ModifiedUnitedHealthcarePolicy CS068KY.13

Surgery of the Knee (for Kentucky Only)

This UnitedHealthcare medical policy governs coverage and medical necessity criteria for surgical procedures of the knee for members in Kentucky, including arthroscopy, arthrotomy, total joint replacement, cartilage repair procedures, and related interventions.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (for Kentucky Only)

Policy CodePolicy CS068KY.13

Change TypeDefinitions addedCPT code list updated

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization using InterQual CP criteria and provide required medical record and regulatory documentation to support medical necessity.

SourceLink

POLICY UPDATE CHANGES

Added definitions for Disabling Pain, Functional Disability, Outerbridge Grades, Radiographic Findings of Osteoarthritis, and Western Ontario and McMaster Universities Arthritis Index.

Updated list of applicable CPT codes to reflect annual edits and removed CPT 27445.

State-specificapplies only to Kentucky

Multipleprocedure and HCPCS/CPT codes referenced

Severalcartilage repair interventions not medically necessary

InterQualInterQual used for medical necessity

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Highhigh early failure reported for some allografts

Insufficientevidence across implant types

Medical Necessity & Coverage Determinations

Decellularized Osteochondral Allografts

Existing evidence on decellularized osteochondral allograft plugs raises concerns about early implant failure and delamination. The literature consists primarily of small case series with short follow-up and reports of high early revision/removal rates.

Decellularized osteochondral allograft plugs (e.g., Chondrofix) have demonstrated high early failure rates in available case series, including substantial proportions of patients requiring revision surgery or implant removal within the first 1–2 years post-implantation.

Johnson et al. (2017) reported that in a case series of 34 individuals treated with decellularized osteochondral allograft plugs for distal femoral osteochondral lesions, 29% (10/34) required revision surgery with removal of the implant at a mean follow-up of 15.5 months (range 6–24 months).

Farr et al. (2016) reported an implant failure rate of 72% within the first 2 years in a prospectively collected series of 23 participants; failure was defined as structural graft damage diagnosed by arthroscopy or MRI or any reoperation resulting in removal of the allograft.

The studies are limited by small sample sizes, short duration of follow-up, single-center designs, and lack of comparative data with established treatments; these limitations markedly reduce generalizability and preclude conclusions about long-term durability or net clinical benefit.

Because of the high early failure rates reported and the low quality and limited quantity of evidence, decellularized osteochondral allografts are considered to have insufficient evidence to support routine clinical use for cartilage repair and are therefore classified as unproven / not medically necessary for these indications.

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.

1–10 of 43

1/5

Updated Applicable CPT CodesCPT

27445

Removed from applicable CPT codes list

Radiographic findings supporting severe osteoarthritis

Accepted radiographic criteriaUnitedHealthcare will accept three or more moderate to severe radiographic findings (narrowing of joint space, osteophyte formation, subchondral sclerosis, subchondral cysts, deformity of bony end plates, thinning or complete loss of articular cartilage) as sufficient to support a diagnosis of severe osteoarthritis.

Examples of radiographic findingsNarrowing of joint space; osteophyte formation; subchondral sclerosis; subchondral cysts; deformity of bony end plates; thinning or complete loss of articular cartilage.

Source guidanceRadiographic findings referenced from American College of Radiology (2025) as listed in policy definitions.

Prior Authorization, Documentation & Provider Responsibilities

Prior Authorization

Prior Authorization Required

Prior authorization is required when applicable. UnitedHealthcare uses InterQual as the primary source for medical/surgical criteria when determining medical necessity and benefit verification; check InterQual criteria (e.g., arthroscopy, arthrotomy, total joint replacement) relevant to the requested knee procedure. Prior authorization requirements are also subject to federal, state, and contractual benefit plan terms—verify the member's plan and obtain authorization as required before scheduling services.

Obtain prior authorization when required by the member's plan or contract
Use InterQual criteria as the primary medical necessity standard
Verify federal, state, and contractual benefit requirements prior to authorization

Documentation Required

Documentation May Be Required

Medical records and supporting documentation may be requested to assess whether the member meets the clinical criteria for coverage. Documentation should demonstrate how the requested service meets InterQual (or other applicable UnitedHealthcare) criteria and may include history, physical exam findings, imaging reports, prior conservative management, and operative reports when relevant.

