CurrentUnitedHealthcarePolicy CSO68PA.W

Surgery of the Knee (for Pennsylvania Only)

UnitedHealthcare Pennsylvania-specific medical policy on surgical procedures of the knee, defining coverage rationale, Not medically necessary determinations for certain cartilage repair implants/techniques, applicable procedure and HCPCS codes, documentation expectations, definitions, and references. Uses InterQual criteria for medical necessity determination of listed procedures.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (for Pennsylvania Only)

Policy CodePolicy CSO68PA.W

Change TypeClarified / Revised

Effective DateSep 1, 2025

Next Review Date

Key ActionEvaluate medical necessity for listed knee procedures using the InterQual CP: Procedures referenced in the policy.

SourceLink

POLICY UPDATE CHANGES

Added language under Medical Records Documentation Used for Reviews clarifying benefit coverage is determined by federal, state, or contractual requirements and that medical records may be required for review.

Updated definition of 'Reduced Allograft Discs' and updated Clinical Evidence and References sections.

7InterQual Procedures Referenced

7Articular Cartilage Repair Types Not Medically Necessary

>30Procedure / HCPCS Codes Listed

Coverage Summary

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This UnitedHealthcare Pennsylvania medical policy (Policy Number: CSO68PA.W) addresses surgery of the knee and defines the scope of covered procedures, applicable codes, documentation expectations, and definitions. The policy uses InterQual clinical criteria to determine when knee surgeries are proven and medically necessary and separately lists specific articular cartilage repair techniques that are considered unproven. status: CURRENT; effective date: September 1, 2025.

High-level finding: the policy concludes that many newer articular cartilage repair technologies (including various minced/particulated cartilage products, BioCartilage, DeNovo products, collagen meniscal implants, reduced allograft discs, decellularized osteochondral allografts, synthetic resorbable polymers, and xenografts) have insufficient evidence of efficacy and are considered unproven or not medically necessary for treatment of cartilage lesions.

Key Facts

Policy NumberCSO68PA.W

SubjectSurgery of the Knee (Pennsylvania)

Effective DateSeptember 1, 2025

StatusCURRENT

InterQual Procedures Referenced7

Articular Cartilage Repair Types Deemed Not Medically Necessary7

Procedure / HCPCS Codes Listed>30

Medical-Necessity Criteria

Coverage Rationale / Medical Necessity

Surgery of the knee is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures:

ANY of the following

Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric)
Arthroscopy or Arthroscopically Assisted Surgery, Knee
Arthroscopy; Diagnostic, +/- Synovial Biopsy, Knee
Arthrotomy, Knee (Pediatric)
Arthrotomy, Knee
Removal and Replacement; Total Joint Replacement (TJR), Knee
Unicondylar or Patellofemoral Knee Replacement
Total Joint Replacement (TJR); Knee

Not Medically Necessary / Unproven Articular Cartilage Repair

Articular cartilage repair is unproven and not medically necessary for treating individuals with any of the following due to insufficient evidence of efficacy:

ALL of the following

Allogeneic minced or particulated cartilage (e.g., BioCartilage, DeNovo NT, DeNovo ET)
Autologous minced or particulated cartilage (e.g., Cartilage Autograft Implantation System (CAIS), Reveille Cartilage Processor)
Collagen Meniscus Implant
Reduced osteochondral discs (e.g., ProChondrix, Cartiform)
Decellularized Osteochondral Allografts (e.g., Chondrofix)

Provider Actions / Documentation

Documentation Required

Use InterQual criteria for medical necessity determination

Medical necessity clinical coverage criteria for listed knee procedures must be evaluated against the InterQual CP: Procedures referenced in the policy.

InterQual CP: Procedures is the referenced criteria set and is used to determine medical necessity for the procedures listed in this policy, including arthroscopy and knee replacement procedures.

Documentation Required

Medical records may be required for review

Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; documentation does not guarantee coverage.

Documentation may be requested for review, but providing records does not guarantee that the service will be covered.

