CMM-312: Knee Surgery-Arthroscopic and Open Procedures

Covers a broad range of knee arthroscopic and open procedures (diagnostic arthroscopy, debridement/loose body removal, meniscal procedures including allograft, ligament reconstructions, select chondral repairs like ACI/MACI and OATS in specified cases, HTO, MUA/lysis) when medically necessary, but excludes many indications and specifically lists several techniques as experimental/unproven or not medically necessary (e.g., subchondroplasty, focal resurfacing, in‑office needle arthroscopy, hybrid ACI/OATS). Key requirements include documented function‑limiting symptoms and specific exam findings, corroborating imaging with Modified Outerbridge/Kellgren‑Lawrence gradings, documented failure of provider‑directed non‑surgical care (typically ≥3 months; diagnostic arthroscopy requires 6 months of pain and 3 months conservative care), and adherence to stated age, BMI, and other contraindication limits.

"General: Knee arthroscopic or open surgical procedures may be considered medically necessary for individuals when surgery is being performed for fracture, tumor, infection or foreign body that has ..."