ModifiedUnitedHealthcarePolicy CS068OH.E

Surgery of the Knee (for Ohio Only)

This UnitedHealthcare medical policy governs coverage and medical necessity criteria for surgical procedures of the knee in Ohio, including arthroscopy, arthrotomy, total and partial knee arthroplasty, and defines coverage stance for various articular cartilage repair products and implants.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (for Ohio Only)

Policy CodePolicy CS068OH.E

Change TypeMaterial updates to documentation and submission requirements

Effective DateJan 1, 2026

Next Review Date

Key ActionWhen requesting prior authorization, submit detailed medical notes and labeled diagnostic images via the external portal (www.uhcprovider.com/paan) as specified to avoid denial or incomplete review.

SourceLink

POLICY UPDATE CHANGES

Added language specifying potential required medical notes and detailed imaging documentation that may be requested during review.

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

Ohio-onlystate-specific applicability

InterQual referenceduses InterQual criteria

Multiple listednot medically necessary / unproven

~40codes provided

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Jan 01, 2026policy revision

Coverage and Medical Necessity Criteria

Procedures covered with InterQual criteria

Covered when medical necessity criteria are met per referenced InterQual CP procedural modules.

InterQual-based coverage: Surgery of the knee (arthroscopy/arthrotomy, diagnostic arthroscopy, total knee replacement, unicompartmental/patellofemoral replacements) is considered proven and medically necessary in certain circumstances when clinical coverage criteria in the listed InterQual CP: Procedures are satisfied.refer to InterQual

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

Articular cartilage repair — not medically necessary

Not medically necessary / unproven for articular cartilage repair.

Unproven cartilage repair products/procedures: The following articular cartilage repair techniques and products are considered unproven and not medically necessary due to insufficient evidence of efficacy: autologous minced or particulated cartilage (e.g., CAIS, Reveille), allogeneic minced or 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), and xenograft implantation.insufficient evidence

Multiple systematic reviews, HTA briefs, case series, and limited-quality studies report inconclusive evidence, device-specific complications (e.g., delamination, graft hypertrophy, implant failure), and small, low-quality cohorts; randomized controlled trials and larger, longer-term studies are needed.

Investigational/Insufficient Evidence product categories

Evidence summaries and coverage-relevant conclusions for specific graft/implant categories.

Decellularized osteochondral allografts: Case series report high short-term failure (Johnson et al. reported 29% revision; Farr et al. reported 72% failure within 2 years). Further large RCTs and longer follow-up are needed before conclusions on effectiveness can be drawn.

Insufficient evidence to support routine use given observed high failure rates.

Reduced osteochondral allograft discs (e.g., Cartiform, ProChondrix): Evidence is limited to small case series (e.g., Mehta et al., n=18 with two failures) and brief evidence reviews; current data are insufficient to draw conclusions regarding clinical benefit.

Larger, controlled studies with longer follow-up are required.

Synthetic resorbable polymers (e.g., TruFit): Available evidence is mainly animal studies and small human series; early improvements may deteriorate on longer follow-up and there are concerns about biocompatibility and graft incorporation. No data demonstrate superiority or equivalence to established treatments such as microfracture or mosaicplasty.

This policy considers routine articular cartilage repair techniques using the specific products and procedures listed below to be not medically necessary due to insufficient evidence of efficacy. The techniques and products include autologous minced or particulated cartilage (for example, Cartilage Autograft Implantation System [CAIS], Reveille), allogeneic minced or particulated cartilage (for example, BioCartilage®, DeNovo NT/ET), Collagen Meniscus Implant, decellularized osteochondral allografts (for example, Chondrofix), reduced osteochondral discs (for example, ProChondrix, Cartiform), synthetic resorbable polymers (for example, PolyGraft BGS, TruFit/TruGraft), and xenograft implantation.

