C1734 — Orthopedic/device/drug matrix for opposing bone-to-bone or soft tissue-to bone (implantable)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
No active coverage policies found for this code (low confidence)
Documentation Required
- Review the member's benefit contract or Summary Plan Description (SPD) to determine defined coverage, exclusions, and benefit limitations.
- Use the written Medical Policy coverage position (not the coding tables) when making benefit coverage determinations.
Key Coverage Criteria
- Treatment of medial compartment knee osteoarthritis to reduce loads on the intraarticular medial joint surface and improve symptoms.
- Use in patients who have failed prior surgical or non-surgical treatment modalities for knee osteoarthritis (per FDA authorization).
- Implantation of a shock/load absorber for mild-to-moderate symptomatic medial knee osteoarthritis only when performed within a research context or clinical trial comparing it to existing management.
- Treatment of osteoarthritis of the knee using a medial knee implantable shock absorber device.
6 Active Policies
ANTHEM-SURG.00162 — SURG.00162 Implantable Shock Absorber for Treatment of Knee Osteoarthritis
BCBSIL-SUR705.051 — Use of a Medial Knee Implantable Shock Absorber
BCBSMT-SUR705.051 — Use of a Medial Knee Implantable Shock Absorber
BCBSNM-SUR705.051 — Use of a Medial Knee Implantable Shock Absorber
BCBSOK-SUR705.051 — Use of a Medial Knee Implantable Shock Absorber
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