Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions

This policy covers osteochondral autograft and allograft procedures to repair symptomatic focal full‑thickness (Outerbridge III–IV) articular cartilage lesions—most commonly unicompartmental knee defects (1.0–2.5 cm²) and selected talar osteochondral or cystic lesions (>1.5 cm² or >3.0 cm³)—in skeletally mature adolescents and adults who are too young for total knee arthroplasty. Coverage requires minimal surrounding degeneration (Outerbridge ≤II), documented normal or concurrently corrected alignment and stability, appropriate prior conservative or marrow‑stimulation treatment when indicated, and excludes skeletally immature patients, bipolar/multifocal lesions, lesions outside the specified size ranges, procedures for joints other than the knee/talus, and investigational techniques (e.g., minced/particulated cartilage, decellularized plugs, reduced allograft discs).

"Symptomatic full-thickness cartilage defects of the knee caused by acute or repetitive trauma in individuals with inadequate response to a prior surgical procedure, when all specified criteria are met"