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UnitedHealthcare medical policy (Nebraska only) governing surgical procedures of the knee, referencing InterQual clinical criteria for specific procedures and specifying that articular cartilage repair procedures (listed devices/techniques) are unproven and not medically necessary. Includes documentation requirements, definitions, applicable procedure and supply codes, evidence summary, FDA notes, and revision history.
Added definitions for Disabling Pain, Functional Disability, Outerbridge Grades, Radiographic Findings of Osteoarthritis, and WOMAC.
Updated list of applicable CPT codes to reflect annual edits; removed 27445.
Archived previous policy version CS068NE.AB.
This UnitedHealthcare medical policy applies to the State of Nebraska only and covers surgical procedures of the knee. Medical necessity determinations for procedure-specific knee surgeries reference InterQual® CP: Procedures (delegated clinical criteria). The policy reviews evidence for novel and implantable articular cartilage repair technologies and states that the listed cartilage repair technologies are unproven and not medically necessary. Effective date: March 1, 2026. Policy number: CS068NE.AC.
General Coverage Rationale
Surgery of the knee is proven and medically necessary in certain circumstances; refer to InterQual CP criteria. This policy applies only to Nebraska and lists articular cartilage repair techniques considered unproven (see Not Medically Necessary group).
General coverage rationale
Click here to view the InterQual criteria.
Medical Records Documentation Required for Reviews
Medical records documentation may be required; when applicable include ALL of the following items.
InterQual criteria reference for medical necessity
Providers must document how the requested knee surgery meets InterQual CP: Procedures medical necessity criteria. Include evidence in the medical record that the case satisfies the specific InterQual procedure criteria being used to support coverage.
Required pre-authorization documentation
| 0737T | Xenograft implantation into the articular surface. |
| 27412 | Autologous chondrocyte implantation, knee. |
| 27415 | Osteochondral allograft, knee, open. |
| 27416 | Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft[s]). |
| 27418 | Anterior tibial tubercleplasty (e.g., Maquet type procedure). |
| 27437 | Arthroplasty, patella; without prosthesis. |
| 27438 | Arthroplasty, patella; with prosthesis. |
| 27440 | Arthroplasty, knee, tibial plateau. |
| 27441 | Arthroplasty, knee, tibial plateau; with debridement and partial synovectomy. |
| 27442 | Arthroplasty, femoral condyles or tibial plateau(s), knee. |
Purpose: to summarize UnitedHealthcare’s coverage position for knee surgery in Nebraska, delegate detailed medical necessity criteria to InterQual® CP: Procedures, and to evaluate evidence for novel/implantable cartilage repair technologies. The policy focuses on procedures and technologies considered unproven/not medically necessary (examples include autologous/allogeneic minced cartilage, BioCartilage®, DeNovo grafts, collagen meniscus implants, decellularized osteochondral allografts, reduced osteochondral discs, synthetic resorbable polymers, and xenografts). The document provides device/implant definitions, evidence summaries, and FDA informational notes clarifying that surgeries are procedures (not regulated by FDA) while devices and tissue products used may be subject to FDA regulation or HCT/P guidance.
| Evidence item | Summary/Value |
|---|---|
| Decellularized OC allograft failure rate | Case series reported 29% required revision within mean 15.5 months; another study reported 72% failure within first 2 years |
| Quality of evidence for BioCartilage/DeNovo NT/Cartiform/ProChondrix | Evidence is limited, low quality, mostly case series; insufficient to establish efficacy |
| TruFit plug evidence | Limited human studies with short-term improvement but deterioration over longer follow-up; no evidence of superiority to established treatments |
Definitions (render as key term: definition):
BioCartilage®: Dehydrated, micronized allograft articular cartilage matrix mixed with blood solution to create a paste-like scaffold for microfracture.
Cartilage Autograft Implantation System (CAIS): Harvests minced autograft cartilage and disperses chondrocytes on a scaffold in a single-stage treatment.
Collagen Meniscus Implants: Implantable porous collagen scaffolds enriched with glycosaminoglycan used as a template for new meniscal tissue generation.
Definitions section expanded; added definitions for Disabling Pain, Functional Disability, Outerbridge Grades, Radiographic Findings of Osteoarthritis, and WOMAC.
Applicable CPT/HCPCS codes list updated to reflect annual edits; removed 27445.
Required documentation for reviews
Not Medically Necessary
Articular cartilage repair is unproven and not medically necessary due to insufficient evidence of efficacy for any of the following devices/techniques.
Not Medically Necessary - Articular cartilage repair
For pre-authorization, submit complete diagnostic reports, recent test results, clinical history, prior therapies, and the physician’s treatment plan. Include revision surgery details when applicable.
Submit diagnostic images when requested
When diagnostic images are requested, submit labeled images via the external portal. Images must be labeled with the date and either the applicable case number or the member’s name and ID. Do not send images by fax.
Inpatient stay justification
If an inpatient stay is requested, include medical documentation supporting at least one acceptable justification for inpatient admission.
Decellularized Osteochondral Allograft Plugs (e.g., Chondrofix): Cylinder-shaped plug of cartilage and subchondral bone harvested from non–weight-bearing area and press-fit into defect.
DeNovo ET / DeNovo NT: Engineered (ET) or particulated natural (NT) juvenile allogeneic cartilage grafts used for cartilage repair.
Disabling Pain: WOMAC pain domain > 40.
Functional Disability: WOMAC functional limitation domain > 40.
Outerbridge Grades: Classification Grade 0–4 describing cartilage condition from normal to exposed subchondral bone.
Minced Cartilage: Cartilage minced and seeded over a scaffold to allow chondrocyte expansion within the defect.
Reduced Allograft Discs (Cartiform/ProChondrix): Wafer-thin allografts with reduced bone containing hyaline cartilage and chondrocytes, used with marrow stimulation.
Radiographic Findings of Osteoarthritis: Narrowing of joint space, osteophytes, subchondral sclerosis, subchondral cysts, deformity of bony end-plates, and thinning or loss of articular cartilage (UHC will accept three or more moderate-to-severe findings to support severe OA diagnosis).
Synthetic Resorbable Polymers: Implants that function as scaffolds for chondral and osteogenic cells with the synthetic polymer resorbed as cells produce matrix.
Xenograft: Graft from a donor of one species to a recipient of another species.
Archived previous policy version CS068NE.AB.