Currentpriority healthPolicy 91571-R9

Osteoarthritis of the Knee

Defines medical necessity and noncoverage/experimental status for various procedures and biologic therapies for knee osteoarthritis for Priority Health plans (HMO/EPO, POS, PPO, ASO, Individual, Medicare, Medicaid). Includes coding guidance and prior authorization requirements.

Policy Summary

Payerpriority health

PolicyOsteoarthritis of the Knee

Policy CodePolicy 91571-R9

Change TypeClarification (E&I designation for biologics)Added related policies

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionProviders must submit prior authorization requests where required by the member's plan and Priority Health Provider Manual showing medical necessity for drugs, services, and procedures; specified codes 27412 and J7330 require prior authorization.

SourceLink

POLICY UPDATE CHANGES

Related Policies section was added.

Autologous cellular implant derived from adipose tissue, bone marrow aspirate concentrate, platelet rich plasma injections, and mesenchymal stem cell injections are considered E&I and not prior authorized by TurningPoint.

6Explicitly listed experimental/unproven treatments

2Procedures listed as medically necessary

11CPT/HCPCS codes listed as not covered

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2Codes requiring prior authorization

Coverage Summary

Overview: This policy addresses treatments and procedures for osteoarthritis of the knee, defining which interventions TurningPoint considers medically necessary and which are experimental, investigational, or unproven. Scope: applies to Priority Health plans including HMO/EPO, POS, PPO, ASO, Individual, Medicare, and Medicaid. Coverage stance: mixed — some procedures (e.g., autologous chondrocyte implantation, MAKOplasty®) are listed as medically necessary while cellular/biologic injections and several interventional procedures are designated E&I. Effective date: 2025-06-01. Last review: 2025-05-01. Headline counts: narrative summary indicates a small set of procedures listed as medically necessary alongside multiple explicitly listed experimental/unproven treatments and a set of CPT/HCPCS codes not covered or requiring prior authorization per the policy.

Quick thresholds & facts

Diagnostic genicular nerve block response threshold>= 50% reduction in pain

Duration of knee pain (Coolief device labeling)> 6 months with conservative therapy

Radiologic osteoarthritis grade (device labeling)grade 2-4

Treatments listed as experimental/unproven (count)6 (e.g., adipose cellular implant, BMAC, PRP, Coolief listed among E&I treatments)

Medical Necessity and Not Medically Necessary Criteria

Medically Necessary Procedures

The following procedures are medically necessary according to TurningPoint criteria:

Autologous chondrocyte implantation (e.g., Carticel) for the repair of articular cartilage.
MAKOplasty® knee resurfacing (MAKO® device may also be used for computer assisted navigation; navigation is not separately payable).

Group all-connector: All of the above must be met for this medically necessary group.

Experimental, Investigational, or Unproven Treatments (Not Medically Necessary)

The following treatments for osteoarthritis of the knee are considered experimental, investigational, or unproven:

Experimental/Investigational or Unproven Treatments

Coding Guidance

Codes Not Covered for Indications in This PolicymixedNot Covered

0232T	Injection(s), platelet rich plasma, any tissue, including image guidance, harvesting and preparation when performed
0481T	Injection(s), autologous white blood cell concentrate (autologous protein solution), any site, including image guidance, harvesting and preparation, when performed
0565T	Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation
0566T	Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral
20999	Unlisted procedure, musculoskeletal system, general
27599	Unlisted procedure, femur or knee
37242	Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; arterial, other than hemorrhage or tumor
64454	Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed (Not covered if billed for Coolief for any product)
64624	Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed (Prior authorization required for Medicare; Not covered if billed for Coolief for any product)
C9809	Cryoablation needle (e.g., iovera system), including needle/tip and all disposable system components (Covered for Medicare and Medicaid)

Prior Authorization Required CodesmixedCovered

27412	Autologous chondrocyte implantation, knee
J7330	Autologous cultured chondrocytes, implant

MAKO device use: MAKOplasty® knee resurfacing is listed as a medically necessary procedure, but use of the MAKO® device for computer assisted navigation is not separately payable; providers should bill the primary procedure and follow the Computer Assisted Surgical Navigation policy (#91641). Billing and payer notes: certain CPT/HCPCS codes associated with biologic/cellular injections and specific procedures are not covered for the indications in this policy and may be denied; prior authorization requirements and member-specific benefits (including Medicare/Medicaid rules and Michigan Medicaid Fee Schedule requirements) must be confirmed per the provider manual.

Provider Actions & Billing Rules

Prior Authorization

Prior authorization may be required

Providers must submit prior authorization requests where required by the member's plan and Priority Health Provider Manual demonstrating medical necessity. Codes requiring prior authorization include 27412 and J7330.

Affected codes: 27412, J7330
Submit PA requests per the member's plan and Priority Health Provider Manual

Denial Risk

Noncoverage of biologic/ cellular injections and certain procedures

Claims billed with the specified not-covered CPT/HCPCS codes for the indications in this policy are not covered and may be denied. Examples of key not-covered codes include 0232T, 0565T, 0566T, 37242, and 64454 or 64624 when billed for Coolief.

