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Horizon BCBSNJ
Uniform Medical Policy ManualSection:Surgery
Policy Number:013
Effective Date: 11/01/2018
Original Policy Date:09/26/1997
Last Review Date:05/12/2020
Date Published to Web: 09/19/2018
Subject:
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

Description:
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IMPORTANT NOTE:

The purpose of this policy is to provide general information applicable to the administration of health benefits that Horizon Blue Cross Blue Shield of New Jersey and Horizon Healthcare of New Jersey, Inc. (collectively “Horizon BCBSNJ”) insures or administers. If the member’s contract benefits differ from the medical policy, the contract prevails. Although a service, supply or procedure may be medically necessary, it may be subject to limitations and/or exclusions under a member’s benefit plan. If a service, supply or procedure is not covered and the member proceeds to obtain the service, supply or procedure, the member may be responsible for the cost. Decisions regarding treatment and treatment plans are the responsibility of the physician. This policy is not intended to direct the course of clinical care a physician provides to a member, and it does not replace a physician’s independent professional clinical judgment or duty to exercise special knowledge and skill in the treatment of Horizon BCBSNJ members. Horizon BCBSNJ is not responsible for, does not provide, and does not hold itself out as a provider of medical care. The physician remains responsible for the quality and type of health care services provided to a Horizon BCBSNJ member.

Horizon BCBSNJ medical policies do not constitute medical advice, authorization, certification, approval, explanation of benefits, offer of coverage, contract or guarantee of payment.
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A variety of procedures are being developed to resurface articular cartilage defects. Autologous chondrocyte implantation (ACI) involves harvesting chondrocytes from healthy tissue, expanding the cells in vitro, and implanting the expanded cells into the chondral defect. Second- and third-generation techniques include combinations of autologous chondrocytes, scaffolds, and growth factors.

PopulationsInterventionsComparatorsOutcomes
Individuals:
  • With focal articular cartilage lesion(s) of the weight-bearing surface of the femoral condyles, trochlea, or patella
Interventions of interest are:
  • Autologous chondrocyte implantation
Comparators of interest are:
  • Marrow stimulation
  • Osteochondral autograft
Relevant outcomes include:
  • Symptoms
  • Change in disease status
  • Morbid events
  • Functional outcomes
  • Quality of life
Individuals:
  • With focal articular cartilage lesions of joints other than the knee
Interventions of interest are:
  • Autologous chondrocyte implantation
Comparators of interest are:
  • Marrow stimulation
  • Osteochondral autograft
Relevant outcomes include:
  • Symptoms
  • Change in disease status
  • Morbid events
  • Functional outcomes
  • Quality of life

BACKGROUND

Articular Cartilage Lesions

Damaged articular cartilage typically fails to heal on its own and can be associated with pain, loss of function, and disability, and may lead to debilitating osteoarthritis over time. These manifestations can severely impair a patient’s activities of daily living and adversely affect quality of life.

Treatment

Conventional treatment options include debridement, subchondral drilling, microfracture, and abrasion arthroplasty. Débridement involves the removal of synovial membrane, osteophytes, loose articular debris, diseased cartilage, and is capable of producing symptomatic relief. Subchondral drilling, microfracture, and abrasion arthroplasty attempt to restore the articular surface by inducing the growth of fibrocartilage into the chondral defect. Compared with the original hyaline cartilage, fibrocartilage has less capability to withstand shock or shearing force and can degenerate over time, often resulting in the return of clinical symptoms. Osteochondral grafts and autologous chondrocyte implantation attempt to regenerate hyaline-like cartilage and thereby restore durable function. Osteochondral grafts for the treatment of articular cartilage defects are discussed in Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions (Policy #064 in the Surgery Section).

