ModifiedPremera Blue Cross of WashingtonPolicy 7.01.160

Cartilage Implants for Joint Pain

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This policy governs coverage of cartilage implant procedures used to treat articular cartilage damage, including implants such as AGILI-C and Cartiva. The policy applies to providers and considers these implants investigational because evidence is insufficient to demonstrate improvement in net health outcomes.

Policy Summary

PayerPremera Blue Cross of Washington

PolicyCartilage Implants for Joint Pain

Policy CodePolicy 7.01.160

Change TypeModified

Effective DateNov 6, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionAdvise that cartilage implants, including AGILI-C and Cartiva, may be denied as investigational.

SourceLink

POLICY UPDATE CHANGES

The policy title changed from "Synthetic Cartilage Implants for Joint Pain" to "Cartilage Implants for Joint Pain."

CPT code 28291 was removed from the policy.

InvestigationalCoverage status

3HCPCS codes listed

21%

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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 DateNov 6, 2026

Last ReviewAug 1, 2026

Next Review DateN/A

Key ActionAdvise that cartilage implants, including AGILI-C and Cartiva, may be denied as investigational.

SourceLink

POLICY UPDATE CHANGES

The policy title changed from "Synthetic Cartilage Implants for Joint Pain" to "Cartilage Implants for Joint Pain."

CPT code 28291 was removed from the policy.

InvestigationalCoverage status

3HCPCS codes listed

21%

Coverage Criteria

Investigational Cartilage Implants

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

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

No positive coverage criteria are provided.

Cartilage implants, including AGILI-C and Cartiva, are considered investigational (unproven) for treating articular cartilage damage and are excluded from coverage on that basis.

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

Agili-C is FDA-approved for knee-joint surface lesions with a treatable area of 1 to 7 cm² without severe osteoarthritis. Use outside these approved parameters is not part of the stated FDA-approved indication.

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

Removed CPT CodeCPT

28291

CPT code removed from the policy

Agili-C Treatable Knee Lesion Area

FDA-approved treatable area1 to 7 cm²

DeviceAgili-C is a cell-free, biocompatible, biodegradable, tapered-shape implant.

Approved useKnee-joint surface lesions without severe osteoarthritis.

Cartiva Lesion Size Contraindication

Contraindicated lesion sizeGreater than 10 mm

ImplantCartiva Synthetic Cartilage Implant

Additional contraindicationInsufficient quality or quantity of bone.

Provider Guidance

Denial Risk

Cartilage implants may be denied as investigational

Cartilage implants, including AGILI-C and Cartiva, are considered investigational (unproven) for treatment of articular cartilage damage and may be denied on that basis. There is not enough evidence to show these treatments are effective.

Clinical Background

Articular cartilage is the smooth, rubbery tissue covering the ends of bones in a joint. Damage may occur as focal lesions or diffuse osteoarthritis and can cause pain, swelling, loss of function, and disability. Because damaged cartilage does not heal well on its own, treatment may include conservative care, debridement, microfracture, osteochondral grafting, autologous chondrocyte implantation, arthrodesis, or joint replacement, depending on the location and severity of disease. Cartilage implants such as the synthetic Cartiva implant and the Agili-C scaffold are intended to repair or replace damaged cartilage; however, the policy states that evidence is insufficient to demonstrate improved health outcomes.

Definitions

Articular Cartilage

TissueSmooth, rubbery tissue covering the ends of bones in a joint.

Joint functionFacilitates joint movement.

Symptom preventionHelps prevent pain during joint movement.

Cartilage Implant

DefinitionA device placed into a joint to replace or repair damaged cartilage.

Natural-material exampleAGILI-C

Synthetic exampleCartiva