ModifiedUnitedHealthcarePolicy CS068KY.12

Surgery of the Knee (Kentucky Only)

This Kentucky-only medical policy summarizes coverage rationale, documentation requirements, definitions, and coding related to surgical procedures of the knee, including arthroscopy, arthrotomy, and joint replacement, and states which cartilage/meniscal repair techniques are considered unproven or not medically necessary.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (Kentucky Only)

Policy CodePolicy CS068KY.12

Change TypeDocumentation requirements added

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit detailed imaging interpretations and labeled diagnostic images when requested to support prior authorization reviews.

SourceLink

POLICY UPDATE CHANGES

Added language specifying the medical notes and imaging documentation that may be required for reviews, including detailed imaging interpretation, labeled diagnostic images, and reports of recent diagnostic tests.

Added requirements for documentation to support inpatient stay requests (e.g., bilateral surgery, significant comorbidities, or lack of outpatient support).

KY-onlystate-specific

InterQualInterQual referenced

60+procedure codes

several

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Coverage Criteria and Evidence

Medical necessity and explicitly not medically necessary techniques

Covered when documented as meeting InterQual clinical coverage criteria for the listed procedures; the policy also lists specific articular cartilage and meniscal scaffold techniques that are considered unproven and not medically necessary.

InterQual-based coverage: Medical necessity determinations for arthroscopy, arthrotomy, diagnostic arthroscopy, and total/partial knee replacement procedures are governed by the referenced InterQual CP criteria (see policy).

Provider must refer to InterQual criteria linked in the policy.

Unproven/not medically necessary techniques: The following articular cartilage repair and meniscal scaffold techniques are considered unproven and not medically necessary due to insufficient evidence of efficacy: autologous minced or particulated cartilage (e.g., Cartilage Autograft Implantation System [CAIS], Reveille Cartilage Processor), allogeneic minced or particulated cartilage (e.g., BioCartilage, DeNovo Natural Tissue [NT] Graft, DeNovo 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.

Listed explicitly as unproven and not medically necessary in policy.

Evidence summaries and documentation-based coverage considerations

Evidence summary nodes: Available clinical evidence for Collagen Meniscus Implant (CMI) shows some long-term implant survival in limited observational studies but with methodological limitations; decellularized osteochondral allografts have reported high short-term failure rates; evidence for osteochondral allograft discs and synthetic resorbable polymers is limited and insufficient to draw conclusions; xenografts are investigational with decellularization methods under early study.

These are evidence statements, not prescriptive coverage criteria.

Documentation requirements for coverage review: Medical records and diagnostic imaging details specified in Policy History/Revision Information may be required to support medical necessity determinations, including complete diagnostic interpretation of imaging (relevant clinical information; detailed findings such as presence/absence of focal full-thickness cartilage defect, size and location of defect, Outerbridge grade, joint space/alignment, ligament tear location/grade; impression; interpreting provider specialty), labeled diagnostic images when requested, reports of recent diagnostic tests (microbiology, synovial exam, ESR, CRP), condition and symptoms, severity and functional impact, cause of defect, pertinent physical exam, comorbidities, prior therapies/surgeries with dates/duration/reason, and the physician's treatment plan (including planned intraoperative interventions).

When inpatient stay is requested, documentation supporting need (e.g., bilateral surgery, significant comorbidities, lack of outpatient support) may also be required.

This policy identifies specific articular cartilage repair techniques that UnitedHealthcare considers unproven and not medically necessary due to insufficient evidence of efficacy. The techniques listed are: autologous minced or particulated cartilage (for example, Cartilage Autograft Implantation System [CAIS], Reveille Cartilage Processor); allogeneic minced or particulated cartilage (for example, BioCartilage®, DeNovo Natural Tissue [NT] Graft, DeNovo ET); Collagen Meniscus Implant (CMI); decellularized osteochondral allografts (for example, Chondrofix); reduced osteochondral discs (for example, ProChondrix, Cartiform); synthetic resorbable polymers (for example, PolyGraft BGS, TruFit plug, TruGraft granules); and xenograft implantation.