For the TruFit/TruGraft class of synthetic resorbable polymer implants, available human studies are limited and mixed. Systematic review data report early improvements at 12 months but deterioration in longer follow-up for some studies and no evidence of bone ingrowth; the reviewers concluded that there are no data available that support superiority or equality of TruFit compared to conservative treatment or mosaicplasty/micro‑fracture, and randomized controlled trials versus established treatments are needed before further clinical use is supported.

Specific product categories designated not medically necessary include autologous and allogeneic minced or particulated cartilage (e.g., CAIS, BioCartilage, DeNovo), decellularized osteochondral allograft plugs, and reduced osteochondral allograft discs (e.g., ProChondrix, Cartiform). These categories are identified because current evidence is limited to small case series, brief evidence reviews, or early-stage reports and does not demonstrate consistent clinical benefit compared with established treatments.

The medical literature for decellularized osteochondral allograft plugs and for reduced osteochondral allograft discs is insufficient to establish clinical value. Published reports describe implant delamination and high short-term failure rates for decellularized plugs and only small case series with methodological limitations for reduced discs; animal and limited human data for synthetic polymers and early-stage xenograft work further underscore the need for larger, controlled trials with longer follow-up before these approaches can be recommended.

Procedure, Supply Codes, and Documentation Elements

Applicable procedure and supply 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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inv-09: Documentation elements

Defect documentationImaging report must document presence/absence of focal full-thickness articular cartilage defect and describe size and location of the focal cartilage defect.

Outerbridge gradeReport must include the Outerbridge grade for the cartilage lesion.

Skeletal plate closure (pediatric)For patients under 18 years, documentation should note closure of skeletal plates.

Additional joint detailsInclude joint space and alignment and ligament tear location and grade as applicable.

Image labeling and identifiersWhen requested, diagnostic images submitted must be labeled with date and the applicable case number or the member's name and ID number.

Prior Authorization, Submission Requirements, and Review Risks

Documentation Required

Image submission and case identification

When requested, diagnostic image(s) must include a visible case identifier: the applicable case number obtained at time of notification, or the member's name and UHC ID number. Images must also be labeled with the date the image was taken.

Submit requested diagnostic image(s) via the external portal at www.uhcprovider.com/paan; faxes will not be accepted.
Include on each image: date taken and either the applicable case number OR member name and ID.

Documentation Required

Required documentation for medical necessity review

Medical records should include a complete diagnostic interpretation of imaging findings and supporting clinical documentation to allow medical necessity review. At minimum include relevant clinical history and a detailed imaging report.

Detailed imaging findings must document: presence or absence of focal full‑thickness articular cartilage defect; size and precise location of any focal cartilage defect; Outerbridge grade; joint space and alignment; ligament tear location and grade; and documented closure of skeletal plates when member is <18 years.

Clinical Background

Articular cartilage is a specialized hyaline tissue covering joint surfaces that provides a smooth, low-friction bearing and distributes load. It has limited intrinsic healing capacity because it is avascular and has low cellularity. Focal cartilage defects from acute injury or inflammatory processes can cause pain, swelling, and functional limitation; without effective repair, defects may progress and contribute to joint deterioration. Because of these biologic limitations, many emerging repair technologies (autograft, allograft, synthetic scaffolds, and biologic particulates) are being investigated, but evidence supporting durable restoration of hyaline cartilage and improved long-term outcomes is currently limited for several newer products and techniques.

Definitions of Products and Techniques

inv-19: BioCartilage

Product 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-like consistency applied over a cartilage defect.

Intended useUsed as a scaffold adjunct to marrow stimulation (microfracture) to fill cartilage defects.

Regulatory noteDescribed in Hayes review (2022) as an allograft-derived scaffold product.

inv-20: Cartilage Autograft Implantation System (CAIS)

Technique summarySingle-stage system that harvests minced autograft cartilage and disperses chondrocytes on a scaffold for implantation.

PurposeDesigned to treat focal cartilage defects using the patient’s own cartilage in a single operative session.

