ModifiedUnitedHealthcarePolicy CSO68LA.T

Surgery of the Knee (Louisiana Only) - Articular Cartilage Repair

This Louisiana-specific medical policy governs clinical coverage and coding guidance for surgical procedures of the knee, including arthroscopy, arthrotomy, meniscal and cartilage procedures, and knee arthroplasty, for UnitedHealthcare members in Louisiana.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (Louisiana Only) - Articular Cartilage Repair

Policy CodePolicy CSO68LA.T

Change TypeRevised coverage languageadded unproven implant categories

Effective DateNov 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization when services are subject to InterQual medical necessity review and document that the procedure meets the referenced InterQual criteria.

SourceLink

POLICY UPDATE CHANGES

Added Collagen Meniscus Implant and Synthetic Resorbable Polymers to the list of unproven and not medically necessary indications.

Revised language pertaining to medical necessity clinical coverage criteria and added reference to InterQual CP: Procedures, Arthrotomy, Knee (Pediatric).

Replaced several named categories (e.g., autologous/allogeneic minced cartilage, osteochondral allograft plugs/discs, xenografts) with updated terminology such as 'autologous minced or particulated cartilage' and 'decellularized osteochondral allografts'.

InterQualexternal medical necessity criteria used

Multiple listedunproven/not medically necessary techniques

Louisianajurisdiction

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

11/01/2024policy revision date

Limitedevidence for synthetic polymers

Coverage and Medical Necessity Criteria

InterQual-based medical necessity

Covered when ALL applicable InterQual clinical coverage criteria for the specific knee procedure are met.

InterQual requirement: Procedure is covered when ALL applicable InterQual CP criteria for the specific knee procedure (for example: Arthroscopy or Arthroscopically Assisted Surgery, Knee; Arthrotomy, Knee; Arthroscopy, Diagnostic, +/- Synovial Biopsy, Knee; Removal and Replacement; Total Joint Replacement (TJR), Knee; Unicondylar or Patellofemoral Knee Replacement) are met.

InterQual clinical protocols are external referenced documents.

Articular cartilage repair — Not medically necessary / Unproven

Not medically necessary for articular cartilage repair when the following techniques are proposed due to insufficient evidence of efficacy:

Unproven cartilage procedures: Use of BioCartilage; Collagen Meniscus Implant (CMI); allogeneic minced or particulated cartilage (e.g., DeNovo NT/ET, BioCartilage); autologous minced or particulated cartilage techniques; decellularized osteochondral allografts (e.g., Chondrofix); reduced osteochondral discs (e.g., ProChondrix, Cartiform); xenograft implantation; and similar techniques for articular cartilage repair.

Listed as unproven and not medically necessary.

Unproven / Not Medically Necessary and Investigational Technologies

Coverage stance based on available evidence and recent policy revisions:

Unproven/Not Medically Necessary Implants: Collagen Meniscus Implant and Synthetic Resorbable Polymers (examples: PolyGraft BGS, TruFit plug, TruGraft granules) are listed as unproven and not medically necessary.

Added to the unproven/not medically necessary list on 11/01/2024.

Limited Evidence Concerns: Synthetic resorbable polymers have limited human data; reported problems include persistent pain, functional deficits, and failure of incorporation, and available studies do not demonstrate reliable bone ingrowth or sustained superiority over established treatments.

Systematic reviews and case series (including 5 studies of TruFit) report early improvements with later deterioration and insufficient long-term evidence.

Xenografts and Decellularized Grafts: Xenografts and decellularized osteochondral grafts remain investigational; decellularization methods are early-stage and safety and efficacy have not been established.

Further clinical studies are required to establish safety and efficacy.

Articular cartilage repair procedures using techniques listed below are considered not medically necessary / unproven due to insufficient evidence of efficacy and therefore are excluded from coverage when proposed for repair of articular cartilage defects.

Surgeries of the knee are procedural and, as such, are not regulated by the U.S. Food and Drug Administration; however, devices and instruments used during surgery and donor tissue products have specific regulatory pathways. When implantable devices or donor tissue (HCT/P) products are used, providers should reference the applicable FDA device or tissue guidance and registries for product-specific regulatory status and donor screening/testing information.

Examples of articular cartilage repair procedures and products included in the policy’s unproven/not medically necessary list include: BioCartilage (allogeneic micronized cartilage extracellular matrix), autologous or allogeneic minced/particulated cartilage techniques (e.g., Cartilage Autograft Implantation System, Reveille processor), DeNovo NT/ET juvenile particulated cartilage grafts, decellularized osteochondral allografts (e.g., Chondrofix), reduced osteochondral discs (e.g., ProChondrix, Cartiform), collagen meniscus implants (collagen scaffolds), and xenograft implantation.

Per the 11/01/2024 policy revision, Collagen Meniscus Implant products and Synthetic Resorbable Polymers (for example, PolyGraft BGS, TruFit plug, TruGraft granules) have been added to the list of technologies considered unproven and not medically necessary for articular cartilage repair due to limited or insufficient clinical evidence and reported adverse outcomes.

