G0428, Collagen meniscus implant procedure for filling meniscal defects (e.g., cmi,
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- Documentation: Medical records may be required to determine if the member meets the clinical criteria for coverage for knee surgery.
- None specified in this Clinical Policy Bulletin.
- Product-specific application details: documentation of product lot, size, number of applications, fixation method (sutures, staples, adhesives), and whether single or multiple applications were performed (many devices are single-use and dosage is per cm2 or per mg for particulates).
- For use of biologic implants/allografts/xenografts: documentation of patient allergies or sensitivities (e.g., known porcine sensitivity excludes Mediskin), informed consent noting product source (human, porcine, bovine, ovine), and rationale for selection.
Key Coverage Criteria
- Covered when the patient meets the medical necessity clinical coverage criteria for knee arthroscopy or arthroscopically assisted surgery, knee diagnostic arthroscopy with or without synovial biopsy, knee arthrotomy, total knee replacement (TJR), unicondylar or patellofemoral knee replacement as outlined in InterQual CP: Procedures: Arthroscopy or Arthroscopically Assisted Surgery, Knee Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric) Arthroscopy, Diagnostic, +/- Synovial Biops [...]
- Aetna considers the Menaflex device (previously known as the Collagen Meniscal Implant and the Collagen Scaffold device) experimental and investigational for repair and reinforcement of the medial meniscus of the knee and all other indications because of insufficient evidence of its effectiveness.
- Use of acellular human dermal allograft in rhinoplasty
- Healing septal perforations using acellular dermis as bioscaffold
- Artiss is approved for attachment of skin grafts onto burn patients (clinical trial basis described).
- AlloSkin: As an allogeneic human, cadaver-derived skin graft for the management of traumatic skin wounds and burn wounds if the wound is too large for autograft. (Note: not AlloSkin AC or AlloSkin RT, which are different products).
13 Active Policies
HUMANA-ALLOGRAFT-TRANSPLANTATION-OF-THE-KNEE-MA, Allograft Transplantation of the Knee
UHC-POL-surgery-knee, Surgery of the Knee
AETNA-CPB-0786, Menaflex
AETNA-CPB-0244, Skin and Soft Tissue Substitutes
SUR705.034, Meniscal Allografts and Other Meniscal Implants
Related Codes
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