CMM-312: Knee Surgery-Arthroscopic and Open Procedures

The guideline approves a wide range of knee arthroscopic and open procedures (e.g., diagnostic arthroscopy, debridement/loose body removal, synovectomy, meniscectomy/repair, meniscal allograft, ACL reconstruction) as medically necessary only when specific, procedure‑by‑procedure criteria are met, and it explicitly excludes many situations and procedures as not medically necessary or investigational (eg, debridement/degenerative meniscal procedures in compartments with Kellgren‑Lawrence ≥2, many ACI/OATS/microfracture indications, most PCL/MCL reconstructions, and other listed exclusions). Key requirements include documented function‑limiting symptoms (generally ≥3 months, 6 months for diagnostic arthroscopy), failure of provider‑directed non‑surgical management, specified physical exam findings, required imaging with weight‑bearing AP and Rosenberg radiographs plus MRI/CT arthrogram correlating to pathology, and procedure‑specific age, BMI, alignment and stability limits (eg, meniscal allograft BMI ≤35 and age ≤49).