CurrentWellCarePolicy CP.MP.26

Clinical Policy: Articular Cartilage Defect Repairs

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Medical necessity criteria and coding guidance for autologous chondrocyte implantation, osteochondral allograft/autograft transplantation, and meniscal allograft transplant of the knee for members/enrollees of WellCare (Centene-affiliated) health plans.

Policy Summary

PayerWellCare

PolicyClinical Policy: Articular Cartilage Defect Repairs

Policy CodePolicy CP.MP.26

Change TypeNo material clinical or coverage changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document age, BMI, lesion size/location, prior conservative therapy and imaging to demonstrate criteria are met before performing cartilage repair procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3procedure types

<=55 yrsmax age

<35BMI threshold

>2 cm2lesion size rule

30+

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CurrentWellCarePolicy CP.MP.26

Clinical Policy: Articular Cartilage Defect Repairs

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Policy Summary

PayerWellCare

PolicyClinical Policy: Articular Cartilage Defect Repairs

Policy CodePolicy CP.MP.26

Change TypeNo material clinical or coverage changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document age, BMI, lesion size/location, prior conservative therapy and imaging to demonstrate criteria are met before performing cartilage repair procedures.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3procedure types

<=55 yrsmax age

<35BMI threshold

>2 cm2lesion size rule

30+

Nationalapplicability

Coverage Criteria

Autologous chondrocyte implantation (ACI) - Medically Necessary

Covered when ALL of the following are met:

ACI criteria: A. Age 18 through 55 years, or documented skeletal maturity if < 18; B. BMI < 35 kg/m2; C. Focal, full-thickness (grade III or IV) articular cartilage defect involving the femoral condyle (medial, lateral, or trochlear); D. Femoral condyle defect size 1 through 10 cm2; E. Disabling symptoms such as locking, swelling, or knee pain that are unresponsive to conservative treatment for a minimum of two months (e.g., medication, physical therapy); F. Previous unsuccessful arthroscopic or surgical revision/repair procedure; G. Knee is stable with intact menisci and ligaments, has normal joint space by X-ray, and is in good alignment (a corrective procedure to stabilize the knee may be performed in combination with or prior to ACI); H. Surgery is not intended to treat osteoarthritis of the knee; I. No previous surgery to repair articular cartilage defects with cartilage transfer; J. Member/enrollee is willing and able to comply with prescribed postoperative rehabilitative program;

Exact criteria must all be met as listed.

Osteochondral allograft (OCA) or osteochondral autograft (OATS/mosaicplasty) - Medically Necessary

Covered when ALL of the following are met:

OCA/OATS criteria part 1: A. Age 18 through 55 years, or documented skeletal maturity if < 18; B. BMI <35 kg/m2; C. Focal, full-thickness (grade III or IV) articular cartilage defect of the lateral or medial femoral condyle, or trochlear region of the knee;

These baseline criteria apply to both autograft and allograft.

Lesion size rule: For osteochondral autograft transplant (e.g., OATS/mosaicplasty), lesion is <= 2 cm2; OR for osteochondral allograft (OCA) transplant, unipolar lesion that is > 2 cm2.

Size determines autograft versus allograft approach.

Additional imaging and clinical features: Disabling symptoms unresponsive to conservative treatment for a minimum of two months; No evidence of arthritis on the corresponding tibial surface; Normal appearing hyaline cartilage surrounding the border of the defect with absent or minimal changes in surrounding articular cartilage; Normal knee alignment; Not currently a candidate for total or partial knee replacement.

All listed conditions must be met for coverage.

Meniscal allograft transplant - Medically Necessary

Covered when ALL of the following are met:

Meniscal allograft criteria: A. Physically active and physiologically young, under age 55; B. Documented mild to moderate articular damage (Outerbridge grade II or less); C. Missing > 50% of a meniscus as a result of previous surgery or injury, or a meniscus tear that cannot be repaired; D. Disabling knee pain refractory to conservative treatment (e.g., medication, physical therapy); E. Normal alignment without varus or valgus deformities; F. None of the following contraindications: 1. Systemic metabolic degenerative disease (eg, gout); 2. BMI > 35 kg/m2; 3. Arthritis of the knees or rheumatoid arthritis; 4. Flattening of the femoral condyles or severe degenerative changes (>50% joint space narrowing, bone on bone, or erosion to subchondral bone); 5. Has undergone partial or total meniscectomy and does not presently have symptoms or problems with their knee.

All criteria and absence of listed contraindications are required.

Unproven/Not supported indications

Minced articular cartilage repair: Current evidence does not support the use of minced articular cartilage repair (allograft or autograft).

Document states this is not supported by current evidence.

Other joints or indications: Current evidence does not support use of ACI, osteochondral allograft transplant, or osteochondral autograft transplant for any other indication, or any other joint surface not listed in the policy.

Coverage limited to knee locations specified.

The available evidence does not support the use of minced articular cartilage repair—whether performed with allograft or autograft tissue—for treatment of articular cartilage defects. This technique is listed in the policy exclusions as not supported by current evidence and therefore is not covered.

