G0428 — Collagen meniscus implant procedure for filling meniscal defects (e.g., cmi, collagen scaffold, menaflex)
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
- 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)
- None specified in this Clinical Policy Bulletin.
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)
12 Active Policies
HUMANA-ALLOGRAFT-TRANSPLANTATION-OF-THE-KNEE-MA — Allograft Transplantation of the Knee - Medicare Advantage
AETNA-CPB-0244 — Skin and Soft Tissue Substitutes
AETNA-CPB-0786 — Menaflex
CARELON-joint-surgery-2024-11-17-updated-2025-01-01 — Joint Surgery
UHC-POL-surgery-knee
Related Codes
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