Policy Changes and Revision History

2026-01-01revisionLatest

Operationalized documentation expectations: added required medical notes and detailed imaging documentation (clinical info, imaging findings including defect size/location, Outerbridge grade, joint alignment, interpreting provider specialty) and clarified image labeling and submission requirements; removed reference link to 'Medical Records Documentation Used for Reviews'.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Knee (for Ohio Only)

Policy CodePolicy CS068OH.E

Change TypeMaterial updates to documentation and submission requirements

Effective DateJan 1, 2026

Next Review Date

SourceLink

On This Page

RCTs versus established methods recommended prior to routine clinical use.

Xenografts: Decellularization and other processing methods are in early investigational stages; additional studies are necessary to establish safety and efficacy before clinical use.

Investigational at present.

Include the interpreting provider's impression and the specialty(ies) of the provider(s) who interpreted the images.

Provide reports of recent diagnostic tests when applicable (e.g., microbiology, synovial exam, ESR, CRP).

Documentation Required

Required documentation for review

Provide clinical notes that document the condition prompting the procedure and prior conservative management. Failure to submit complete medical notes may delay review or result in denial.

Document condition requiring procedure, symptoms, severity of pain, and functional limitations affecting activities of daily living.
List prior therapies/treatments tried, failed, or contraindicated with dates, duration, and reason for discontinuation; include date of any failed previous surgery to the same joint, if applicable.
Include physician's treatment plan (pre‑op discussion, additional interventions or products planned) and consideration of arthroscopic approach if applicable.

Prior Authorization

Provider action: inpatient justification and documentation

If an inpatient stay is requested, include medical notes that support inpatient admission. Examples of acceptable justification include bilateral surgery, significant comorbidities with current treatments, or documented barriers to safe outpatient post‑operative care.

When requesting inpatient level of care, clearly state which inpatient criterion is met: bilateral procedure; list of significant comorbidities and current treatments; or specific barriers to outpatient care and post‑operative support.
For revision surgery, include details of the complication and a complete staged surgical plan.

Example referenceDescribed in Farr et al., 2012 as a single-stage CAIS approach.

inv-21: Collagen Meniscus Implants (CMI)

CompositionImplantable porous meniscus scaffold composed of collagen fibers enriched with glycosaminoglycan.

Intended functionUsed as a template and scaffold to support generation of new meniscal-like tissue after meniscal loss.

SynonymAlso referred to as collagen scaffold or Menaflex in some contexts.

inv-22: Decellularized Osteochondral Allograft Plugs

Graft formCylinder-shaped plug of healthy cartilage tissue and subchondral bone taken from a non-weightbearing donor site.

Implantation methodMatched to the defect surface area and impacted into place to restore a smooth cartilage surface.

Example deviceListed generically as decellularized osteochondral allograft plugs (e.g., Chondrofix referenced).

inv-23: Minced Cartilage

Procedure summaryMinced pieces of cartilage are seeded over a scaffold to allow even distribution and chondrocyte expansion within the defect.

GoalProvide structural and mechanical protection while chondrocytes repopulate the lesion site.

Literature contextTechnique described in McCormick et al., 2008 as a minced cartilage approach.

inv-24: Reduced Allograft Discs

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

Intended adjunctOften used in conjunction with marrow stimulation to allow host mesenchymal stem cell infiltration from underlying bone marrow.

ExamplesExamples include Cartiform (Arthrex) and ProChondrix CR (Allosource).

inv-25: HCT/P

Regulatory categoryHuman cells, tissues, and cellular and tissue-based products (HCT/P) are regulated under FDA guidance; tissue establishments must register with the FDA and perform donor screening and testing.

FDA scopeFDA does not premarket-review minimally processed tissues transplanted for normal structural functions, but regulates tissue banking, good tissue practices, and infectious disease screening/testing.

Recordkeeping/requirementsTissue establishments must prepare written procedures to prevent communicable disease spread and maintain records per CBER guidance.