Document medical necessity for prior authorization

Prior authorization must document that the patient meets all medical necessity criteria: BMI < 35, age 49 years or younger, a stable knee with intact or reconstructed ligaments and menisci (concurrent ligament stabilization or meniscal procedure at the time of OATS is acceptable), normal tibiofemoral and/or patellofemoral alignment, function-limiting symptoms, and failure of provider-directed non-surgical management for at least three months.

Prior authorization: lesion documentation and timing

Include clinical documentation of lesion size and location, imaging or arthroscopy evidence of a full-thickness defect, prior treatments attempted, rationale for graft type, and timing for fresh allografts (fresh allografts require implantation within 72 hours of donor death).

• Lesion size and location
• Prior non-surgical treatments attempted and duration
• Rationale for autograft vs allograft choice
• Timing requirement for fresh allografts (implantation within 72 hours)

Verify product coverage and prior authorization

Verify member benefits and whether the product or product-specific service is covered under the applicable contract; if the commercial product covers the service, medical policy criteria apply and prior authorization requirements must be followed.

• Services are contract dependent; confirm coverage before submitting requests
• When covered by a commercial product, apply the medical policy criteria and obtain prior authorization as required

Require ≥3 months of failed non-surgical management

Provide documentation of failure of provider-directed non-surgical management for at least three (3) months prior to approval for OATS/mosaicplasty.

List prior conservative management tried

Document the specific non-surgical therapies tried (examples include supervised physical therapy/therapeutic exercise, activity modification/rest, intraarticular injections, weight loss, assistive devices, medications) as part of conservative care prior to surgery.

• Physical therapy and therapeutic exercises
• Activity modification/relative rest
• Intraarticular injections
• Weight loss and assistive devices
• Prescription or over-the-counter medications

Provide required imaging or arthroscopy evidence

Ensure imaging or arthroscopic documentation demonstrates a full-thickness distal femoral or patellar chondral defect using CT arthrogram, MRI with Modified Outerbridge Grade III or IV, or arthroscopy with Outerbridge Grade III or IV.

Document defect size and morphology per procedure

Document defect size and morphology with sharp, definite borders surrounded by normal-appearing hyaline cartilage; ensure defect size meets procedure-specific thresholds (autograft/mosaicplasty ≤ 2.5 cm2 total; allograft ≤ 10.0 cm2 total).

• Sharp, definite lesion borders with surrounding normal hyaline cartilage
• Autograft/mosaicplasty: defect ≤ 2.5 cm2 total
• Allograft: defect ≤ 10.0 cm2 total

Submit complete supporting clinical documentation

Include supporting clinical documentation in the prior authorization or claim: lesion size and location, graft source (autograft vs allograft), timing of fresh allograft harvest and implantation, prior non-surgical management, and any correction of malalignment or concurrent stabilization procedures.

• Lesion size and location
• Graft source (autograft or allograft)
• Timing of fresh allograft harvest/implantation
• Prior non-surgical management details
• Details of any alignment correction or concurrent stabilization/meniscal procedures

Use specified CPT and ICD-10 codes for authorization and billing

Use the specified CPT procedure codes and the listed ICD-10 diagnosis code ranges on authorizations and claims: CPT 27415, 27416, 29866, 29867 and the ICD-10 ranges such as M12.561–M12.569, M17.0–M17.9, M22.40–M22.42, and other chondral/knee condition codes provided in the policy.

• CPT: 27415, 27416, 29866, 29867
• ICD-10 code ranges: M12.561–M12.569; M17.0–M17.9; M22.40–M22.42; other listed ranges

Avoid investigational indications

Do not submit requests or expect coverage for procedures performed for indications other than full-thickness distal femoral or patellar chondral defects as specified in the policy; such uses are considered investigational and would be denied.

Hybrid ACI/OATS is investigational — risk of denial

Claims for hybrid autologous chondrocyte implantation performed with an osteochondral autograft transfer system (Hybrid ACI/OATS) may be denied because this technique is considered investigational under this policy.

Codes may not be covered in all circumstances

Be aware that listed procedure and diagnosis codes may not be covered under all circumstances; verify coverage and applicable code annotations prior to billing.