroscopy codes 29877–29883 listed as relevant; HCPCS/DRUG: J7330, S2112. Policy status: CURRENT. Note: coding history includes recent removals/updates (e.g., CPT 29870 removed per history).

Key Thresholds for ACI/MACI Coverage

Lesion size>= 1.5 cm2

Age (adolescent skeletal maturity)>= 15 years (documented closure of growth plates)

Age (adult candidate)Younger than 55 years (too young for total knee arthroplasty)

Outerbridge gradeLesion Grade III or IV; surrounding cartilage Grade II or less

ASAASA classification III or higher indicates increased anesthesia risk

MELD> 8 (advanced liver disease indicates increased risk)

COPD FEV1FEV1 < 50%

Asthma FEV1FEV1 < 80% despite treatment (poorly controlled)

BMI thresholdMorbid obesity: BMI >= 50 (may affect site-of-service/outcomes); BMI >35 may affect outcomes

OSA AHIAHI >= 15 (moderate to severe OSA)

Site of Service for Elective Surgical Procedures

We will review the site of service for medical necessity. Site of service is defined as the location where the surgical procedure is performed, such as an off campus-outpatient hospital or medical center, an on campus-outpatient hospital or medical center, an ambulatory surgical center, or an inpatient hospital or medical center.

ANY of the following

On-campus outpatient hospital/medical center allowed when ANY of the following increased-risk conditions are present
- Examples of increased risk (any)
  - Anesthesia Risk: ASA classification III or higher; personal history of complication of anesthesia; documentation of alcohol dependence or history of cocaine use; prolonged surgery (greater than 3 hours).
  - Cardiovascular Risk: Uncompensated chronic heart failure (NYHA class III or IV); recent myocardial infarction (less than 3 months); poorly controlled, resistant hypertension (3 or more drugs to control blood pressure); recent cerebrovascular accident (less than 3 months); increased risk for cardiac ischemia (drug eluting stent placed less than 1 year or angioplasty less than 90 days); symptomatic cardiac arrhythmia despite medication; significant valvular heart disease.

Procedure — Autologous Chondrocyte Implantation (MACI)

Procedure - Autologous Chondrocyte Implantation (MACI)

Autologous chondrocyte implantation may be considered medically necessary when ALL of the following criteria are met:

MACI medical necessity criteria

Symptom requirement: Severe disabling knee pain and loss of knee function caused by acute or repetitive trauma that interferes with activities of daily living or work ability is present
Age requirement (one of)
- Adolescent: skeletally mature with documented closure of growth plates (e.g., age 15 years or older)>= 15 years
- Adult: too young to be appropriate candidate for total knee arthroplasty or other reconstructive knee surgery (e.g., younger than 55 years of age)

Investigational / Not Covered

ACI is considered investigational when criteria below are met:

Investigational indications

Non-knee joints: Autologous chondrocyte implantation for joints other than the knee (including the talar/ankle) is investigational
Other indications: Any indications other than those listed in the medically necessary criteria are considered investigational

Coverage stance: mixed. The policy considers ACI/MACI medically necessary for specified knee lesions when all criteria are met (size, Outerbridge grade, stability, alignment, age). Autologous chondrocyte implantation for joints other than the knee (for example, the talus/ankle) is stated as investigational.

Coding

Covered / Relevant Procedure CodesCPTCovered

27412	Autologous chondrocyte implantation, knee
29877	Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)
29879	Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture
29880	Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral, including any meniscal shaving) including debridement/shaving of articular cartilage (chondroplasty), same or separate compartment(s), when performed
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)