Procedure and Billing Codes

Selected procedure codes (part 1)CPT

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.

Selected procedure codes (part 2)CPT

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.
27443	Arthroplasty, femoral condyles or tibial plateau(s), knee; with debridement and partial synovectomy.
27445	Arthroplasty, knee, hinge prosthesis (Walldius type).
27446	Arthroplasty, knee, condyle and plateau; medial or lateral compartment.
27447	Arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty).
27486	Revision of total knee arthroplasty, with or without allograft; 1 component.
27487	Revision of total knee arthroplasty, with or without allograft; femoral and entire tibial component.

Arthroscopy-related CPT codesCPT

29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g.: mosaicplasty) (includes harvesting of the autograft(s)).
29867	Arthroscopy, knee, surgical; osteochondral allograft (e.g.: mosaicplasty).
29868	Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral.
29870	Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure).
29871	Arthroscopy, knee, surgical; for infection, lavage and drainage.
29873	Arthroscopy, knee, surgical; with lateral release.
29874	Arthroscopy, knee, surgical; for removal of loose body or foreign body.
29875	Arthroscopy, knee, surgical; synovectomy, limited.
29876	Arthroscopy, knee, surgical; synovectomy, major; two or more compartments.
29877	Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty).

1–10 of 21

1/3

Other HCPCS/CPT codes (state fee schedule note applies)mixed

G0428	Collagen meniscus implant procedure for meniscal defects (e.g., CMI, collagen scaffold, Menaflex) filling.
J7330	Autologous cultured chondrocytes, implant.
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells).

Affected/Referenced Codesmixed

affected codes

Policy revision notes reference affected codes (no explicit CPT/HCPCS/ICD codes listed in this document segment).

No numeric thresholds specified

Numeric thresholdsNo numeric thresholds or measurable cutoffs are specified in this policy for coding, service selection, or coverage determinations.

Prior authorization implicationPrior authorization and medical necessity review are determined by whether the procedure meets InterQual clinical coverage criteria rather than by numeric thresholds.

Coding guidanceProcedure and HCPCS/CPT codes listed in the policy are for reference; coverage depends on clinical criteria rather than numeric criteria.

Provider Requirements, Prior Authorization, and Denial Risk

Prior Authorization

Prior Authorization per InterQual

Prior authorization is required for knee procedures when applicable clinical coverage is assessed using InterQual criteria. Submit requests per InterQual CP: Procedures (e.g., Arthroscopy or Arthroscopically Assisted Surgery, Knee; Arthrotomy, Knee; Total Joint Replacement, Knee). Failure to obtain prior authorization when required may result in claim denial.

InterQual-based review applies to the listed knee procedures and cartilage repair interventions.
Include InterQual decision support documentation with the prior authorization request.

Denial Risk

InterQual-based Denial Risk and Unproven Techniques

Procedures or implants that do not meet InterQual medical necessity criteria or that are listed as unproven/not medically necessary in this policy are at risk for denial. Examples include collagen meniscus implants, synthetic resorbable polymers (e.g., TruFit, TruGraft, PolyGraft BGS), autologous/allogeneic minced or particulated cartilage, decellularized osteochondral allografts, reduced osteochondral discs, and xenograft implantation.

Clinical Background and Evidence Summary

Articular cartilage is a thin layer of hyaline connective tissue that provides a low-friction, load-bearing surface in synovial joints and has limited intrinsic healing capacity. Focal chondral and osteochondral defects can cause pain, swelling, and functional impairment. Repair approaches under evaluation include marrow-stimulation techniques (e.g., microfracture), autologous osteochondral grafting (mosaicplasty), autologous or allogeneic minced/particulated cartilage implantation, decellularized or reduced osteochondral allografts, synthetic resorbable polymer scaffolds, and scaffold-based implants. Many of the newer scaffold and implant techniques have limited human data; reported issues include implant delamination, failure of incorporation, persistent pain, and functional deficits, and larger comparative trials are needed to establish safety and effectiveness.

Definitions and Device/Product Examples

BioCartilage

TermBioCartilage

DefinitionDehydrated, micronized allograft articular cartilage matrix intended to provide a scaffold for microfracture; small particles are mixed with a blood solution to create a paste-like consistency applied over a cartilage defect.

Clinical roleUsed as a scaffold adjunct to microfracture for articular cartilage defects.

CAIS

TermCartilage Autograft Implantation System (CAIS)

DefinitionHarvests minced autograft cartilage and disperses chondrocytes on a scaffold in a single-stage treatment.

Clinical role

Policy Revision History

2024-11-01policy_revisionLatest

Coverage rationale and medical necessity language revised; InterQual CP reference added and the list of unproven/not medically necessary indications was updated to add Collagen Meniscus Implant and Synthetic Resorbable Polymers (examples: PolyGraft BGS, TruFit plug, TruGraft granules).

