DraftUnitedHealthcarePolicy CS068ID.B

Surgery of the Knee (Idaho)

Medical policy governing surgical procedures of the knee for Idaho members (including Idaho Medicaid Plus), describing coverage rationale, documentation requirements, definitions, and applicable procedure codes. Affects providers requesting authorization or reimbursement for knee surgeries in Idaho.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (Idaho)

Policy CodePolicy CS068ID.B

Change TypeOperational (documentation and submission requirements added)

Effective DateMay 1, 2026

Next Review Date

Key ActionWhen requesting prior authorization, submit complete medical records and, upon request, labeled diagnostic images via the external portal to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added language specifying medical notes that may be required including detailed imaging interpretation, labeled diagnostic images when requested, reports of specific diagnostic tests (microbiological, synovial exam, ESR, CRP), clinical history, prior therapies, and physician's treatment plan.

Removed reference link to the guidelines titled 'Medical Records Documentation Used for Reviews'.

1state-specific policy (Idaho)

9+InterQual knee procedures referenced

10+CPT/HCPCS codes listed

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Coverage Criteria

InterQual-based coverage

Covered when the referenced InterQual CP criteria are met for the specific procedure requested.

InterQual-based coverage: Medical necessity clinical coverage criteria are those specified in the InterQual CP procedures listed (Arthroscopy or Arthroscopically Assisted Surgery, Knee; Arthrotomy, Knee; Total Joint Replacement, Knee; Unicondylar or Patellofemoral Knee Replacement; and related InterQual knee procedure lists).

Provider must refer to the referenced InterQual CP for specific inclusion/exclusion criteria, clinical qualifiers, and procedural indications.

Articular cartilage repair — not medically necessary/unproven

Not medically necessary/unproven for treating individuals due to insufficient evidence of efficacy:

Unproven/Not Medically Necessary Procedures: Autologous minced or particulated cartilage (e.g., Cartilage Autograft Implantation System [CAIS], Reveille Cartilage Processor); Allogeneic minced or particulated cartilage (e.g., BioCartilage, DeNovo NT/ET); Collagen Meniscus Implant (CMI); Decellularized osteochondral allografts (e.g., Chondrofix); Reduced osteochondral discs (e.g., ProChondrix, Cartiform); Synthetic resorbable polymers (e.g., PolyGraft BGS, TruFit, TruGraft); Xenograft implantation.

These listed articular cartilage repair technologies are considered investigational, unproven, and not medically necessary due to insufficient evidence of efficacy and safety.

Overall medical necessity stance

Coverage stance based on available clinical evidence summarized below:

General evidence-based coverage stance: Use of collagen meniscus implants, osteochondral allograft plugs/discs, synthetic resorbable polymers, and xenografts is not supported by sufficient high-quality evidence to recommend routine clinical use; further randomized controlled trials and longer-term comparative studies are needed.

Statements supported by systematic reviews, retrospective series, and case series reporting heterogeneous outcomes and in some reports high failure rates.

Specific findings from studies: Published studies report mixed outcomes: systematic reviews and narrative summaries conclude evidence is insufficient to recommend meniscal scaffolds as sole treatment due to heterogeneity and concurrent procedures (Kohli et al.) [chunk 18]; retrospective case series report 87.8% of CMI implants in situ at mean 10.9 years but note study limitations (Lucidi et al.) [chunk 19]; small series report 10-year and 14-year survival rates for lateral CMI of 85% and 64% respectively, with declining outcomes over time (Grassi et al.) [chunk 20]; decellularized osteochondral allografts have demonstrated high early failure rates (29% revision in Johnson et al.; 72% failure within 2 years in Farr et al.) [chunk 21]; evidence for reduced osteochondral discs and synthetic resorbable polymers is limited to small case series or preclinical studies and is insufficient to draw conclusions (Hayes, Mehta, Verhaegen) [chunks 22, 23, 24]; xenograft approaches and decellularization methods remain early-stage and investigational [chunk 25].

These study-level findings inform the policy stance that these technologies remain investigational or not routinely covered in the absence of stronger comparative evidence.

This policy considers a range of articular cartilage repair technologies that have been evaluated for knee surgery. Examples include autologous minced or particulated cartilage systems (e.g., Cartilage Autograft Implantation System [CAIS], Reveille Cartilage Processor), allogeneic minced or particulated cartilage products (e.g., BioCartilage®, DeNovo NT/ET), collagen meniscus implants (CMI), decellularized osteochondral allografts (e.g., Chondrofix), reduced osteochondral allograft discs (e.g., ProChondrix, Cartiform), synthetic resorbable polymers (e.g., PolyGraft BGS, TruFit, TruGraft), and xenograft implantation.

