Osteoarthritis of the Knee: Selected Treatments

Covered: arthroscopic debridement (± partial meniscectomy) only for mild-to-moderate knee OA (Outerbridge I–II) with knee pain plus mechanical symptoms from loose bodies and/or meniscal tears, arthroscopic partial meniscectomy for traumatic meniscal tears unless moderate/severe OA is present (Outerbridge III–IV), and intra‑articular glucocorticoid injections — listed CPT/ICD codes are covered when the policy’s selection criteria are met. Excluded/limited: extended‑release triamcinolone acetonide (Zilretta) is deemed not medically necessary, arthroscopic partial meniscectomy for degenerative meniscal tears is experimental/investigational, and a broad set of surgical, biologic and device treatments (e.g., stem‑cell/adipose therapies, bone marrow aspirate concentrate, genicular artery embolization, radiofrequency ablation, extracorporeal shock wave therapy, MISHA, sustained acoustic medicine) are considered experimental/investigational.

"Arthroscopic debridement (with or without partial meniscectomy) for persons presenting with mild-to-moderate (Outerbridge classification I and II, not III or IV) osteoarthritis (OA) with knee pain ..."