ModifiedUnitedHealthcarePolicy CS068KY.13

Surgery of the Knee (Kentucky)

Defines UnitedHealthcare Kentucky coverage stance and clinical guidance for surgical procedures of the knee, including arthroscopy, arthrotomy, and cartilage repair technologies; applies to members in Kentucky and providers submitting requests to UHC Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (Kentucky)

Policy CodePolicy CS068KY.13

Change TypeDefinitions addedCPT list updated

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionApply the referenced InterQual procedural criteria to determine medical necessity for knee surgeries and reference the updated CPT list for prior authorization.

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.

MultipleInterQual sets cited

MultipleProcedures considered unproven

SeveralDevices with insufficient evidence

Up to 72%Reported early failure rate

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Coverage Criteria and Unproven Procedures

Procedures covered per InterQual

Covered when medical necessity is met per referenced InterQual criteria

InterQual-based medical necessity: Surgery of the knee (arthroscopy, arthrotomy, total joint replacement, unicondylar/patellofemoral replacement and pediatric variants) is considered proven and medically necessary when the member meets the medical necessity clinical coverage criteria as defined in the InterQual CP procedural topic lists referenced in the policy.see InterQual

Provider must apply InterQual criteria for each specific procedure

Articular cartilage repair - Unproven / Not medically necessary

Not medically necessary / unproven procedures

Articular cartilage repair technologies considered unproven: Autologous minced/particulated cartilage; allogeneic minced/particulated cartilage (e.g., BioCartilage, DeNovo NT/ET); Collagen Meniscus Implant; Decellularized Osteochondral Allografts (e.g., Chondrofix); Reduced osteochondral discs (e.g., ProChondrix, Cartiform); Synthetic Resorbable Polymers (e.g., PolyGraft BGS, TruFit, TruGraft); Xenograft implantation; and related named products are unproven and not medically necessary due to insufficient evidence of efficacy.insufficient evidence

Specific product examples are listed in the policy

BioCartilage

Products with inconclusive evidence

BioCartilage (particulated extracellular matrix): Evidence is inconclusive; available data are limited to case studies at high risk of bias and do not permit conclusions about clinical benefit versus microfracture alone; randomized controlled trials with adequate sample size are needed.evidence insufficient

ECRI evidence analysis and Hayes review note limited case-study data and need for RCTs

Collagen Meniscus Implant

Collagen meniscus implants (CMI) evidence summary

CMI outcomes and limitations: Evidence is insufficient to demonstrate efficacy of collagen meniscus implants; observational series report implant survival in some cohorts but no clear superiority to partial meniscectomy, high rates of concurrent procedures, small sample sizes, and loss of chondroprotective benefit by 20 years in at least one long-term study.evidence insufficient

Multiple observational studies and systematic review highlight limitations and need for RCTs

Decellularized Osteochondral Allografts

Decellularized osteochondral allografts

Decellularized osteochondral allograft plugs: Reported delamination and high early failure rates (e.g., 29% requiring revision in one series; 72% failure reported within first 2 years in another); current evidence is insufficient to support routine use and larger comparative trials are needed.high failure/insufficient evidence

Case series with short follow-up report high early failure

Osteochondral Allograft Discs

Osteochondral allograft discs

Reduced osteochondral allograft discs: Evidence consists only of small case series and is insufficient to draw conclusions about effect on health outcomes; larger randomized comparative studies with longer follow-up are needed.insufficient evidence

Hayes brief and small clinical series

Synthetic Resorbable Polymers

Synthetic resorbable polymers

Synthetic resorbable polymers (e.g., TruFit, TruGraft, PolyGraft BGS): Evidence is primarily animal studies and limited human case reports/series; early improvements may deteriorate over longer follow-up with concerns about graft incorporation and biocompatibility; evidence insufficient for routine clinical use.insufficient evidence

Systematic reviews and clinical reports note limited human data and inconsistent long-term outcomes

Xenografts

Xenografts for cartilage/bone: Investigational with mixed outcomes; systematic review and case series report a substantial proportion of poor results, failures to integrate, and high rates of persistent pain in some series; safety and efficacy are unproven and require additional high-quality studies.insufficient evidence

Systematic review and clinical case series report mixed and frequently unfavorable outcomes

Articular cartilage repair technologies listed in this policy (including autologous and allogeneic minced/particulated cartilage, BioCartilage, collagen meniscus implants, decellularized osteochondral allografts, reduced osteochondral discs, synthetic resorbable polymers, and xenograft implantation) are considered unproven and not medically necessary for treating knee cartilage defects because current evidence does not demonstrate clear efficacy compared with established treatments.

Specific products and techniques named in the policy (for example, BioCartilage, DeNovo NT/ET, Cartilage Autograft Implantation System, Collagen Meniscus Implant/meniscal scaffolds, Chondrofix, ProChondrix/Cartiform, TruFit/TruGraft, and xenograft materials) lack sufficient high-quality comparative data. The available literature is dominated by case reports, small case series, and heterogeneous observational studies with frequent concurrent procedures, which precludes conclusions that these products, when used as the sole treatment, improve clinical outcomes versus standard approaches.