With autologous chondrocyte implantation, a region of healthy articular cartilage is identified and biopsied through arthroscopy. The tissue is sent to a facility licensed by the U.S. Food and Drug Administration (FDA) where it is minced and enzymatically digested, and the chondrocytes are separated by filtration. The isolated chondrocytes are cultured for 11 to 21 days to expand the cell population, tested, and then shipped back for implantation. With the patient under general anesthesia, an arthrotomy is performed, and the chondral lesion is excised up to the normal surrounding cartilage. Methods to improve the first-generation autologous chondrocyte implantation procedure have been developed, including the use of a scaffold or matrix-induced autologous chondrocyte implantation composed of biocompatible carbohydrates, protein polymers, or synthetics. The only FDA approved matrix-induced autologous chondrocyte implantation product to date is supplied in a sheet, which is cut to size and fixed with fibrin glue. This procedure is considered technically easier and less time-consuming than the first-generation technique, which required suturing of a periosteal or collagen patch and injection of chondrocytes under the patch.

Desired features of articular cartilage repair procedures are the ability (1) to be implanted easily, (2) to reduce surgical morbidity, (3) not to require harvesting of other tissues, (4) to enhance cell proliferation and maturation, (5) to maintain the phenotype, and (6) to integrate with the surrounding articular tissue. In addition to the potential to improve the formation and distribution of hyaline cartilage, use of a scaffold with matrix-induced autologous chondrocyte implantation eliminates the need for harvesting and suture of a periosteal or collagen patch. A scaffold without cells may also support chondrocyte growth.

Regulatory Status

The culturing of chondrocytes is considered by the FDA to fall into the category of manipulated autologous structural cells, which are subject to a biologic licensing requirement. In 1997, Carticel® (Genzyme; now Vericel) received the FDA approval for the repair of clinically significant, “...symptomatic cartilaginous defects of the femoral condyle (medial-lateral or trochlear) caused by acute or repetitive trauma...”

In December 2016, MACI® (Vericel) received FDA approval for “the repair of symptomatic, single or multiple full-thickness cartilage defects of the knee with or without bone involvement in adults.” MACI® consists of autologous chondrocytes that are cultured onto a bioresorbable porcine-derived collagen membrane. In 2017, production of Carticel® was phased out, and MACI® is the only autologous chondrocyte implantation product available in the United States (U.S.).

A number of other second-generation methods for implanting autologous chondrocytes in a biodegradable matrix are currently in development or testing or are available outside of the U.S. They include Atelocollagen (Koken), a collagen gel; Bioseed® C (BioTissue Technologies), a polymer scaffold; CaReS (Ars Arthro), collagen gel; Cartilix (Biomet), a polymer hydrogel; Chondron (Sewon Cellontech), a fibrin gel; Hyalograft C (Fidia Advanced Polymers), a hyaluronic acid-based scaffold; NeoCart (Histogenics), an autologous chondrocyte implantation with a 3-dimensional chondromatrix in a phase 3 trial; and Novocart®3D (Aesculap Biologics), a collagen-chondroitin sulfate scaffold in a phase 3 trial. ChondroCelect® (TiGenix), characterized as a chondrocyte implantation with a completed phase 3 trial, uses a gene marker profile to determine in vivo cartilage-forming potential and thereby optimizes the phenotype (eg, hyaline cartilage vs. fibrocartilage) of the tissue produced with each autologous chondrocyte implantation cell batch. Each batch of chondrocytes is graded based on the quantitative gene expression of a selection of positive and negative markers for hyaline cartilage formation. Both Hyalograft C and ChondroCelect® have been withdrawn from the market in Europe.

Related Policies

  • Continuous Passive Motion Device (Policy #017 in the DME Section)
  • Meniscal Allografts and Other Meniscal Implants (Policy #023 in the Surgery Section)
  • Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions (Policy #064 in the Surgery Section)
  • Orthopedic Applications of Stem Cell Therapy (Including Allografts and Bone Substitutes Used with Autologous Bone Marrow) (Policy #129 in the Treatment Section)

Policy:
(NOTE:
Effective December 3, 2018, Horizon Blue Cross Blue Shield of New Jersey (“Horizon BCBSNJ”) contracted with TurningPoint Healthcare Solutions, LLC (TurningPoint) to manage our Surgical and Implantable Device Management Program (“the Program”). TurningPoint conducts Prior Authorization and Medical Necessity Determination reviews of certain orthopedic services to be provided to members included in the scope of the Program. The scope of the program includes members enrolled in the Horizon BCBSNJ plans for the effective dates noted below.

For services rendered December 3, 2018 and after, the Program includes members enrolled in Horizon BCBSNJ Fully Insured plans.

