CMM-312: Knee Surgery-Arthroscopic and Open Procedures

This guideline limits coverage to arthroscopic/open knee procedures performed for fracture, tumor, infection, foreign body, or specific indications (e.g., diagnostic arthroscopy, debridement/loose body removal, synovectomy, meniscectomy/repair) only when strict, procedure‑specific criteria are met, and it expressly excludes many procedures as not medically necessary or experimental (examples: ACL/PCL/ALL reconstruction or repair, LEAT, in‑office arthroscopy, meniscal allograft, subchondroplasty, focal resurfacing, most OATS/ACI hybrids). Key requirements include corroborating imaging (plain radiographs with Kellgren‑Lawrence grading, MRI/CT arthrogram, orthogonal films when applicable), specific physical exam and mechanical findings, documented function‑limiting symptoms, failure of provider‑directed non‑surgical management (generally ≥3 months), and detailed documentation of lesion size, Outerbridge/Modified Outerbridge grade, stability, BMI/age limits, and prior surgeries as specified.