Accordingly, the policy states that articular cartilage repair using the enumerated techniques and products is not medically necessary due to insufficient evidence of efficacy. Robust randomized controlled trials with adequate sample size and long‑term follow up are needed to establish safety and comparative effectiveness before routine coverage can be supported.

Evidence reviewers specifically note that meniscal scaffolds and collagen meniscus implants are not supported as a sole treatment for partial meniscal defects because studies show a high rate of concurrent procedures, heterogeneous outcomes, and relatively high failure rates; therefore their use as an isolated therapy is not recommended pending higher‑quality comparative trials.

Applicable Codes, Thresholds, and Coding Notes

Applicable procedure codes (partial list)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.
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 20

1/2

Applicable procedure and HCPCS/G codes (continued)mixed

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 (e.g., osteochondritis dissecans fragmentation, chondral fragmentation).
29875	Arthroscopy, knee, surgical; synovectomy, limited (e.g., plica or shelf resection) (separate procedure).
29876	Arthroscopy, knee, surgical; synovectomy, major, 2 or more compartments (e.g., medial or lateral).
29877	Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty).
29879	Arthroscopy, knee, surgical; abrasion arthroplasty (includes chondroplasty where necessary) or multiple drilling or microfracture.

1–10 of 23

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Coding edits notedCPT

27445

Removed from applicable CPT list

WOMAC pain threshold for disabling pain

WOMAC pain domain thresholdWOMAC pain domain score > 40 defines disabling pain (Quintana et al., 2009)

Source instrumentWestern Ontario and McMaster Universities Arthritis Index (WOMAC)

Use contextApplied to define 'Disabling Pain' in policy eligibility/definitions

WOMAC functional limitation threshold for functional disability

WOMAC functional limitation thresholdWOMAC functional limitation domain score > 40 defines functional disability (Quintana et al., 2009)

Source instrument

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

InterQual criteria required for medical necessity

InterQual clinical criteria must be met for medical necessity determinations for knee procedures. When requesting prior authorization, include documentation demonstrating how the member meets the applicable InterQual® CP criteria (for example: Arthroscopy or Arthroscopically Assisted Surgery, Knee; Arthrotomy, Knee; Total Joint Replacement, Knee; etc.).

InterQual criteria required for medical necessity — include relevant InterQual decision support reference in request

Prior Authorization

Coding / prior authorization note

Prior authorization may be required for surgical procedures and related implants or biologic products. Submit prior authorization requests with full clinical documentation and expected procedure codes. Availability of a CPT/HCPCS code in the Applicable Codes section is for reference only and does not guarantee coverage or authorization.

Coding/prior authorization note — check payer-specific prior authorization rules before scheduling
Listing of procedure/diagnosis codes is not a guarantee of coverage

Clinical Background

Articular cartilage has limited intrinsic healing capacity, and symptomatic chondral and osteochondral defects can cause pain, swelling, and functional limitation. A range of experimental surgical approaches and implantable products have been developed to address these defects, including autologous and allogeneic minced cartilage procedures, particulate extracellular matrices used as scaffolds (eg, BioCartilage), decellularized osteochondral allograft plugs, reduced osteochondral allograft discs, synthetic resorbable polymer implants, and xenograft materials. While these approaches aim to restore cartilage structure and function, the published evidence consists largely of small case series, animal studies, and select observational reports that demonstrate inconsistent incorporation, reports of persistent pain or functional deficits, and, in some series, high early failure or delamination rates; therefore, long‑term outcomes and comparative effectiveness versus established treatments remain uncertain.

Definitions and Key Terms

BioCartilage

DefinitionBioCartilage: an 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 applied over a cartilage defect (Hayes 2022; updated 2025)

Clinical evidence summaryEvidence is inconclusive; limited case-study data with high risk of bias; randomized controlled trials needed to show benefit versus microfracture alone

Policy stanceConsidered unproven/not medically necessary when used as listed technologies without sufficient evidence

Cartilage Autograft Implantation System

DefinitionCartilage Autograft Implantation System: device/process that harvests minced autograft cartilage and disperses chondrocytes on a scaffold in a single-stage treatment (Farr et al., 2012)

Representative example

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (Kentucky)

Policy CodePolicy CS068KY.13

Change TypeDefinitions addedCPT list updated

Effective DateJun 1, 2026

Next Review DateN/A

Key ActionApply the referenced InterQual procedural criteria to determine medical necessity for knee surgeries and reference the updated CPT list for prior authorization.

SourceLink

On This Page

Western Ontario and McMaster Universities Arthritis Index (WOMAC)

Use contextApplied to define 'Functional Disability' in policy eligibility/definitions

FDA applicability

FDA regulation of surgeriesSurgeries of the knee are procedures and therefore not regulated by the FDA

FDA regulation of devices/tissueDevices and instruments used during surgery require FDA approval; certain tissue products are subject to HCT/P and FDA tissue-banking requirements

FDA informational guidancePolicy references FDA websites for premarket and HCT/P information (accessed January 26, 2026)

Billing Rule

Coding inclusion is not coverage

Inclusion of a procedure or device code in the policy’s Applicable Codes section does not imply that the service is a covered benefit or that payment will be made. Code lists are provided for reference; coverage is determined by benefit plan language, medical necessity criteria, and applicable laws.

