Unicondylar Interpositional Spacer as a Treatment of Unicompartmental Arthritis of the Knee

This policy addresses use of a unicondylar interpositional spacer for treatment of unicompartmental (typically medial) knee osteoarthritis—generally for mild-to-moderate symptomatic disease in select patients (commonly older, low‑activity, lighter-weight individuals, e.g., >60 years and <180 lb) as an alternative to osteotomy or unicompartmental arthroplasty or as a bone‑preserving option. However, the policy deems these spacers experimental/investigational and not covered, restricts use to devices with FDA 510(k) clearance under product code HSH, requires isolated compartment disease and prior failure of conservative therapy, and discourages free‑floating spacers and shock‑absorber implants outside of research settings.

"Initial treatment of uni- and bi-compartmental knee osteoarthritis with conservative measures such as analgesics, viscosupplementation, and arthroscopic debridement."