Not-covered example codes: 0232T, 0565T, 0566T, 37242, 64454 (when billed for Coolief), 64624 (when billed for Coolief)

Background & Evidence Summary

Background and rationale: The policy reviews clinical evidence and guideline recommendations for knee osteoarthritis. Guideline bodies (ACR/Arthritis Foundation and OARSI) strongly recommend against stem cell injections and recommend against intraarticular PRP for OA knee due to very low-quality evidence and lack of standardization. The policy notes that autologous cellular implants (adipose-derived), BMAC, PRP, and mesenchymal stem cell injections are considered experimental & investigational. MAKOplasty is described as a robotic-assisted partial knee resurfacing procedure with insufficient evidence to fully assess impact on outcomes, and genicular artery embolization (GAE) has limited and low-quality trial evidence suggesting potential pain benefit but requires further study. These guideline conclusions and limited evidence base support the E&I determinations and the selective coverage positions in the policy.

Source	Summary
ACR/Arthritis Foundation Guideline (2019)
Strong recommendation against stem cell injections in knee/hip osteoarthritis.
OARSI Guideline (2019)
Strong recommendation against intraarticular stem cell therapy and intraarticular platelet rich plasma for OA knee due to extremely low-quality evidence and lack of standardization.
Device labeling Coolief
Indicated for creating RF lesions of genicular nerves for management of moderate-to-severe knee pain >6 months with conservative therapy and positive response (≥50% reduction) to a diagnostic genicular nerve block.

Medicare Determinations

Name	Type	Effective Date	Notes
Medicare requirements for CPT 64624
informational

Prior authorization required for CPT 64624 for Medicare; CPT 64624 described as destruction by neurolytic agent, genicular nerve branches including imaging guidance; Not covered if billed for Coolief for any product.

Definitions

Policy definitions

E&IExperimental & Investigational

BMACBone marrow aspirate concentrate

PRPPlatelet rich plasma

Revision History

2025-06-01effective_dateLatest

Policy effective date set to June 1, 2025.

2025-05-01last_reviewLatest

Policy last reviewed on May 1, 2025.

added

Policy Summary

Payerpriority health

PolicyOsteoarthritis of the Knee

Policy CodePolicy 91571-R9

Change TypeClarification (E&I designation for biologics)Added related policies

Effective DateJun 1, 2025

Next Review DateN/A

SourceLink

On This Page

Autologous adipose-derived implants: Autologous cellular implant derived from adipose tissue (autologous adipose derived regenerative cell therapy or autologous microfragmented adipose injection, e.g., Lipogems) for any musculoskeletal indication.
BMAC injections: Bone marrow aspirate concentrate (BMAC) injections.
PRP injections: Platelet rich plasma (PRP) injections.
Coolief Cooled RFA: Coolief Cooled Radiofrequency Ablation for the treatment of hip and/or knee pain associated with osteoarthritis of the knee.
Genicular artery embolization: Genicular articular (genicular artery) embolization (GAE).
Mesenchymal stem cell injections.

Group any-connector: Any one of the above treatments is considered experimental, investigational, or unproven per policy.

Coolief Cooled Radiofrequency Ablation Indications (device labeling vs policy)

Device labeling indicates indication but policy status notes it is considered experimental/unproven for OA knee per TurningPoint policy:

Coolief device labeling: Indicated (per device) for creating radiofrequency lesions of nervous tissue for the relief of pain, and lesions of the genicular nerves for management of moderate-to-severe knee pain > 6 months with conservative therapy, radiologically confirmed osteoarthritis (grade 2-4), and positive response (≥50% reduction in pain) to a diagnostic genicular nerve block.

device labeling per Coolief 510(k)

Policy status: Policy: Coolief Cooled Radiofrequency Ablation is listed among treatments considered experimental, investigational, or unproven for OA of the knee.

refer to TurningPoint policy listing

Claims with these codes for the policy indications may be denied

Billing Rule

Computer navigation not separately payable

The MAKO® device may be used for computer assisted navigation, but navigation is not separately payable. Bill the primary procedure per Computer Assisted Surgical Navigation policy #91641.

Bill the primary procedure per policy #91641

Documentation Required

Coverage subject to member benefit and plan documents

Coverage is subject to the member's specific benefits and plan documents. Providers must verify member-specific benefits and, for Medicaid members, ensure appropriate coding is included on the Michigan Medicaid Fee Schedule. If there is a conflict between this policy and a plan document, the plan document governs.

Verify member-specific benefits before rendering services
For Medicaid members, ensure the coding appears on the Michigan Medicaid Fee Schedule
Plan documents supersede this policy when conflicts exist

Prior Authorization

Medicare prior authorization note for neurolytic genicular nerve destruction

Prior authorization is required for CPT 64624 for Medicare; per the policy, billing 64624 or 64454 for Coolief is not covered.

CPT 64624: prior authorization required for Medicare
Billing 64624 or 64454 for Coolief is not covered under this policy

Related Policies section was added. Related policies listed: Autologous Chondrocyte Implant/Meniscal Allograft #91443; Computer Assisted Surgical Navigation #91641; Neuroablation for Pain Management #91647.

clarified