Coding inclusion is not coverage — verify member benefits and medical necessity prior to delivering services

Denial Risk

Potential denial triggers

Requests may be denied when documentation is incomplete, lacks evidence of meeting InterQual or other specified medical necessity criteria, or when the requested technology is considered investigational or unproven per the policy (e.g., collagen meniscus implants, synthetic resorbable polymers, xenografts, decellularized osteochondral allografts). Common denial triggers include insufficient operative findings, lack of prior conservative management when required by criteria, concurrent procedures that confound indication, or use of devices/products without supporting evidence.

Potential denial triggers — insufficient clinical documentation or failure to meet InterQual criteria
Potential denial triggers — procedures or implants identified as investigational/unproven in policy (see supporting evidence sections)
Potential denial triggers — absence of required conservative therapy or unclear indication

Note

Device/tissue regulatory documentation (informational)

Provide regulatory and sourcing information for devices and biologic/tissue products used in surgery when requested. Informational documentation that may be required includes FDA 510(k)/PMA/PMN references for devices when available, FDA HCT/P registration or tissue establishment information for donor-derived products, and manufacturer labeling or regulatory clearances for collagen meniscus implants or other scaffold products. NOTE: FDA approval/clearance is informational and does not by itself determine coverage.

Device/tissue regulatory documentation (informational) — FDA 510(k)/PMA references where applicable
Device/tissue regulatory documentation (informational) — HCT/P registration and tissue establishment information for donor-derived products

Documentation Required

Use of meniscal scaffolds vs established treatments

Meniscal scaffolds (for example, collagen meniscus implants) are considered investigational/unproven in this policy because current evidence is insufficient to demonstrate clinical benefit over established treatments. When proposing scaffold use, submit robust supporting evidence specific to the product and the member’s indication, and document why established treatments (such as meniscal repair, partial meniscectomy, or meniscal allograft when indicated) are not appropriate.

Use of meniscal scaffolds vs established treatments — provide rationale for scaffold instead of repair, partial meniscectomy, or allograft
Use of meniscal scaffolds vs established treatments — include product-specific clinical evidence and prior authorization justification

Reveille Cartilage Processor is a device described for cutting autologous minced cartilage into particles for implantation

Policy implicationMinced/autograft implantation techniques are under evaluation and considered unproven per policy when evidence is insufficient

Minced Cartilage

DefinitionMinced Cartilage: procedure using minced cartilage pieces seeded over a scaffold to distribute chondrocytes to expand within the defect

Device exampleReveille Cartilage Processor: high-speed blade and sieve to cut autologous minced cartilage into small particles for implantation (Igarashi et al., 2020)

Policy stanceTechniques are investigational/unproven with limited clinical evidence

Reduced Allograft Discs

DefinitionReduced Allograft Discs: wafer-thin allografts with reduced bony portion containing hyaline cartilage, chondrocytes, growth factors, and extracellular matrix proteins; often used with marrow stimulation (Mehta et al., 2022)

Evidence summaryExisting evidence limited to small case series; insufficient to draw conclusions about effect on health outcomes

Policy stanceConsidered unproven/not medically necessary due to insufficient evidence

Outerbridge Grades

Grade definitionsOuterbridge Grades: Grade 0 normal; Grade I softening/swelling; Grade II partial-thickness fissures not to subchondral bone or ≤1.5 cm; Grade III fissuring to subchondral bone >1.5 cm; Grade IV exposed subchondral bone

ReferenceSlattery and Kweon, 2018 (definitions used in policy)

Use in policyApplied to describe cartilage lesion severity in clinical assessments

Disabling Pain

Definition in policyDisabling Pain: WOMAC pain domain score > 40 (Quintana et al., 2009)

Added to policyDefinition added in Policy History/Revision Information on 06/01/2026

Clinical useThreshold used to characterize symptom severity for eligibility/assessment

Functional Disability

Definition in policyFunctional Disability: WOMAC functional limitation domain score > 40 (Quintana et al., 2009)

Added to policyDefinition added in Policy History/Revision Information on 06/01/2026

Clinical useUsed to define functional impairment in policy assessments

Radiographic Findings of Osteoarthritis

Radiographic criteriaRadiographic findings of osteoarthritis include joint space narrowing, osteophyte formation, subchondral sclerosis, subchondral cysts, deformity of bony end plates, and thinning or complete loss of articular cartilage

Policy acceptance standardUHC will accept three or more moderate to severe radiographic findings as sufficient to support diagnosis of severe osteoarthritis

ReferenceAmerican College of Radiology, 2025

WOMAC

Instrument nameWOMAC — Western Ontario and McMaster Universities Arthritis Index

Domains referencedPain domain and Functional limitation domain used in policy thresholds

Policy noteWOMAC thresholds (>40) define 'Disabling Pain' and 'Functional Disability' per policy definitions added 06/01/2026