27428
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
15.19
Facility
$1040.44
Non-Facility
$1040.44
Documentation Required
- Documentation confirming normal knee alignment
- Refer to the applicable MAC LCD for required documentation when a MAC LCD applies (Humana applies the MAC's LCD to requests in the MAC jurisdiction).
- Refer to the CMS Medicare Coverage Database and CMS Online Manual System (IOMs) and Transmittals for the most current applicable NCD/LCD/LCA and documentation requirements.
- This policy chunk does not provide specific documentation requirements (e.g., operative notes, imaging, prior treatment records); obtain documentation requirements from the applicable MAC LCD or Humana policy sections not included in this chunk.
Key Coverage Criteria
- An example of an FDA-approved CMI is the Collagen Meniscus Implant XL.
- Reconstruction of knee ligaments using allograft tissue as an alternative to autograft.
- Related Medicare Advantage Medical/Pharmacy Coverage Policy: Bone Graft Substitutes (see related policy for possible relevant guidance)
- Reconstruction of the meniscus of the knee (meniscal transplantation) using allograft tissue.
- Use of allograft tissue procured from genetically unrelated cadaver donors, processed, stored and utilized according to FDA and AATB standards (implied required condition for use).
- Reconstruction with allograft tendons for the anterior cruciate ligament (ACL)
3 Active Policies
CARELON-joint-surgery-2024-11-17-updated-2025-01-01 — Joint Surgery
CARELON-level-of-care-for-surgical-procedures-2025-11-15 — Level of Care for Surgical Procedures
HUMANA-ALLOGRAFT-TRANSPLANTATION-OF-THE-KNEE-MA — Allograft Transplantation of the Knee - Medicare Advantage
Related Codes
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