CMM-312: Knee Surgery-Arthroscopic and Open Procedures

CMM-312 covers a broad array of knee arthroscopic and open procedures only when strict criteria are met — documented function‑limiting symptoms, specified physical exam findings and corroborating imaging, and failure of provider‑directed conservative care for defined timeframes (commonly 3 months, 6 months for stand‑alone diagnostic arthroscopy), with additional lesion‑size, age, BMI and prior‑surgery limits and detailed documentation (e.g., Kellgren‑Lawrence/Outerbridge grades, MRI/CT findings, lesion measurements). Procedures outside those criteria are excluded or deemed not medically necessary, and several techniques are listed as experimental/unproven (e.g., subchondroplasty, focal resurfacing, hybrid ACI/OATS, OATS/mosaicplasty of distal femur or patella, in‑office diagnostic arthroscopy), with specific radiographic osteoarthritis or high Outerbridge grades serving as contraindications for many repairs.

"Medial collateral ligament (MCL) repair/reconstruction is considered not medically necessary in an acute injury setting, including an isolated MCL repair."