S2112, Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high 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.
- Documentation of skeletal maturity / documented closure of growth plates (e.g., radiographic evidence or age documentation).
- Clinical baseline and follow-up outcome measures (as used in studies): KOOS, IKDC subjective score, VR-12, Tegner activity scale, pain VAS, FAAM, AOFAS scores where applicable to document functional change over time.
- Postoperative imaging follow-up (MRI or second-look arthroscopy) to assess graft incorporation, defect fill, and repair tissue characteristics (e.g., MOCART score, OCAMRISS where applicable).
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 [...]
- The member is skeletally mature with documented closure of growth plates (e.g., 15 years or older).
- Osteochondral autografts (OATS or mosaicplasty) are considered medically necessary for symptomatic focal full-thickness articular cartilage defects of the knee when ALL of the following criteria are met:
- The member has disabling symptoms limiting ambulation that have not been relieved by appropriate non-surgical therapies (e.g., medication, physical therapy).
- The member is not considered a candidate for total knee replacement (i.e., member is under 55 years of age).
- The member has focal, full thickness (Outerbridge grade III or IV) unipolar lesions on the weight bearing surface of the femoral condyles or trochlea.
11 Active Policies
UHC-POL-surgery-knee, Surgery of the Knee
AETNA-CPB-0637, Osteochondral Autografts (Mosaicplasty, OATS)
BCBSIL-SUR705.035, Autologous Chondrocyte Implantation (ACI) for Focal Articular Cartilage Lesions
BCBSMT-SUR705.035, Autologous Chondrocyte Implantation (ACI) for Focal Articular Cartilage Lesions
BCBSNM-SUR705.035, Autologous Chondrocyte Implantation (ACI) for Focal Articular Cartilage Lesions
Related Codes
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