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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 will be used to determine your coverage.

Administrative Process

Does not require prior authorization.

Coverage

Autologous chondrocyte implantation (ACI) is covered as per the indications listed below.

Indications that are covered

  1. The member meets the inclusion criteria as follows:
    1. An isolated focal articular cartilage defect (grade III or IV chondromalacia) localized to the femoral condyles
    2. No evidence of arthritis on the articular surface of the corresponding tibia
    3. No evidence of malalignment (genu varus or valgus)
    4. Normal ligamentous stability (no evidence of MCL, ACL, PCL, or posterolateral corner injuries and resulting instability)
    5. Appropriate inclusion ages (15 to 45)
    6. Demonstration of ability to comply with protocol by patient (non-weight bearing for eight weeks, use of CPM machine for 8 weeks, 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

29999

Unlisted procedure, arthroscopy

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. Hayes, Inc. Hayes Medical Technology Directory Report. Autologous Chondrocyte Implantation of the Knee. Lansdale, PA: Hayes, Inc.; July, 2013. Reviewed July, 2016.
  2. 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 July 25, 2017.)

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Policy activity

  • 07/07/1997 - Date of origin
  • 10/01/2017 - Effective date
Review date
  • 08/2017
Revision date
  • 09/27/2017

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