For services rendered July 15, 2019 and after, the Program includes members enrolled in Horizon BCBSNJ Medicare Advantage plans.

For services to be rendered January 20, 2020 and after, the Program will also include members enrolled in New Jersey State Health Benefits Program (SHBP)/School Employees’ Health Benefits Program (SEHBP) plans.

Please note that this policy’s criteria and guidelines only apply to members enrolled in plans that DO NOT participate in the Program. Visit our TurningPoint webpage for instructions on accessing the policy criteria and guidelines that TurningPoint will follow as they conduct PA/MND reviews as part of the Program. You may also call TurningPoint at 1-833-436-4083, Monday through Friday between 8 a.m. and 5 p.m., Eastern Time to request policy content.

NOTE: For Medicare Advantage, Medicaid and FIDE-SNP, please refer to the Coverage Sections below for coverage guidance.)

1. Autologous chondrocyte implantation is considered medically necessary for the treatment of disabling full-thickness articular cartilage defects of the knee caused by acute or repetitive trauma, when all of the following criteria are met:
    a. Member is between ages 15 and 55 years.

    b. Focal, full-thickness (grade III or IV) unipolar lesions of the patella or the weight-bearing surface of the femoral condyles or trochlea at least 1.5 cm2 in size.

    c. Cartilage defect is confirmed by appropriate diagnostic imaging (e.g., MRI, arthroscopic imaging, weight-bearing x-rays).

    d. Documented minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge grade II or less), and normal-appearing hyaline cartilage surrounding the border of the defect.
      (NOTE: The Outerbridge Classification is the most commonly used classification system to objectively assess chondral and osteochondral injuries of the knee:
      Grade 0 = normal cartilage;
      Grade I = cartilage with softening and swelling;
      Grade II = a partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 cm in diameter;
      Grade III = fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm;
      Grade IV = exposed subchondral bone.)

    e. Member has had at least 6 months of knee pain that has failed conservative treatment measures (e.g., medications, physical therapy, activity modification, bracing, ice/heat, injections).

    f. Member has had inadequate response to a prior arthroscopic or surgical repair procedure (e.g., microfracture).

    g. Member does not have any of the following contraindications:
      • presence of synovial disease, inflammation, osteoarthritis, or infection
      • history of malignancy or current unresected tumor in the limb
      • misalignment and instability of the joint
        (NOTE: correction of underlying joint abnormalities should be done before or at the time of autologous chondrocyte implantation.)
      • severe obesity (BMI >35 kg/m2).

2. Autologous chondrocyte implantation for all other joints, including talar, and any indications other than those listed above is considered investigational.


Medicare Coverage:
There is no National Coverage Determination (NCD) for Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions. In the absence of an NCD, coverage decisions are left to the discretion of Local Medicare Carriers. Novitas Solutions, Inc, the Local Medicare Carrier for jurisdiction JL, has not issued a determination for this service. Therefore, Medicare Advantage Products will follow the Horizon BCBSNJ Medical Policy.

Medicaid Coverage:
For members enrolled in Medicaid and NJ FamilyCare plans, Horizon BCBSNJ applies the above medical policy.

FIDE-SNP:

For members enrolled in a Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP): (1) to the extent the service is covered under the Medicare portion of the member’s benefit package, the above Medicare Coverage statement applies; and (2) to the extent the service is not covered under the Medicare portion of the member’s benefit package, the above Medicaid Coverage statement applies.


Policy Guidelines: (Information to guide medical necessity determination based on the criteria contained within the policy statements above.)

For smaller lesions (eg, <4 cm2), if débridement is the only prior surgical treatment, then consideration should be given to marrow-stimulating techniques before autologous chondrocyte implantation (ACI) is performed.

The average defect size reported in the literature is about 5 cm2; many studies treated lesions as large as 15 cm2.

Severe obesity (eg, body mass index >35 kg/m2) may affect outcomes due to the increased stress on weight-bearing surfaces of the joint.

Misalignment and instability of the joint are contraindications. Therefore, additional procedures, such as repair of ligaments or tendons or creation of an osteotomy for realignment of the joint, may be performed at the same time. In addition, meniscal allograft transplantation may be performed in combination, either concurrently or sequentially, with ACI. The charges for the culturing component of the procedure are submitted as part of the hospital bill.

