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Coverage criteria policies

Autologous chondrocyte implantation (ACI)

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for autologous chondrocyte implantation (ACI) (27412), and for the autologous cultured chondrocytes implant (J7330).

Coverage

Autologous chondrocyte implantation (ACI) is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

  1. Autologous chondrocyte implant and implantation is covered when all of the following criteria are met:
    1. Member has an isolated focal articular cartilage defect (grade III or IV chondromalacia) localized to the femoral condyles (medial, lateral, or trochlear) or the patella; and
    2. No evidence of arthritis on the articular surface of the corresponding tibia; and
    3. No evidence of malalignment (genu varus or valgus); and
    4. Normal ligamentous stability (no evidence of medial collateral ligament (MCL), anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), or posterolateral corner injuries and resulting instability); and
    5. Is age 15 to 55; and
    6. Has demonstrated ability to comply with protocol (non-weight bearing for eight weeks, use of CPM machine for 8 weeks, and ability to cooperate during the 8 to16 week period where a formal exercise program is necessary).

Indications that are not covered

  1. ACI for any indications other than those listed above is considered investigational and not covered because the reliable evidence does not permit conclusions concerning safety, effectiveness, or effect on health outcomes.

Definitions

Autologous chondrocyte implantation (ACI) is a procedure which uses a person's own cartilage cells to repair a defect or tear to the articular cartilage of the knee. The cartilage cells are removed from the body, grown in the manufacturer's lab, and implanted into the affected knee. The goal is that the implanted cartilage will be similar to the knee's normal hyaline cartilage, which has the durability to withstand the wear and tear of the knee movement.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

CPT Code

Description

27412

Autologous chondrocyte implantation, knee

HCPC Code

Description

J7330

Autologous cultured chondrocytes, implant

S2112

Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. American Academy of Orthopedic Surgeons. (2010). The diagnosis and treatment of osteochondritis dissecans: Guideline and evidence report. Retrieved from https://www.aaos.org/CustomTemplates/Content.aspx?id=22821&ssopc=1
  2. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. (2000). Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis & Rheumatism, 43(9), 1905–1915.
  3. Brittberg, M., Recker, D., Ilgenfritz, J., & Saris, D. B. F. on behalf of the SUMMIT Extension Study Group. (2018). Matrix-applied characterized autologous cultured chondrocytes versus microfracture: Five-year follow-up of a prospective randomized trial. The American Journal of Sports Medicine, 46(6), 1343–1351.
  4. ECRI Institute. (2013). Carticel Autologous Cultured Chondrocytes (Genzyme Biosurgery Corp.) for Repairing Articular Cartilage Knee Injuries. Plymouth Meeting, PA: ECRI Institute.
  5. Hayes, Inc. Hayes Medical Technology Directory Report. Comparative Effectiveness Review of First-Generation Autologous Chondrocyte Implantation of the Knee. Lansdale, PA: Hayes, Inc.; July, 2017. Reviewed July, 2018.
  6. Hayes, Inc. Hayes Medical Technology Directory Report. Comparative Effectiveness Review of Second- and Third-Generation Autologous Chondrocyte Implantation of the Knee. Lansdale, PA: Hayes, Inc.; July, 2017. Reviewed July, 2018.
  7. Mandl, L. A., & Martin, G. M. Overview of surgical therapy of knee and hip osteoarthritis. In: UpToDate, Tugwell, P. (Ed), UpToDate, Waltham, MA. (Accessed on August 3, 2018.)
  8. National Institute for Health and Care Excellence. (2017). Autologous chondrocyte implantation for treating symptomatic articular cartilage defects of the knee. NICE technology appraisal guidance (TA477).
  9. Riboh, J. C., Cvetanovich, G. L., Cole, B. J., & Yanke, A. B. (2017). Comparative efficacy of cartilage repair procedures in the knee: a network meta‑analysis. Knee Surgery, Sports Traumatology, Arthroscopy, 25(12), 3786–3799. doi: 10.1007/s00167-016-4300-1

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Policy activity

  • 07/07/1997 - Date of origin
  • 01/01/2019 - Effective date
Review date
  • 08/2018
Revision date
  • 08/14/2018

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