CMM-312: Knee Surgery-Arthroscopic and Open Procedures

This guideline deems specific arthroscopic and open knee procedures (e.g., diagnostic arthroscopy, debridement/chondroplasty, loose/foreign body removal, synovectomy, meniscectomy/repair, discoid meniscus procedures) medically necessary when used for fracture, tumor, infection or foreign body or when strict, procedure‑specific criteria are met, while many procedures (including ACL/PCL/MCL/LCL reconstructions, meniscal allograft transplantation, autologous chondrocyte implantation and other listed interventions) or surgery in the presence of advanced osteoarthritis are designated not medically necessary/experimental. Coverage requires documented function‑limiting pain, specified durations of failed provider‑directed non‑surgical management (commonly ≥3 months; diagnostic arthroscopy 6 months), correlating exam findings, required imaging/arthroscopic documentation (including Kellgren‑Lawrence and Outerbridge grading), and compliance with age/BMI and lesion‑specific criteria (with limited acute‑locked knee exceptions).