Clinical Background & Rationale

Articular cartilage has a limited intrinsic ability to heal. Damage from acute injury or degenerative and inflammatory processes can produce pain, swelling, mechanical symptoms, and progressive functional disability. A variety of surgical strategies have been developed to restore cartilage structure or function—ranging from marrow-stimulation techniques and autograft transfer to cell-based therapies and biologic or synthetic scaffolds—but many of the newer implant and scaffold technologies lack robust comparative effectiveness data and long-term outcome evidence. Accordingly, selection of established, evidence-based surgical treatments should be guided by validated clinical criteria (e.g., InterQual) and the available evidence for durable clinical benefit.

Defined Terms & Measurement Instruments

BioCartilage

DefinitionAn extracellular matrix consisting of cartilage allograft intended to provide a scaffold for microfracture defects; small particles are mixed with a blood solution to create a paste-like consistency that is applied over a cartilage defect.

Intended useApplied over microfracture defects to act as a scaffold for cartilage repair.

PreparationParticles are mixed with a blood solution to create a paste-like consistency prior to application.

Cartilage Autograft Implantation System

DefinitionA cartilage autograft implantation system harvests minced autograft cartilage and disperses chondrocytes on a scaffold in a single-stage treatment.

Procedure type

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (for Kentucky Only)

Policy CodePolicy CS068KY.13

Change TypeDefinitions addedCPT code list updated

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization using InterQual CP criteria and provide required medical record and regulatory documentation to support medical necessity.

SourceLink

On This Page

Include clinical notes, imaging, prior treatment attempts, and any specialty evaluations
Provide operative reports or device documentation if available

Documentation Required

Regulatory & Tissue Documentation

Documentation for surgical implants, biologics, and tissue products must reflect regulatory status and product details. For devices and instruments used in knee surgery, include FDA approval/clearance information (PMA, 510(k), or PMN) when available. For human-derived or tissue-based products, include donor screening, tissue establishment registration, HCT/P classification, and any relevant manufacturing or handling documentation.

For devices: provide FDA product code and approval/clearance documentation (PMA/510(k)/PMN) when applicable
For tissue products: document HCT/P status, donor screening/testing, and establishment registration
For collagen or scaffold products: include product identifiers and any premarket approval information

Note

FDA Status Is Not Coverage

FDA approval, clearance, or regulation of a device or tissue product does not, by itself, guarantee that the service or product will be a covered benefit under a member's plan. Coverage decisions are based on medical necessity, benefit plan terms, and applicable federal, state, or contractual requirements. Always verify benefit coverage and medical necessity in addition to regulatory status.

Do not assume coverage solely because a device or tissue product has FDA clearance/approval
Confirm benefit, network, and medical necessity before billing or implanting devices/products

Single-stage autologous minced cartilage harvest and implantation onto a scaffold.

Reference studyDescribed in Farr et al., 2012 within policy definitions.

Minced Cartilage

DefinitionA procedure that uses minced pieces of cartilage seeded over a scaffold to allow even distribution of chondrocytes, promoting structural and mechanical protection within the defect.

MechanismMinced cartilage particles are seeded on a scaffold to enable chondrocyte expansion and matrix formation in the defect.

Devices referencedIncludes processors such as the Reveille Cartilage Processor for creating particulate graft material.

Outerbridge Grades

Grade 0Normal.

Grade ICartilage with softening and swelling.

Grade IIPartial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter.

Grade IIIFissuring to the level of subchondral bone in an area with a diameter of more than 1.5 cm.

Grade IVExposed subchondral bone.

Disabling Pain / Functional Disability

Disabling PainDefined as Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain domain score greater than 40.

Functional DisabilityDefined as WOMAC functional limitation domain score greater than 40.

Measurement instrumentWOMAC domains used to quantify pain and functional limitation per Quintana et al., 2009.

Outerbridge Grades (policy revision)

Policy changeOuterbridge Grades were added as a defined term in the policy definitions effective 06/01/2026.

Revision contextListed among definitions added in the 06/01/2026 summary of changes (also added: Disabling Pain, Functional Disability, Radiographic Findings of Osteoarthritis, and WOMAC).

ImplicationOuterbridge classification is now an explicit defined term referenced within the policy.

WOMAC

Definition addedWestern Ontario and McMaster Universities Arthritis Index (WOMAC) was added to policy definitions as a standardized patient-reported outcome instrument referenced in outcome assessments.

Use in policyWOMAC pain and functional domains are used to define Disabling Pain and Functional Disability (thresholds > 40).

Revision dateIncluded in the 06/01/2026 Summary of Changes.