Regulatory notes are informational only: surgeries of the knee are procedures and are not regulated by the FDA, while devices and surgical instruments used during procedures do require FDA review and marketing clearance/approval. Minimally processed human tissues transplanted for normal structural function (for example, meniscal allografts) do not require FDA premarket review, though tissue establishments must follow registration, donor screening, testing, and good tissue-practice requirements. Additionally, certain donor-derived cartilage products (e.g., DeNovo NT) are regulated as HCT/Ps under FDA CBER guidance.

The following specific technologies are identified in the policy as unproven and not medically necessary due to insufficient evidence: autologous minced or particulated cartilage (e.g., CAIS, Reveille), allogeneic minced or particulated cartilage (e.g., BioCartilage®, DeNovo NT/ET), collagen meniscus implant (CMI), decellularized osteochondral allografts (e.g., Chondrofix), reduced osteochondral discs (e.g., ProChondrix, Cartiform), synthetic resorbable polymers (e.g., PolyGraft BGS, TruFit, TruGraft), and xenograft implantation.

Evidence quality and outcomes vary by implant type. For collagen meniscus implants (CMI), systematic reviews have concluded that current evidence is insufficient to support routine use because studies are heterogeneous and often include many concurrent procedures. For decellularized osteochondral allograft plugs, case series report concerning early failure rates (for example, revisions in 29% of patients in one series and a reported 72% failure rate within 2 years in another). Evidence for reduced osteochondral allograft discs is limited to small case series and cannot yet support conclusions about clinical benefit. Studies of synthetic resorbable polymers are primarily preclinical or small clinical series and have reported variable outcomes and biocompatibility concerns. Overall, these technologies lack high-quality randomized trials and long-term comparative data to demonstrate consistent safety and efficacy.

Coding

Applicable CPT/HCPCS Codesmixed

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.

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Documentation elements — imaging labeling and submission expectations (date, case number/member ID) when requested.

Required image labelingWhen requested, diagnostic images must be labeled with the date taken and the applicable case number obtained at time of notification or the member's name and ID number on the image(s)

Submission methodUpon request, diagnostic images must be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be accepted

Imaging types that may be requestedMRI, CT, X-ray, and/or bone scan may be requested to show the abnormality for which surgery is being requested

Required imaging report elementsComplete diagnostic interpretation including relevant clinical information, detailed findings (closure of growth plates if age <18, presence/absence/size/location of full-thickness cartilage defect, Outerbridge grade, joint space/alignment, ligament tear location/grade), impression, and specialty(ies) of interpreting provider(s)

Provider Actions & Prior Authorization Requirements

Prior Authorization

Prior Authorization: Image Submission Requirements

Prior authorization may require submission of labeled diagnostic images. When requested, diagnostic image(s) that demonstrate the abnormality for which surgery is being requested (e.g., MRI, CT, X-ray, bone scan) must be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be accepted. Images must be labeled with the date taken and the applicable case number obtained at the time of notification, or the member's name and ID number on the image(s). Consultation with the requesting surgeon may be of benefit to select the optimal images.

Submit diagnostic images via the external portal at www.uhcprovider.com/paan when requested; faxes will not be accepted
Images must be labeled with the date taken and either the applicable case number or the member's name and ID number
Acceptable imaging: MRI, CT, X‑ray, and/or bone scan (as applicable)

Documentation Required

Required Medical Records and Imaging

Medical notes documenting the following elements may be required to assess whether the member meets clinical criteria for coverage. Failure to provide required documentation may result in delay or denial of the request.

Background

Articular cartilage has a limited intrinsic capacity for healing. Damage from acute injury or chronic inflammatory conditions can produce pain, swelling, and functional disability. A variety of restorative approaches—autologous and allogeneic tissue transplants, scaffolds, synthetic implants, and biologic matrices—are under evaluation, but many lack robust long-term evidence to show they reliably restore durable, hyaline-like cartilage and prevent progression to osteoarthritis.

Definitions

BioCartilage definition — dehydrated, micronized allograft matrix scaffold for microfracture.

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.

Intended useScaffold for microfracture procedures

CAIS — Cartilage Autograft Implantation System definition.

TermCAIS (Cartilage Autograft Implantation System)

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