Fresh osteochondral allografting may be considered medically necessary as a technique to repair:
Full-thickness chondral defects of the knee caused by acute or repetitive trauma when other cartilage repair techniques (eg, microfracture, osteochondral autografting or autologous chondrocyte implantation) would be inadequate due to lesion size, location, or depth.
Large (area >1.5 cm2) or cystic (volume >3.0 cm3) osteochondral lesions of the talus when autografting would be inadequate due to lesion size, depth, or location.
Revision surgery after failed prior marrow stimulation for large (area >1.5 cm2) or cystic (volume >3.0 cm3) osteochondral lesions of the talus when autografting would be inadequate due to lesion size, depth or location.
Osteochondral allografting for all other joints is considered investigational.
Osteochondral autografting, using 1 or more cores of osteochondral tissue, may be considered medically necessary:
For the treatment of symptomatic full-thickness cartilage defects of the knee caused by acute or repetitive trauma in patients who have had an inadequate response to a prior surgical procedure, when all of the following have been met:
Adolescent patients should be skeletally mature with documented closure of growth plates (eg, ≥15 years). Adult patients should be too young to be considered an appropriate candidate for total knee arthroplasty or other reconstructive knee surgery (eg, ≤55 years)
Focal, full-thickness (grade III or IV) unipolar lesions on the weight-bearing surface of the femoral condyles, trochlea, or patella that are between 1 and 2.5 cm2 in size
Documented minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge grade II or less), and normal-appearing hyaline cartilage surrounding the border of the defect
Normal knee biomechanics or alignment and stability achieved concurrently with osteochondral grafting.
Large (area >1.5 cm2) or cystic (volume >3.0 cm3) osteochondral lesions of the talus.
Revision surgery after failed marrow stimulation for osteochondral lesion of the talus.
Osteochondral autografting for all other joints and any indications other than those listed above is considered investigational.
Treatment of focal articular cartilage lesions with autologous minced or particulated cartilage is considered investigational.
Treatment of focal articular cartilage lesions with allogeneic minced or particulated cartilage is considered investigational.
Treatment of focal articular cartilage lesions with decellularized osteochondral allograft plugs (eg, Chondrofix) is considered investigational.
Treatment of focal articular cartilage lesions with reduced osteochondral allograft discs (eg, ProChondrix, Cartiform) is considered investigational.
