Articular Cartilage Defect Repairs - UHCprovider.com

UnitedHealthcare Commercial Medica l Policy Articular Cartilage Defect Repairs Policy Number: 2022T0030X. Effective Date: May 1, 2022 Instructions for Use Table of Contents Page Related Commercial Policy Coverage Rationale .. 1 Surgery of the knee Documentation 2. Outpatient Surgical Procedures Site of Service Definitions .. 3. Applicable Codes .. 4 Community Plan Policy Description of Services .. 5 Articular Cartilage Defect Repairs Clinical 6. Food and Drug 16. References .. 17. Policy History/Revision Information .. 19. Instructions for 19. Coverage Rationale ACT and Microfracture Autologous chondrocyte transplantation (ACT) is proven and medically necessary for treating individuals with symptomatic full-thickness Articular Cartilage defects when all of the following criteria are met: The lesion is: o Greater than or equal to 2 squared centimeters o A result of acute or repetitive trauma o Single or multiple full thickness (Outerbridge Classification of grade III or IV) Articular Cartilage Defect of the femoral condyle (medial, lateral or trochlea) and/or patella knee is stable with intact menisci and ligaments Normal joint space and alignment confirmed by X-ray No active inflammatory or other arthritis, clinically and by X-ray Failed non-surgical conservative management ( , physical therapy, braces, and/or nonsteroidal anti-inflammatory dru)

History of partial-thickness defects Osteochondritis dissecans (OCD) Malignancy in the bone, cart ilage, fat or muscle of the treated limb Active infection in the affected knee Instability of the knee History of total meniscectomy Repeat ACT Related Commercial Policy • Surgery of the Knee

Tags:

  Knee, Repair, Partial, Defects, Cartilage, Meniscectomy, Articular, Articular cartilage defect repairs

Information

Related search queries