27414
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- No specific documentation requirements are specified in this document.
- Medical records and documentation demonstrating that the service is reasonable and necessary in accordance with Medicare requirements (specific documentation elements are referenced but not listed in this excerpt).
- Documentation that the (unspecified) ACT/ACI requirements have been met (the policy states requirements must be met but does not include them in this text).
- No documentation requirements are specified in this excerpt.
Key Coverage Criteria
- Surgical treatment of osteochondral and subchondral defects of the shoulder — CPT 23929 (Unlisted procedure, shoulder).
- Osteochondral defect (damage to articular cartilage and underlying subchondral bone)
- Often used in conjunction with marrow stimulation (eg, microfracture) purportedly allowing the host mesenchymal stem cells to infiltrate the graft from the underlying bone marrow after stimulation to promote chondrogenesis or cartilage formation (inferred clinical scenario: use with marrow stimulation/microfracture to treat focal chondral/osteochondral lesions).
- Hybrid ACI performed in combination with an OATS (hybrid ACI/OATS) provides an osteochondral core to immediately restore the condylar contour and mechanical function, while implanted chondrocytes have time to mature over several years.
- ACI is an established procedure for treating large defects.
- Osteochondral defects associated with osteoarthritis
1 Active Policy
HUMANA-OSTEOCHONDRAL-AND-SUBCHONDRAL-DEFECTS-SURGERY-MA — Osteochondral and Subchondral Defects Surgery - Medicare Advantage
Related Codes
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