The entire matrix-induced ACI procedure consists of 4 steps: (1) initial arthroscopy and biopsy of normal cartilage, (2) culturing of chondrocytes on an absorbable collagen matrix, (3) a separate arthrotomy to place the implant, and (4) postsurgical rehabilitation. The initial arthroscopy may be scheduled as a diagnostic procedure; as part of this procedure, a cartilage defect may be identified, prompting biopsy of normal cartilage in anticipation of a possible chondrocyte transplant. The biopsied material is then sent for culturing and returned to the hospital when the implantation procedure (ie, arthrotomy) is scheduled.
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Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

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Index:
Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions
Autologous Chondrocyte Transplantation (Implantation) and Other Cell-based Treatments of Focal Articular Cartilage Lesions
BioCart II
CAIS (Cartilage Autograft Implantation System)
Carticel
Cartilage Autograft Implantation System (CAIS)
Cartilage Cell, Transplantation
Cartilix
Cartipatch
Chondrocyte, Transplantation
Chondroselect
Hyalograft C
MACI (Matrix-Induced Autologous Chondrocyte Implantation)
Matrix-Induced Autologous Chondrocyte Implantation (MACI)
NeoCart
Transplantation, Autologous Chondrocyte
DeNovo NT Graft
DeNovo ET Graft
NeoCartilage

References:
1. Blue Cross and Blue Shield Association Technology Evaluation Center. Autologous chondrocyte transplantation. TEC Assessment. 1996;Volume 11:Tab 8.

2. Blue Cross and Blue Shield Association Technology Evaluation Center. Autologous chondrocyte transplantation. TEC Assessment. 1997;Volume 12:Tab 26.

3. Blue Cross and Blue Shield Association Technology Evaluation Center. Autologous chondrocyte transplantation. TEC Assessment. 2000;Volume 15:Tab 12.

4. Blue Cross and Blue Shield Association Technology Evaluation Center. Autologous chondrocyte transplantation of the knee. TEC Assessment. 2003;Volume 18:Tab 2.

5. Niemeyer P, Pestka JM, Kreuz PC, et al. Characteristic complications after autologous chondrocyte implantation for cartilage defects of the knee joint. Am J Sports Med. 2008 Nov;36(11). PMID 18801942

6. Free online Modified Cincinnati Knee Rating System calculator. OrthoToolKit. https://www.orthotoolkit.com/cincinnati/. Accessed February 18, 2020.

7. Greco NJ, Anderson AF, Mann BJ, et al. Responsiveness of the International Knee Documentation Committee Subjective Knee Form in comparison to the Western Ontario and McMaster Universities Osteoarthritis Index, modified Cincinnati Knee Rating System, and Short Form 36 in patients with focal articular cartilage defects. Am J Sports Med. 2010 May;38(5). PMID 20044494

8. Gusi N, Olivares PR, Rajendram R. The EQ-5D Health-Related Quality of Life Questionnaire [Abstract]. In: Preedy VR, Watson RR, eds. Handbook of Disease Burdens and Quality of Life Measures. New York: Springer; 2010:87-89.

9. Roos EM, Engelhart L, Ranstam J, et al. ICRS Recommendation Document: Patient-Reported Outcome Instruments for Use in Patients with Articular Cartilage Defects. Cartilage. 2011 Apr;2(2). PMID 26069575

10. Roos EM, Lohmander LS. The Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis. Health Qual Life Outcomes. 2003 Nov;1:64. PMID 14613558

11. Collins NJ, Misra D, Felson DT, et al. Measures of knee function: International Knee Documentation Committee (IKDC) Subjective Knee Evaluation Form, Knee Injury and Osteoarthritis Outcome Score (KOOS), Knee Injury and Osteoarthritis Outcome Score Physical Function Short Form (KOOS-PS), Knee Outcome Survey Activities of Daily Living Scale (KOS-ADL), Lysholm Knee Scoring Scale, Oxford Knee Score (OKS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Activity Rating Scale (ARS), and Tegner Activity Score (TAS). Arthritis Care Res (Hoboken). 2011 Nov;63 Suppl 11:S208-28. PMID 22588746

