Z87.892 — Personal history of anaphylaxis
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Informed consent with realistic expectations documented in the medical record.
- When applicable, documentation of prior surgeries (e.g., prior marrow stimulation techniques) and their timing, and rationale if ACI is being considered after prior treatments.
- Past surgical history: documentation of prior cartilage procedures (e.g., microfracture, marrow-stimulation, osteochondral grafting) because prior procedures affect outcomes and may influence appropriateness (studies stratify and report prior surgeries).
- For deep osteochondral lesions or procedures combining bone grafting, documentation of defect depth (>8–10 mm) and rationale for bone graft/combined technique (e.g., 'sandwich' technique).
Key Coverage Criteria
- Aetna considers autologous chondrocyte implants medically necessary for repairing cartilage defects of the knee in members who have symptoms of disabling knee pain related to a full thickness, focal chondral defect with all of the following:
- Age 15 years or older with documented growth plate closure, or adults less than 55 years of age;
- Body mass index (BMI) less than or equal to 35 (see Appendix);
- Cooperative person for post-operative weight bearing restrictions and activity restrictions together with a potential for completion of post-operative rehabilitation;
- Failure of conservative therapy (minimum of 2 months of physical therapy);
- Focal articular cartilage defect down to but not through the subchondral bone on a load bearing surface of the femoral condyle (medial, lateral, trochlear) or the patella) (i.e., grade IV chondral defect);
1 Active Policy
AETNA-CPB-0247 — Autologous Chondrocyte Implantation
Related Codes
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