CMM-312: Knee Surgery-Arthroscopic and Open Procedures

This guideline covers diagnostic arthroscopy and specific therapeutic knee arthroscopic or open procedures (e.g., debridement/loose body removal, synovectomy, meniscectomy/repair, meniscal allograft, and surgery for fracture/tumor/infection/foreign body) only when ALL procedure‑specific criteria are met — including function‑limiting pain, specified physical exam findings, imaging confirmation (MRI/CT arthrogram and weight‑bearing AP/Rosenberg radiographs), documented failure of provider‑directed conservative care for required durations, and applicable age, BMI and lesion‑size limits. It explicitly excludes many other indications and lists numerous procedures as not medically necessary or experimental (e.g., arthroscopic debridement for Kellgren‑Lawrence Grade ≥2 OA, subchondroplasty, focal resurfacing, in‑office diagnostic arthroscopy, many ACI/OATS scenarios, and certain ligament repairs), and requires specific documentation (symptom duration, non‑surgical management, exam and imaging findings, intraoperative grading, lesion size, TT‑TG/stress films) to authorize coverage.