Autologous chondrocyte implantation (ACI), osteochondral allograft (OCA), and osteochondral autograft transplantation are limited to the specific knee locations and indications described in this policy. Use of these procedures for any other joint or indication (i.e., outside the knee femoral condyles or trochlea as specified) is not supported by current evidence and is excluded from coverage.

When there is a conflict between this clinical policy and applicable state Medicaid coverage provisions, the state Medicaid provisions take precedence. Providers should ensure decisions and claims also comply with the member’s contract and any applicable state or federal requirements.

Procedures that the policy explicitly states are not supported by current evidence (see exclusions, including minced articular cartilage repair and use of ACI/OCA/autograft for non‑listed joints/indications) are considered not medically necessary under this policy.

Coding and Key Clinical Thresholds

Procedure CPT codes referencedCPT

27407	Repair, primary, torn ligament and or capsule of knee; cruciate.
27412	Autologous chondrocyte implantation, knee.
27415	Osteochondral allograft, knee, open.
27416	Osteochondral autograft(s), knee, open (e.g., mosaicplasty) (includes harvesting of autograft[s]).
28446	Open osteochondral autograft, talus (includes obtaining graft[s]).
29866	Arthroscopy, knee, surgical; osteochondral autograft(s) (e.g. mosaicplasty) (includes harvesting of the autograft[s]).
29867	Arthroscopy, knee, surgical; osteochondral allograft (e.g., mosaicplasty).
29868	Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion), medial or lateral.

HCPCS codes referencedHCPCS

J7330	Autologous cultured chondrocytes, implant.
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)

Lesion size — procedure selection

Autologous chondrocyte implantation (ACI)Lesion size 1–10 cm2 (femoral condyle full‑thickness defects)

Osteochondral autograft (OATS/mosaicplasty)Lesion size ≤ 2 cm2

Osteochondral allograft (OCA)Unipolar lesion > 2 cm2

Age

Age range (standard)18 through 55 years

Younger patientsIf under 18, documented skeletal maturity is required

Meniscal allograft note

Provider Actions, Prior Authorization & Documentation

Prior Authorization

Obtain prior authorization for listed cartilage repair CPT/HCPCS codes

Prior authorization is expected for procedures and implants/products listed in the policy (CPT: 27412, 27415, 27416, 29866, 29867, 29868, 28446; HCPCS: J7330, S2112). Obtain authorization prior to performing these services and include documentation that demonstrates all applicable medical necessity criteria are met.

Include procedure CPT/HCPCS code(s) on the request
Ensure authorization request references the specific cartilage repair procedure and any implant (e.g., J7330)

Prior Authorization

Secure prior authorization when required by the member's plan

This clinical policy is a medical necessity guide to assist coverage decisions and benefits administration; providers must obtain prior authorization when required by the member's benefit plan and follow plan-level administrative policies and procedures.

Verify whether the member's benefit plan requires prior authorization before scheduling the procedure

Background

Articular cartilage is a layer of hyaline cartilage with limited intrinsic healing capacity. Focal, full‑thickness defects (Outerbridge grade III–IV) commonly result from trauma and can produce persistent symptoms such as pain, swelling, mechanical locking, and functional impairment. Repair and restoration options discussed in this policy—including autologous chondrocyte implantation (ACI), osteochondral allograft transplantation for larger defects, and osteochondral autograft (mosaicplasty/OATS) for smaller defects—are intended to address symptomatic, focal full‑thickness cartilage loss in select patients; meniscal allograft transplantation is discussed where meniscal deficiency contributes to cartilage damage.

Definitions

Autologous chondrocyte implantation (ACI) — overview

DefinitionAutologous chondrocyte implantation (ACI) is a two‑stage procedure in which healthy cartilage cells are harvested, cultured, and later reimplanted into the defect under a membranous patch.

IndicationUsed for focal, full‑thickness (grade III/IV) articular cartilage defects of the femoral condyle (1–10 cm2) when conservative therapy has failed.

Procedure overviewFirst stage: arthroscopic harvest of cartilage for cell culture; second stage: implantation of cultured chondrocytes into the defect covered by a membrane patch, with postoperative rehabilitation required.

Osteochondral allograft (OCA)

DefinitionOsteochondral allograft (OCA) transplant is the transfer of cadaveric viable articular cartilage with underlying subchondral bone to cover large (> 2 cm2), full‑thickness cartilage defects of the knee.

Policy Summary

PayerWellCare

PolicyClinical Policy: Articular Cartilage Defect Repairs

Policy CodePolicy CP.MP.26

Change TypeNo material clinical or coverage changes

Effective Date

Next Review Date

Key ActionObtain prior authorization and document age, BMI, lesion size/location, prior conservative therapy and imaging to demonstrate criteria are met before performing cartilage repair procedures.

