CMM-312: Knee Surgery-Arthroscopic and Open Procedures

This guideline authorizes a wide range of knee arthroscopic and open procedures (diagnostic arthroscopy, debridement/loose‑body removal, synovectomy, meniscal surgery, ligament reconstructions, cartilage-restoration procedures, HTO, MUA, etc.) as medically necessary only when procedure‑specific criteria are met — including documented function‑limiting symptoms (typically ≥3 months or ≥6 months for diagnostic arthroscopy), required physical exam findings, imaging confirmation with appropriate Kellgren‑Lawrence/Modified Outerbridge gradings, and prior failure of provider‑directed non‑surgical management (with limited acute‑injury exceptions). The policy explicitly excludes many procedures or indications not meeting those criteria, restricts surgery in the presence of advanced osteoarthritis (K‑L/Outerbridge thresholds vary by procedure), and lists numerous specific not‑medically‑necessary or experimental therapies (e.g., Hybrid ACI/OATS, certain meniscal allograft and ACI scenarios, and other procedure‑specific exclusions).