The policy specifically flags several device and implant categories as having insufficient clinical evidence to support routine use for osteochondral/cartilage repair: synthetic resorbable polymers (limited human data, mostly animal studies and small case series, with reports of poor incorporation and biocompatibility issues), osteochondral allograft discs (evidence limited to small case series and insufficient to draw conclusions), and xenografts (decellularization methods are still investigational and safety/efficacy data are not established). Additionally, decellularized osteochondral allografts have been associated with high early failure rates in some series and therefore are not supported by current evidence.

Products and procedures using autologous or allogeneic minced/particulated cartilage are referenced explicitly in the coverage determination. Examples cited in the policy include BioCartilage® (dehydrated, micronized allograft cartilage matrix used as a scaffold with microfracture), and DeNovo NT (particulated juvenile allograft cartilage). The policy lists these approaches among those considered unproven and not medically necessary because current evidence does not demonstrate consistent efficacy compared with established treatments.

The policy summarizes the evidence for synthetic resorbable polymer implants as inadequate for routine clinical use: most published work is preclinical or small case series, with limited human data and reports of persistent pain, functional deficits, and failure of graft incorporation. Systematic reviews of devices such as the TruFit plug note initial short-term improvement but deterioration on longer follow-up and no clear evidence of superiority or equivalence to established treatments; randomized controlled trials are lacking. Because of these limitations and concerns about biocompatibility and long-term outcomes, use of these implants is unsupported by sufficient clinical evidence.

Applicable Procedure and Billing Codes

Applicable procedure and HCPCS/CPT 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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Prior Authorization, Documentation, and Submission Requirements

Prior Authorization

Prior authorization and documentation — medical records may be required to assess criteria

Prior authorization and supporting medical records may be requested to assess whether the member meets clinical criteria. Medical notes documenting prior therapies/treatments tried, failed, or contraindicated must include dates, duration, and reason for discontinuation. Failure to provide this prior treatment documentation may result in denial.

Include dates, duration, and reason for discontinuation for each prior therapy or treatment

Documentation Required

Diagnostic images and labeling required for review — detailed imaging reports and labeled diagnostic images may be requested

Detailed diagnostic imaging interpretation and, when requested, the actual diagnostic image(s) are required for review. When images are requested they must be labeled with the date taken and either the applicable case number obtained at time of notification or the member's name and ID number. Diagnostic images (MRI, CT, X-ray, bone scan, etc.) must be submitted via the external portal at www.uhcprovider.com/paan; faxes will not be accepted.

Clinical Background

Articular cartilage serves to provide a smooth, low-friction surface for joint motion and to absorb mechanical load, but it has a limited intrinsic healing capacity. Full-thickness cartilage defects do not reliably regenerate mature hyaline cartilage, and untreated defects can lead to persistent pain, joint swelling, impaired function, and progression to larger defects or osteoarthritis. Because biologic repair of cartilage is challenging, a variety of autologous, allogeneic, scaffold, and synthetic approaches have been investigated; however, many of these techniques lack robust comparative evidence demonstrating durable clinical benefit.

Product and Technique Definitions

DeNovo NT — definition and brief description

TermDeNovo NT (Natural Tissue) Graft

DescriptionManually particulated juvenile allograft cartilage mixed intraoperatively with fibrin glue and implanted into a prepared cartilage lesion.

Intended useFill focal chondral defects by implanting donor juvenile cartilage fragments to provide native cartilage matrix and chondrocytes.

Regulatory noteProduct described in clinical literature (Farr et al., 2012) and subject to FDA HCT/P tissue establishment requirements (see FDA section).