12. Lee WC, Kwan YH, Chong HC, et al. The minimal clinically important difference for Knee Society Clinical Rating System after total knee arthroplasty for primary osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2017 Nov;25(11). PMID 27324635

13. Clement ND, MacDonald D, Simpson AH. The minimal clinically important difference in the Oxford knee score and Short Form 12 score after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2014 Aug;22(8). PMID 24253376

14. Copay AG, Eyberg B, Chung AS, et al. Minimum Clinically Important Difference: Current Trends in the Orthopaedic Literature, Part II: Lower Extremity: A Systematic Review. JBJS Rev. 2018 Sep;6(9). PMID 30179898

15. Bin Abd Razak HR, Acharyya S, Tan SM, et al. Predictors of Midterm Outcomes after Medial Unicompartmental Knee Arthroplasty in Asians. Clin Orthop Surg. 2017 Dec;9(4). PMID 29201296

16. Lee WC, Bin Abd Razak HR, Allen JC, et al. Achieving Minimum Clinically Important Difference in Oxford Knee Score and Short Form-36 Physical Component Summary Is Less Likely with Single-Radius Compared with Multiradius Total Knee Arthroplasty in Asians. J Knee Surg. 2019 Mar;32(3). PMID 29635649

17. Riboh JC, Cvetanovich GL, Cole BJ, et al. Comparative efficacy of cartilage repair procedures in the knee: a network meta-analysis. Knee Surg Sports Traumatol Arthrosc. Dec 2017;25(12):3786-3799. PMID 27605128

18. Devitt BM, Bell SW, Webster KE, et al. Surgical treatments of cartilage defects of the knee: Systematic review of randomised controlled trials. Knee. Jun 2017;24(3):508-517. PMID 28189406

19. Mundi R, Bedi A, Chow L, et al. Cartilage restoration of the knee: a systematic review and meta-analysis of level 1 studies. Am J Sports Med. Jul 2016;44(7):1888-1895. PMID 26138733

20. Mistry H, Connock M, Pink J, et al. Autologous chondrocyte implantation in the knee: systematic review and economic evaluation. Health Technol Assess. Feb 2017;21(6):1-294. PMID 28244303

21. Harris JD, Siston RA, Pan X, et al. Autologous chondrocyte implantation: a systematic review. J Bone Joint Surg Am. Sep 15 2010;92(12):2220-2233. PMID 20844166

22. Sacolick DA, Kirven JC, Abouljoud MM, et al. The Treatment of Adult Osteochondritis Dissecans with Autologous Cartilage Implantation: A Systematic Review. J Knee Surg. 2019 Nov;32(11). PMID 30396204

23. Bartlett W, Skinner JA, Gooding CR, et al. Autologous chondrocyte implantation versus matrix-induced autologous chondrocyte implantation for osteochondral defects of the knee: a prospective, randomised study. J Bone Joint Surg Br. May 2005;87(5):640-645. PMID 15855365

24. Saris D, Price A, Widuchowski W, et al. Matrix-applied characterized autologous cultured chondrocytes versus microfracture: two-year follow-up of a prospective randomized trial. Am J Sports Med. Jun 2014;42(6):1384- 1394. PMID 24714783

25. Brittberg M, Recker D, Ilgenfritz J, et al. Matrix-Applied Characterized Autologous Cultured Chondrocytes Versus Microfracture: Five-Year Follow-up of a Prospective Randomized Trial. Am J Sports Med. 2018 May;46(6). PMID 29565642

26. Basad E, Ishaque B, Bachmann G, et al. Matrix-induced autologous chondrocyte implantation versus microfracture in the treatment of cartilage defects of the knee: a 2-year randomised study. Knee Surg Sports Traumatol Arthrosc. Apr 2010;18(4):519-527. PMID 20062969

27. Basad E, Wissing FR, Fehrenbach P, et al. Matrix-induced autologous chondrocyte implantation (MACI) in the knee: clinical outcomes and challenges. Knee Surg Sports Traumatol Arthrosc. Dec 2015;23(12):3729-3735. PMID 25218576

28. Schuette HB, Kraeutler MJ, McCarty EC. Matrix-assisted autologous chondrocyte transplantation in the knee: a systematic review of mid- to long-term clinical outcomes. Orthop J Sports Med. Jun 2017;5(6):2325967117709250. PMID 28620621

