29868
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
24.47
Facility
$1512.39
Non-Facility
$1512.39
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; refer to the protocol titled Medical Records Documentation Used for Reviews
- Updated imaging documentation requirement: "complete diagnostic interpretation of imaging findings including, at a minimum: relevant clinical information, detailed report of imaging findings, impression, and specialty(ies) of the provider(s) who interpreted the images"
- Medical Records Documentation Used for Reviews (general): medical records documentation used for reviews to determine whether member meets clinical criteria (note: documentation does not guarantee coverage)
- 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").
Key Coverage Criteria
- Surgery of the knee is proven and medically necessary in certain circumstances (see InterQual® CP: Procedures).
- Refer to InterQual® CP: Arthroscopy or Arthroscopically Assisted Surgery, Knee
- Refer to InterQual® CP: Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric)
- Refer to InterQual® CP: Arthroscopy, Diagnostic, +/- Synovial Biopsy, Knee
- Refer to InterQual® CP: Arthrotomy, Knee
- Refer to InterQual® CP: Arthrotomy, Knee (Pediatric)
13 Active Policies
AETNA-CPB-0247 — Autologous Chondrocyte Implantation
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
UHC-POL-surgery-knee — Surgery of the Knee
UMR-POL-UMR-surgery-knee — Surgery of the Knee
Related Codes
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