CMM-312: Knee Surgery-Arthroscopic and Open Procedures

This policy deems a broad set of knee arthroscopic and open procedures medically necessary (diagnostic arthroscopy, debridement/loose body removal, synovectomy, meniscal procedures and allograft, ligament reconstructions, cartilage restoration [ACI/MACI, OATS], microfracture, patellofemoral procedures, HTO, lysis of adhesions/MUA) when criteria are met, and explicitly excludes many other indications or experimental/unproven procedures (e.g., ACL repair is E/IU) or cases with disqualifying degenerative changes. Coverage requires documented function‑limiting pain, procedure‑specific physical findings, failure of provider‑directed non‑surgical management for specified timeframes (commonly ≥3 months; diagnostic arthroscopy 6 months), corroborating imaging and lesion size/grade, and adherence to procedure‑specific age, BMI, prior‑surgery and Kellgren‑Lawrence/Outerbridge thresholds.

"Meniscectomy/Meniscal repair: 'Meniscectomy (partial or total) or meniscal repair is considered not medically necessary for any other indication or condition."