BioCartilage — definition and intended use as scaffold for microfracture

TermBioCartilage

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (Kentucky Only)

Policy CodePolicy CS068KY.12

Change TypeDocumentation requirements added

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit detailed imaging interpretations and labeled diagnostic images when requested to support prior authorization reviews.

SourceLink

On This Page

Provide complete diagnostic interpretation including defect size/location, Outerbridge grade, joint space/alignment, ligament tear location and grade, impression, and interpreting provider specialty(ies)
When requested, submit the specific diagnostic image(s) that demonstrate the abnormality and ensure images are labeled with date and case number or member name/ID

Denial Risk

Insufficient documentation — failure to provide supporting medical record documentation may result in denial

Documented absence of required information — such as missing detailed imaging interpretation, unlabeled or missing diagnostic images, or lack of prior treatment history (including dates and durations) — may be deemed insufficient and can result in denial of the request. Medical records should include the condition requiring the procedure, symptoms, severity, pertinent physical exam, co-morbid conditions, and physician's treatment plan.

Missing detailed imaging interpretation or unlabeled/missing diagnostic images may be inadequate for review
Omission of prior therapies with dates/duration/reason for discontinuation can lead to denial

Note

Use of InterQual for criteria — InterQual is primary; fallback to UnitedHealthcare policies if not applicable

UnitedHealthcare uses InterQual® as the primary source for medical/surgical criteria. If InterQual® does not have applicable criteria, UnitedHealthcare may apply its own Medical Policies, Coverage Determination Guidelines, and/or Utilization Review Guidelines (including those approved by the Kentucky Department for Medicaid Services) in making coverage determinations.

InterQual® is primary for medical/surgical criteria; ASAM is used for substance use
If InterQual® is not applicable, UnitedHealthcare Medical Policies and related guidelines may be used

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

Intended useUsed as a scaffold adjunct to microfracture to fill defects and support repair tissue formation.

Source citationHayes (2022) description in Definitions section.

Reduced Allograft Discs — wafer-thin allografts with reduced bony portion

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

DescriptionWafer-thin allografts with reduced bony portion that contain hyaline cartilage, chondrocytes, growth factors, and extracellular matrix proteins.

Intended useOften used in conjunction with marrow stimulation to allow host mesenchymal stem cells to infiltrate the graft and promote chondrogenesis and biomechanical stability.

ExamplesCartiform (Arthrex); ProChondrix CR (AlloSource).

Minced Cartilage — technique using minced cartilage pieces seeded over a scaffold

TermMinced Cartilage

DescriptionProcedure using minced pieces of cartilage seeded over a scaffold to distribute chondrocytes evenly within the defect for tissue regeneration.

Techniques/devicesMay involve autologous processors (e.g., Reveille) or manual mincing; used as a single-stage approach to deliver cartilage fragments and cells.

RationaleProvides structural and mechanical protection while allowing chondrocytes to expand within the defect.

Collagen meniscus implant (CMI) — bioresorbable collagen scaffold description

TermCollagen meniscus implant (CMI)

DescriptionBioresorbable, implantable porous meniscal scaffold composed primarily of bovine type I collagen (collagen scaffold) designed to support generation of new meniscus-like tissue.

Intended usePlaced into meniscal defects as a template and support to promote tissue ingrowth and replacement of lost meniscal tissue.

Regulatory noteCMI products are bioresorbable collagen devices; FDA Premarket Approval information available under product code OLC.

DeNovo NT / donor-derived particulated juvenile cartilage — regulatory and tissue establishment notes

TopicDeNovo NT / donor-derived particulated juvenile cartilage

Regulatory classificationRegulated under FDA Human Cell, Tissue, and Cellular and Tissue-Based Products (HCT/P) guidelines administered by CBER.

Tissue establishment requirementsTissue establishments must register with the FDA, screen and test donors, follow written procedures to prevent communicable disease transmission, and maintain required records.

Scope of FDA oversightCBER regulates donor screening/testing and good tissue practices but does not regulate the surgical transplantation procedure itself.