C1763, Connective tissue, non-human (includes synthetic)
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Documentation Required
- Functional outcome measures: pre- and post-operative scores such as Modified Harris Hip Score (MHHS) and Visual Analog Scale (VAS) (used to document clinical improvement in studies).
- Detailed documentation of BMAC/BMDCT procedures: harvest technique, preparation method, cellular characterization/quality of the BMAC (authors note inconsistent reporting and recommend following consensus guidelines).
- Procedure-specific details for adjuvants: if intraosseous ibandronate used, document technique, dose/administration and safety monitoring (Kumar et al. 2021 reported technique and safety in their small series).
- Imaging documentation of baseline and follow-up radiographic progression (to support assessment of progression-free survival and collapse).
Key Coverage Criteria
- “When bilateral core decompression is indicated, it can be done simultaneously on both hips...”
- Aetna considers core decompression medically necessary for the treatment of early/pre-collapse (stage I or II; before X-ray changes are evident) avascular necrosis of the hip (femoral head and/or neck).
- HCPCS code S2325 (Hip core decompression) — covered if selection criteria are met.
- Core decompression (CD) for management of pre-collapse stage of ONFH.
- Adjunctive approaches for early (pre-collapse) femoral head osteonecrosis that are repeatedly discussed as treatment options (with varying evidence): "core decompression combined with bone grafting", "core decompression and implantation of autologous BMMC/BMSCs/bone marrow cells", "core decompression combined with PRP/PRF/platelet concentrates", "core decompression with synthetic bone graft substitute (calcium sulfate and calcium phosphate)", "core decompression combined with bone morphogenetic [...]
- Pre-collapse stage of osteonecrosis of the femoral head (ONFH)
3 Active Policies
CIGNA-0178, Breast Reconstruction Following Mastectomy or Lumpectomy
CIGNA-0068, Tissue Engineered Skin Substitutes
AETNA-CPB-0753, Core Decompression for Avascular Necrosis
Related Codes
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