Covered / HCPCS and Supply CodesHCPCSCovered

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

Removed/Updated CPT and HCPCS codes noted in historymixed

29870	Arthroscopy, knee, diagnostic (removed per coding update)
29877	Arthroscopy, knee, drilling (noted in history of removals/updates)
29879	Arthroscopy, knee, abrasion arthroplasty (noted in history of removals/updates)
29880	Arthroscopy, knee, loose body removal (noted in history of removals/updates)
29881	Arthroscopy, knee, synovectomy (noted in history of removals/updates)
29882	Arthroscopy, knee, partial meniscectomy (noted in history of removals/updates)
29883	Arthroscopy, knee, meniscal repair (noted in history of removals/updates)
S2112	HCPCS code S2112 (removed in prior update)

Billing Rule

Coding and billing updates — follow current code set

Follow current payer code sets and billing guidance. Note coding updates in the policy history, including removal of CPT 29870 effective 2026-04-01. Culturing charges (J7330) are billed as part of the hospital bill. Always use the current code set in the policy and payer systems.

29870 (removed effective 2026-04-01)
J7330 (culturing charges submitted as part of hospital bill)

Provider Actions

Prior Authorization

Medical necessity review / prior authorization

Elective ACI procedures will be reviewed for medical necessity and require review/authorization prior to performance.

Documentation Required

Medical record documentation required

Provide office visit notes with relevant history and physical exam documenting that medical necessity criteria are met. Include the following specifics:

Individual's age
Size and description of the lesion (lesion ≥ 1.5 cm2 threshold)
Outerbridge grade classification for the lesion (Grade III or IV) and surrounding cartilage (Grade II or less)
Description of surrounding articular cartilage and border of the defect
Exam findings: joint alignment, joint space, ligament stability or reconstruction plans

Background, Evidence & Definitions

Background: Autologous chondrocyte implantation (ACI) is a two-step procedure involving an initial arthroscopic biopsy of healthy cartilage, ex vivo expansion/culturing of chondrocytes, and a separate implantation surgery to fill full-thickness cartilage defects and promote hyaline-like cartilage regeneration. Matrix-associated techniques (MACI) seed autologous chondrocytes onto a bioresorbable collagen membrane that is cut to size and fixed in the defect; MACI is the currently available FDA-approved matrix-based ACI product in the U.S.

Item	Summary
Strength of evidence for knee lesions	Sufficient — RCTs, systematic reviews, observational studies show improved outcomes vs microfracture for large lesions
Evidence for non-knee joints	Insufficient — case series and systematic reviews; investigational for non-knee joints (including talus/ankle)
Literature update through	February 17, 2025
Key referenced guideline	AAOS Clinical Practice Guideline on Osteochondritis Dissecans (updated Dec 1, 2023)
NICE guidance	TA508 Autologous chondrocyte implantation for knee (2018)

Term	Definition
Outerbridge classification	Grading system for joint cartilage breakdown; Grade III = partial thickness cartilage loss with focal ulceration; Grade IV = full thickness cartilage loss with exposed subchondral bone
ASA	American Society of Anesthesiologists physical status classification (ASA 1-5)
MACI	Matrix-induced autologous chondrocyte implantation — autologous chondrocytes cultured on a bioresorbable collagen membrane

Medicare Determinations

Determination	Number	Effective Date	Notes
Medicare National Coverage			None — no national coverage determination (NCD)

Revision History

Sept 12, 2017approval

New policy approved Sept 12, 2017; policy reinstated and may be considered medically necessary when criteria are met; investigational when criteria not met. (Effective Jan 5, 2018 per history.)

04/01/26coding update

Coding update removed CPT code 29870.

09/08/23documentation correction

Correction to Documentation Requirements removed BMI and MRI requirement that had been inadvertently left in August 2023 criteria.

Policy Summary

PayerPremera Bluecross

PolicyAutologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

Policy CodePolicy 7.01.48

Change TypeCoding updatesdocumentation correctionASC site-of-service addition

Effective Date

Next Review Date

Key ActionSubmit office visit notes with lesion size, age, Outerbridge grade and surrounding cartilage description; obtain prior authorization and follow current coding.

SourceLink

On This Page

Liver Risk: Advanced liver disease (MELD Score greater than 8).