Definitions & Background

This policy evaluates surgical knee procedures and multiple articular cartilage repair technologies and summarizes the clinical evidence, which is largely limited to small case series, early-stage studies, or low-quality reports. The Description of Services and Definitions sections note that because cartilage has limited healing capacity, a variety of autologous and allogeneic approaches have been proposed, but the clinical literature does not yet support many of these techniques.

The policy specifically reviews minced or particulated autologous and allogeneic cartilage (including CAIS, Reveille, DeNovo NT/ET, and BioCartilage), collagen meniscal scaffolds, reduced osteochondral allograft discs (Cartiform, ProChondrix), decellularized osteochondral allografts (e.g., Chondrofix), synthetic resorbable polymer implants (e.g., TruFit, PolyGraft BGS), and xenografts, concluding that evidence is insufficient to demonstrate consistent safety and efficacy.

Term	Definition
BioCartilage
Dehydrated, micronized allograft articular cartilage matrix intended to provide a scaffold for microfracture; the small particles are mixed with a blood solution to create a paste-like consistency that is applied over a cartilage defect.
CAIS (Cartilage Autograft Implantation System)
Harvests minced autograft cartilage and disperses chondrocytes on a scaffold in a single-stage treatment.
Collagen Meniscus Implants
Implantable porous meniscus scaffolds composed of collagen fibers, enriched with glycosaminoglycan, used as a template/support for generation of new tissue to replace the lost menisci.
Decellularized Osteochondral Allograft Plugs
Cylinder-shaped plug of healthy cartilage tissue and subchondral bone taken from a non-weightbearing area matched to the defect and pushed into place, leaving a smooth cartilage surface in the joint.
DeNovo ET/NT
DeNovo ET: engineered 3-dimensional hyaline-like cartilage from cultured allogeneic juvenile chondrocytes; DeNovo NT: manually particulated juvenile allograft cartilage mixed with fibrin glue before implantation.
Reduced Allograft Discs
Wafer-thin allografts with reduced bony portion containing hyaline cartilage, chondrocytes, growth factors, and extracellular matrix proteins; often used with marrow stimulation to permit host mesenchymal stem cell infiltration and promote chondrogenesis.
Synthetic Resorbable Polymers
Implants functioning as a scaffold for chondral and osteogenic cells that are resorbed as cells produce their normal matrices.
Xenograft
Graft of tissue taken from a donor of one species and grafted into a recipient of another species.

Key evidence points summarized in the policy include: limited-quality or small-sample studies and case series for minced/particulated cartilage and BioCartilage with inconclusive results; systematic reviews and evidence briefs (ECRI, Hayes) concluding the body of evidence is very low quality or insufficient.

Reported failure and revision findings cited: decellularized osteochondral allografts demonstrated a 72% failure rate within the first 2 years (Farr et al., 2016) and a case series reported 29% of patients required revision surgery at a mean 15.5 months (Johnson et al., 2017).

For synthetic resorbable polymers (e.g., TruFit), early improvements were reported but longer-term follow-up showed deterioration and inconsistent incorporation, and overall evidence was insufficient to support clinical use versus established treatments.

Not Medically Necessary / Experimental

In summary, the policy states that the listed articular cartilage repair techniques are considered unproven and not medically necessary per the Medical‑Necessity Criteria: refer to the policy’s Not Medically Necessary / Unproven Articular Cartilage Repair criteria for the exact list.

Not Medically Necessary / Unproven Articular Cartilage Repair

Allogeneic minced or particulated cartilage (e.g., BioCartilage, DeNovo NT, DeNovo ET)Not medically necessary / insufficient evidence

Autologous minced or particulated cartilage (e.g., CAIS, Reveille Cartilage Processor)Not medically necessary / insufficient evidence

Collagen Meniscus ImplantNot medically necessary / insufficient evidence

Reduced osteochondral discs (e.g., ProChondrix, Cartiform)Not medically necessary / insufficient evidence

Decellularized Osteochondral Allografts (e.g., Chondrofix)Not medically necessary / insufficient evidence

Synthetic Resorbable Polymers (e.g., PolyGraft BGS, TruFit, TruGraft)Not medically necessary / insufficient evidence

Xenograft implantationNot medically necessary / insufficient evidence

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
27442	Arthroplasty, femoral condyles or tibial plateau(s), knee.

OpenPayer