CMM-312: Knee Surgery-Arthroscopic and Open Procedures

This EviCore guideline authorizes a broad set of knee arthroscopic and open procedures (e.g., diagnostic arthroscopy, debridement/loose body removal, synovectomy, meniscal procedures including allograft, ACL reconstruction, cartilage restoration, HTO, MUA/lysis) only when strict, procedure‑specific criteria are met — including required imaging (plain radiographs with Kellgren‑Lawrence grading and MRI/CT arthrogram or orthogonal films as specified), defined physical‑exam findings, symptom severity/duration (generally ≥3 months of failed provider‑directed non‑surgical care; diagnostic arthroscopy commonly ≥6 months) and procedure‑specific BMI/age/prior‑surgery limits. Procedures not meeting these criteria are deemed not medically necessary and many techniques are listed as experimental/investigational (e.g., in‑office diagnostic arthroscopy, ACL repair, hybrid ACI/OATS, subchondroplasty, focal resurfacing), with mandatory documentation of all imaging, exam, symptom duration, conservative treatment attempts, and demographic/clinical thresholds.