ModifiedPremera Blue Cross of WashingtonPolicy 7.01.160

Cartilage Implants for Joint Pain

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This policy governs coverage of cartilage implants used to treat articular cartilage damage, including AGILI-C and Cartiva. These implants are classified as investigational because evidence is insufficient to demonstrate improved net health outcomes.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyCartilage Implants for Joint Pain

Policy CodePolicy 7.01.160

Change TypeModified

Effective DateNovember 6, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionExpect claims for AGILI-C and Cartiva to be denied because these implants are considered investigational.

SourceLink

POLICY UPDATE CHANGES

The policy scope was expanded from synthetic cartilage implants to include cartilage implants more broadly.

CPT code 28291 was removed from the policy.

InvestigationalCoverage status

3HCPCS codes listed

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ModifiedPremera Blue Cross of WashingtonPolicy 7.01.160

Cartilage Implants for Joint Pain

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Sign up for premerabluecrossofwashington Policy 7.01.160 alerts

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Policy Summary

PayerPremera Blue Cross of Washington

PolicyCartilage Implants for Joint Pain

Policy CodePolicy 7.01.160

Change TypeModified

Effective DateNovember 6, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionExpect claims for AGILI-C and Cartiva to be denied because these implants are considered investigational.

SourceLink

POLICY UPDATE CHANGES

The policy scope was expanded from synthetic cartilage implants to include cartilage implants more broadly.

CPT code 28291 was removed from the policy.

InvestigationalCoverage status

3HCPCS codes listed

Coverage Criteria

Cartilage Implants

Cartilage implants are considered investigational.

Investigational cartilage implants: Cartilage implants, including AGILI-C and Cartiva, are considered investigational for the treatment of articular cartilage damage.

Available evidence is insufficient to show that these implants are effective.

Investigational Cartilage Implants

Synthetic cartilage implants are considered investigational for the treatment of articular cartilage damage.

Investigational treatment: Synthetic cartilage implants are considered investigational for the treatment of articular cartilage damage.

Investigational services are generally not eligible for coverage under the policy unless the member benefit plan provides otherwise.

For Cartiva, lesions greater than 10 mm and insufficient bone quality or quantity are identified as contraindications.

Cartilage implants, including AGILI-C and Cartiva, are considered investigational for treatment of articular cartilage damage because available evidence is insufficient to demonstrate effectiveness.

Evidence is insufficient to determine that synthetic cartilage implants improve net health outcomes for early-stage or advanced first MTP osteoarthritis. Evidence is also insufficient for cartilage repair implants used for knee cartilage or osteochondral defects.

Synthetic cartilage implants used to treat articular cartilage damage are considered investigational.

Coding and Product Information

HCPCSHCPCS

L8641	Metatarsal joint implant
L8642	Hallux implant
L8699	Prosthetic Implant, not otherwise specified

FDA Product Codesmixed

PNW	FDA product code for the Cartiva Synthetic Cartilage Implant
QRU	FDA product code for Agili-C

Historical Codes AddedHCPCS

L8641	Code added when the policy was created; description not provided in this window
L8642	Code added when the policy was created; description not provided in this window

Removed CPT CodeCPT

28291

CPT code removed in the 2026 annual review; description not provided in this window

Agili-C Treatable Knee Lesion Area

Treatable lesion area1 to 7 cm²

DeviceAgili-C

FDA-approved indicationKnee-joint surface lesions without severe osteoarthritis

Cartiva Lesion Size Contraindication

Lesion-size contraindicationGreater than 10 mm

DeviceCartiva Synthetic Cartilage Implant

Provider and Claims Actions

Denial Risk

Investigational cartilage implants

Claims for cartilage implants, including AGILI-C and Cartiva, may be denied because these devices are considered investigational for the treatment of articular cartilage damage.

Denial Risk

Investigational cartilage implant treatment

Synthetic cartilage implants are considered investigational for the treatment of articular cartilage damage.

Clinical Background

Articular cartilage is the smooth, rubbery tissue covering the ends of bones in a joint, helping the joint move easily and without pain. Damage may result in focal cartilage or osteochondral lesions or diffuse osteoarthritis and may cause pain, swelling, impaired movement, loss of function, and disability. Cartilage implants are intended to replace or repair damaged tissue; examples include Cartiva for the first metatarsophalangeal joint and Agili-C for knee cartilage or osteochondral defects. The evidence reviewed for these applications was insufficient to establish improved net health outcomes.

Definitions

Articular Cartilage

TissueSmooth, rubbery tissue

LocationCovers the ends of bones in a joint

FunctionHelps the joint move easily and without pain

Cartilage Implant

TypeDevice

PlacementPlaced into a joint

PurposeReplaces or repairs damaged cartilage