SourceLink

On This Page

Meniscal allograft candidates generally should be physiologically young and under age 55

Body mass index (BMI)

BMI threshold (all procedures)BMI < 35 kg/m2

Contraindication for meniscal allograftBMI > 35 kg/m2 listed as a contraindication

Documentation requirementBMI should be documented in supporting records

Follow the Health Plan's administrative policies and procedures for submitting requests

Step Therapy

Confirm and document minimum two months of conservative therapy

Document at least two months of conservative therapy (examples provided in the policy) showing symptoms were unresponsive prior to requesting certain operative cartilage repair procedures.

Conservative measures include medication, physical therapy, weight reduction, braces/orthotics, and intra‑articular injections
Record start and end dates and the patient's clinical response over a minimum two‑month period

Note

Align requests with policy criteria and plan rules

Ensure all authorization and medical records demonstrate that the request aligns with the policy's coverage criteria and with applicable plan rules.

State clearly which policy criteria are met (e.g., age, BMI, lesion size/location, prior conservative therapy) in the request
If policy criteria are not met, indicate rationale and any mitigating clinical factors

Documentation Required

Include required supporting clinical and imaging documentation

Provide complete supporting documentation with the authorization request, including: age or documented skeletal maturity, BMI, lesion grade and exact anatomic location, precise lesion size (cm2), documentation of prior conservative therapies and duration, prior related surgical history, knee stability/meniscal status, imaging (X‑ray/MRI) showing joint space and alignment, and patient willingness/ability to comply with postoperative rehabilitation.

Include imaging reports that show lesion size and surrounding cartilage appearance
Document prior failed arthroscopic/surgical procedures and conservative treatment dates

Documentation Required

Confirm coverage alignment with member contract and applicable state/Medicare rules

Before performing or billing services, confirm the requested services and claims conform to the member's contract, applicable state Medicaid provisions (which take precedence if conflicting), and Medicare NCDs/LCDs for Medicare members.

Verify state Medicaid manual when applicable and adjust requests to state requirements
Review NCDs/LCDs for Medicare members and the member's coverage documents prior to submission

Denial Risk

Risk of denial if ACI criteria are not fully met

Requests for autologous chondrocyte implantation (ACI) that do not meet all listed ACI criteria (for example: age 18–55 or documented skeletal maturity, BMI <35 kg/m2, focal full‑thickness femoral condyle defect 1–10 cm2, and prior unsuccessful conservative/surgical therapy) may be denied.

If any ACI criteria are unmet, document clinical justification and consider alternative covered options
Explicitly document lesion size, grade, prior conservative therapy, and prior surgical history in the authorization request

Denial Risk

Risk of denial for OCA/OATS/meniscal allograft when criteria unmet

Osteochondral autograft/allograft (OATS/OCA) or meniscal allograft requests may be denied if documentation does not satisfy lesion size/location, absence of arthritis, correct alignment, or BMI limits (e.g., autograft ≤2 cm2; allograft >2 cm2; BMI <35 kg/m2).

Document lesion size precisely to support autograft versus allograft approach
Provide imaging and clinical evidence of no tibial articular surface arthritis and normal knee alignment

Note

Coverage decisions subject to member contract and state/federal rules

Coverage decisions are governed by the member's coverage documents and applicable legal/regulatory requirements; when state Medicaid provisions conflict with this policy, the state manual takes precedence.

Coverage is subject to evidence of coverage, certificate of coverage, policy, or contract terms and plan‑level administrative procedures
Check for and follow state Medicaid provisions and Medicare NCDs/LCDs as applicable

Lesion size guidance

Indicated for unipolar lesions > 2 cm2 (per policy criteria).

Clinical contextUsed when lesion size or location makes autograft or other procedures unsuitable; requires normal tibial surface and appropriate alignment for success.

Osteochondral autograft (OATS / mosaicplasty)

DefinitionOsteochondral autograft (OATS/mosaicplasty) involves harvesting small osteochondral cylinders from low weight‑bearing areas of the patient’s joint and transplanting them into the defect to create a mosaic of hyaline cartilage islands.

Lesion size guidanceTypically indicated for lesions ≤ 2 cm2 (per policy criteria).

Procedure noteCan be performed arthroscopically or via open techniques and includes harvesting of autograft(s).

Meniscal allograft transplant

DefinitionMeniscal allograft transplantation is a surgical procedure that grafts a donor meniscus into the recipient knee to restore the meniscal cushion and relieve knee pain.

IndicationsConsidered when > 50% of a meniscus is missing or the tear is irreparable, in physically active, physiologically young patients (typically under 55) with normal alignment and mild to moderate articular damage.

ContraindicationsContraindications include systemic metabolic degenerative disease (eg, gout), BMI > 35 kg/m2, arthritis of the knees or rheumatoid arthritis, or severe degenerative changes of the femoral condyles.

Referenced procedures and topics

Procedures referencedAutologous chondrocyte implantation (ACI/MACI)

Related cartilage repair techniquesMosaicplasty / OATS and microfracture (comparative context and guidance cited)

Broader topicsOsteochondral allograft transplantation and general cartilage restoration approaches (supported by cited guidelines and systematic reviews).