28103
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
6.50
Facility
$361.73
Non-Facility
$361.73
Documentation Required
- Documentation that an adequate autologous graft is not available (e.g., prior autograft already used) when tendon allograft is being considered for ACL reconstruction (text: "Tendon allograft for reconstruction of the ACL should only be employed when an adequate autologous graft is not available").
- Pre-operative clinical and imaging evaluation documenting lesion characteristics (e.g., for osteochondral allograft: lesion size, depth, etiology such as OCD, osteonecrosis, or traumatic osteochondral fracture) — the document repeatedly describes use of radiographic, CT and MRI for pre-operative assessment (e.g., "Patients were evaluated clinically and radiographically, and by CT scan pre‑operatively").
- Record of prior treatments and prior surgeries (many studies report that most patients had prior surgery or failed prior bone marrow stimulation procedures).
Key Coverage Criteria
- Chronic instability of knee [including lateral, medial, anterior and posterior ligaments] (ICD-10: M23.50 - M23.52) - covered if selection criteria are met
- Patellar tendinitis (ICD-10: M76.50 - M76.52) - covered if selection criteria are met
- Allograft transplant of the knee (knee ligaments, osteochondral, and meniscus) medically necessary when selection criteria are met.
- Semitendinosus allograft of ankle (CPT codes covered if selection criteria are met: 27695, 27696, 27698)
- Allografts of the knee ligaments (Anterior Cruciate Ligament (ACL), Posterior Cruciate Ligament (PCL), Medial Collateral Ligament (MCL), Lateral Collateral Ligament (LCL), and Medial Patello-Femoral Ligament (MPFL)) are medically necessary as an alternative to autografts for knee ligament reconstruction.
- Osteochondral (Femoral Articulation Only) — member has one of the following conditions: avascular necrosis lesions of the femoral condyle; or osteochondral dissecans lesions of the distal femur; or otherwise healthy, active, non-elderly members with osteochondral dissecans lesions of the distal femur who have either failed earlier arthroscopic procedures or are not candidates for such procedures because of the size, shape, or location of the lesion; AND the lesion on the distal femur meets all o [...]
1 Active Policy
AETNA-CPB-0364 — Allograft Transplants of the Extremities
Related Codes
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