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (Louisiana Only) - Articular Cartilage Repair

Policy CodePolicy CSO68LA.T

Change TypeRevised coverage languageadded unproven implant categories

Effective DateNov 1, 2024

Next Review DateN/A

Key ActionObtain prior authorization when services are subject to InterQual medical necessity review and document that the procedure meets the referenced InterQual criteria.

SourceLink

On This Page

Services not meeting InterQual criteria may be denied as not medically necessary.
Newly added implants/procedures in the unproven list are subject to denial risk until sufficient evidence supports medical necessity.

Documentation Required

Clinical Necessity Documentation

Document clinical necessity thoroughly. The medical record should clearly state the indication, prior treatments tried and failed, relevant imaging and exam findings, and how the requested service meets InterQual medical necessity elements.

Attach operative notes, imaging reports, and clinic notes showing failed conservative therapy when applicable.
Indicate which InterQual criteria are met in your documentation to facilitate timely review.

Documentation Required

Regulatory and Donor Documentation

When devices, implants, or donor tissue are used, include regulatory and donor information in the submission. For tissue-derived products, provide Human Cell, Tissue, and Cellular and Tissue-Based Product (HCT/P) registration details and donor screening/testing documentation when available. For devices, include FDA approval/clearance or relevant manufacturer Instructions for Use.

Provide FDA 510(k)/PMA information or manufacturer documentation for devices when applicable.
Include HCT/P establishment registration and donor screening/testing records for allogeneic donor tissue products (e.g., DeNovo NT).

Note

Consider Established Treatments First

Consider established, evidence-based treatments first. Randomized controlled trials comparing newer implants (for example, TruFit) with established treatments such as microfracture or mosaicplasty are lacking; consider conservative management or established surgical options prior to using implants or techniques deemed unproven.

When alternative, established treatments exist, document rationale for selecting an unproven implant and explain why standard options are unsuitable for the patient.
RCT-level evidence is recommended before broader adoption of newer synthetic implants; absence of such evidence increases denial risk.

Single-stage autologous minced cartilage implantation technique to repopulate defects with the patient’s chondrocytes.

Collagen Meniscus Implant (CMI)

TermCollagen Meniscus Implant (CMI)

DefinitionImplantable porous meniscus scaffold composed of collagen fibers enriched with glycosaminoglycan, used as a template and support for generation of new meniscal-like tissue.

Regulatory noteDescribed as a bioresorbable, primarily bovine type I collagen product; FDA references provided for device information.

DeNovo NT / DeNovo ET

TermsDeNovo NT / DeNovo ET

DeNovo ET definitionEngineered Tissue (ET): an in vitro grown, 3-dimensional hyaline-like cartilage tissue created by culturing disaggregated allogeneic chondrocytes derived from juvenile human donors.

DeNovo NT definitionNatural Tissue (NT): manually particulated cartilage obtained from juvenile allograft donor joints; tissue fragments are mixed intraoperatively with fibrin glue before implantation.

Reduced Allograft Discs

TermReduced Allograft Discs (e.g., Cartiform, ProChondrix)

DefinitionWafer-thin allografts with a reduced bony portion that contain hyaline cartilage with chondrocytes, growth factors, and extracellular matrix proteins; often used with marrow stimulation to allow host stem cell infiltration and chondrogenesis.

Clinical roleImplanted to augment osteochondral defects, typically in combination with marrow stimulation techniques.

Reveille Cartilage Processor

TermReveille Cartilage Processor

DefinitionA high-speed blade and sieve device used to cut autologous minced cartilage into small particles for implantation.

Clinical roleUsed to prepare autologous minced cartilage for single-stage implantation techniques.

Synthetic Resorbable Polymers — examples

TermSynthetic Resorbable Polymers

DefinitionSynthetic scaffold implants intended to function as a scaffold for chondral and osteogenic cells and to be resorbed as native matrix is produced; examples include TruFit, TruGraft, and PolyGraft BGS.

Evidence summaryHuman evidence is limited and includes small case series and reports; concerns reported include persistent pain, functional deficits, and failure of incorporation.

TruFit plug

TermTruFit plug

DefinitionA bi-phasic synthetic scaffold (polylactide-co-glycolide copolymer layers) designed to stimulate cartilage and subchondral bone formation for osteochondral defects.

Evidence summaryClinical studies (5 studies) report early improvement at 12 months but some deterioration on longer follow-up; no data demonstrate bone ingrowth and further RCTs versus established treatments are recommended.

HCT/P

TermHCT/P (Human Cell, Tissue, and Cellular and Tissue-Based Products)

DefinitionDonor tissue products derived from human cartilage are regulated under FDA HCT/P guidelines; tissue establishments must register and follow donor screening/testing and recordkeeping requirements, though transplantation procedures themselves are surgical and not regulated as devices.

Regulatory noteFDA CBER guidance applies to establishment registration and safety procedures; FDA approval alone is not a basis for coverage.