1)
All cartilage transplant procedures require preauthorization.
2)
QualChoice considers allograft transplant of the knee (anterior
cruciate ligament, osteochondral and meniscus) medically necessary when the
following criteria are met:
a)
Anterior
Cruciate Ligament (ACL):
i)
Members with
ACL deficiency who are not candidates for autogenous transplantation (e.g.,
individuals whose autogenous tissues have been compromised by previous surgery,
previous injury), or
ii)
Members with
pathology such as chronic patellar tendonitis, and hamstring injury,
or
iii)
Members with
any other contra-indications to using their own tissue such as collagen disease
or generalized ligamentous laxity.
b)
Osteochondral:
i)
Treatment of
an isolated, traumatic injury that is full-thickness depth (grade 4, down to
and/or including the bone) lesion, preferably surrounded by normal, healthy
(non-arthritic) cartilage. The opposing articular surface should be generally
free of disease or injury; or
ii)
Non-repairable stage 3 or 4 osteochondritis dissecans; or
iii)
Avascular
necrosis lesions of the femoral condyle; or
iv)
Otherwise
healthy, active members who have either failed earlier arthroscopic procedures
or are not candidates for such procedures because of the size, shape, or
location of the lesion.
c)
Meniscus:
i)
Members under
the age of 45, and
ii)
Pre-operative
studies (MRI or previous arthroscopy) reveal absence or near-absence of the
meniscus, and
iii)
Degenerative
changes must be absent or minimal, and
iv)
Knee must be stable (i.e., intact or reconstructed ACL).
3)
QualChoice considers autologous osteochondral Mosaicplasty
(cartilage transfer from a non-weight bearing area) of the knee to be medically
necessary for members who have a full thickness cartilage defect of a weight
bearing area who meet all of the following criteria:
a)
Skeletally
mature (age>15) and under the age of 50, AND
b)
Minimal
underlying degenerative changes, AND
c)
BMI ≤30, AND
d)
The defect
causes symptoms that significantly interfere with the member’s activities of
daily living, AND
e)
EITHER
i)
Focal
chondral defect between 1.0 and 3.0 sq. cm. in size OR
ii)
Osteochondritis dissecans defect between 1.0 and 5.0 sq. cm. in
size
4)
QualChoice considers autologous chondrocyte implantation (e.g.,
Carticel®, MACI®) of the knee to be medically necessary for members who have a
single or (for MACI) multiple full thickness cartilage defect of the weight
bearing surface of the femoral condyle, patella or trochlea, caused by acute or
repetitive trauma who meet all the following criteria:
a)
Skeletally
mature (age>15) under the age of 55, AND
b)
Minimal
underlying degenerative changes, AND
c)
A stable knee
with intact or reconstructed ligaments (ACL or PCL)
d)
Normal joint
alignment OR plans for ensuring normal joint alignment through concurrent
procedures such as tibial tubercle osteotomy.
e)
Normal joint
space
f)
Absence of
osteoarthritis or generalized tibial chondromalacia
g)
Normal
articular cartilage at the lesion border (contained lesion)
h)
The defect
causes symptoms that significantly interfere with the member’s activities of
daily living, AND
i)
The defect is
at least 1.5 to 10 sq. cm. in size, AND
j)
Failure of
non-surgical management for at least three (3) months in duration
k)
Previous surgical repair has failed
l)
BMI is less than 35
m)
Appropriate
glycemic control with Hba1c of 8mg/dl or less, in members with diabetes.
n)
Individual must be capable and willing to participate in a
supervised post-operative physical rehabilitation program.
Codes
Used In This BI:
J7330 Autologous cultured chondrocytes, implant
S2112 Arthroscopy,
knee, surgical, for harvesting of cartilage (chondrocytes)
27412 Autologous
Chondrocyte Implantation, knee
27415 Ostrochondral
Allograft, knee, open;
27416 Ostrochondral
Auto graft, knee, open; (e.g., Mosaicplasty)
29866 Arthroscopy, Knee, Surgical; Osteochondral auto graft(s)
29867 Arthroscopy, knee, surgical; Osteochondral allograft;
29868 Arthroscopy, knee, surgical; meniscal transplantation, medial or
lateral