Pulmonary Risk: COPD with FEV1 less than 50%; poorly controlled asthma (FEV1 less than 80% despite treatment); moderate to severe obstructive sleep apnea (OSA) (AHI >=15).

Renal Risk: End stage renal disease on dialysis.

Other: Morbid obesity (BMI >=50); pregnancy; bleeding disorder requiring replacement factor, blood products, or special infusion product (DDAVP does not meet this criterion); anticipated need for transfusion(s).

Ambulatory Surgical Center (ASC) — preferred medically necessary site for certain elective surgical procedures when ASC is available, appropriate, and safe.

Off campus-outpatient hospital/medical center — considered medically necessary when ASC is not appropriate or accessible per criteria (no qualifying ASC within 30 miles, no ASC with necessary equipment, physician lacks privileges at ASC, ASC guidelines prohibit use related to individual health/weight), or when individual is aged 18 or younger, or when the service is performed in conjunction with an additional service requiring hospital outpatient department in the same operative session.

Not medically necessary sites of service

On campus-outpatient hospital/medical center when the site of service criteria listed above are not met.
Inpatient hospital/medical center — considered NOT medically necessary for these elective surgical procedures.

Prior Authorization

Provider Actions — Site of Service

Prior authorization requirements and billing/coding actions for providers related to site-of-service and the procedure.

Prior authorization: Obtain prior authorization when required by the member's benefit plan for elective surgical procedures and for site-of-service review; verify member benefits and prior authorization requirements before scheduling.
Culturing charges billing: The charges for the culturing component of autologous chondrocyte implantation are submitted as part of the hospital bill—ensure culturing charges are billed appropriately on the facility claim rather than separately when applicable.
Coding updates: Update coding practices to reflect CPT/HCPCS coding changes effective 2024-04-01 and 2026-04-01; verify use of current CPT/HCPCS codes and descriptions at the time of billing.
Provider documentation: Maintain documentation that supports medical necessity for the chosen site of service, including clinical conditions that justify an on-campus outpatient hospital when ASC is not appropriate or when increased-risk conditions are present.

Lesion characteristics: Focal, full-thickness (grade III or IV Outerbridge scale) unipolar lesions of the weight-bearing surface of the femoral condyles, trochlea, or patella that are at least 1.5 cm2 in size>= 1.5 cm2; Outerbridge grade III or IV

Surrounding cartilage exam requirements

Stable ligaments: Stable knee with intact or reconstructed ligaments (ACL or PCL) or repairs are planned with the procedure
Normal alignment: Normal joint alignment
Normal joint space

Strength of evidence for knee lesions: Sufficient — systematic reviews, randomized controlled trials, and observational studies show improved outcomes of ACI/MACI versus microfracture for large knee lesions, especially in the long term. Evidence for non-knee joints: Insufficient (case series and systematic reviews). Literature update through February 17, 2025. Key guideline references include the AAOS Clinical Practice Guideline (updated Dec 1, 2023) and NICE TA508 (2018) on ACI for the knee.

Note

Check member benefits; policy exclusion for Medicare Advantage

Consult the member benefit booklet or contact member services to determine coverage for a specific member. This medical policy does not apply to Medicare Advantage.

Billing Rule

Coding updates and code removal — follow current code set

Coding history includes multiple updates and removals; most recently CPT 29870 was removed (effective 2026-04-01). Providers must follow the current code set in the policy and payer systems.

29870 removal (effective 2026-04-01)

Nov 7, 2025policy additionLatest

Added related policy 11.01.525 Site of Service Ambulatory Service Center (ASC) Select Surgical Procedures; ASC site-of-service criteria added effective following 90-day provider notification.

multiple datesrenumbering

Policy renumbered between 7.01.48 and 7.01.569 and replaced/renumbered on multiple dates per history (renumberings and replacements noted).

various (annual reviews)annual review

Subsequent annual and interim reviews documented with literature updates and minor edits; policy statements generally unchanged.