29. Meyerkort D, Ebert JR, Ackland TR, et al. Matrix-induced autologous chondrocyte implantation (MACI) for chondral defects in the patellofemoral joint. Knee Surg Sports Traumatol Arthrosc. Oct 2014;22(10):2522-2530. PMID 24817164

30. Zak L, Aldrian S, Wondrasch B, et al. Ability to return to sports 5 years after matrix-associated autologous chondrocyte transplantation in an average population of active patients. Am J Sports Med. Dec 2012;40(12):2815-2821. PMID 23108635

31. Ebert JR, Fallon M, Wood DJ, et al. A prospective clinical and radiological evaluation at 5 years after arthroscopic matrix-induced autologous chondrocyte implantation. Am J Sports Med. Jan 2017;45(1):59-69. PMID 27587741

32. Ebert JR, Fallon M, Zheng MH, et al. A randomized trial comparing accelerated and traditional approaches to postoperative weight-bearing rehabilitation after matrix-induced autologous chondrocyte implantation: findings at 5 years. Am J Sports Med. Jul 2012;40(7):1527-1537. PMID 22539536

33. Ebert JR, Smith A, Edwards PK, et al. Factors predictive of outcome 5 years after matrix-induced autologous chondrocyte implantation in the tibiofemoral joint. Am J Sports Med. Jun 2013;41(6):1245-1254. PMID 23618699

34. Ebert JR, Schneider A, Fallon M, et al. A comparison of 2-year outcomes in patients undergoing tibiofemoral or patellofemoral matrix-induced autologous chondrocyte implantation. Am J Sports Med. Sep 01 2017:363546517724761. PMID 28910133

35. Harris JD, Cavo M, Brophy R, et al. Biological knee reconstruction: a systematic review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy. Oct 26 2011;27(3):409-418. PMID 21030203

36. Andriolo L, Merli G, Filardo G, et al. Failure of autologous chondrocyte implantation. Sports Med Arthrosc Rev. Mar 2017;25(1):10-18. PMID 28045868

37. Nawaz SZ, Bentley G, Briggs TW, et al. Autologous chondrocyte implantation in the knee: mid-term to long-term results. J Bone Joint Surg Am. May 21 2014;96(10):824-830. PMID 24875023

38. Minas T, Von Keudell A, Bryant T, et al. The John Insall Award: A minimum 10-year outcome study of autologous chondrocyte implantation. Clin Orthop Relat Res. Jan 2014;472(1):41-51. PMID 23979923

39. Minas T, Gomoll AH, Rosenberger R, et al. Increased failure rate of autologous chondrocyte implantation after previous treatment with marrow stimulation techniques. Am J Sports Med. May 2009;37(5):902-908. PMID 19261905

40. Ebert JR, Smith A, Fallon M, et al. Incidence, degree, and development of graft hypertrophy 24 months after matrix-induced autologous chondrocyte implantation: association with clinical outcomes. Am J Sports Med. Sep 2015;43(9):2208-2215. PMID 26163536

41. Shimozono Y, Yasui Y, Ross AW, et al. Scaffolds based therapy for osteochondral lesions of the talus: A systematic review. World J Orthop. Oct 18 2017;8(10):798-808. PMID 29094011

42. Niemeyer P, Salzmann G, Schmal H, et al. Autologous chondrocyte implantation for the treatment of chondral and osteochondral defects of the talus: a meta-analysis of available evidence. Knee Surg Sports Traumatol Arthrosc. Sep 2012;20(9):1696-1703. PMID 22037894

43. American Academy of Orthopaedic Surgeons. Clinical Practice Guideline on the Diagnosis and Treatment of Osteochondritis Dissecans. Rosemont, IL: AAOS; 2010.

44. National Institute for Health and Care Excellence (NICE). Autologous chondrocyte implantation for treating symptomatic articular cartilage defects of the knee [TA508 ]. 2018; https://www.nice.org.uk/guidance/TA508/chapter/1-Recommendations. Accessed February 20, 2020.


Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*
    27412
HCPCS
    J7330
    S2112

* CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.
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Medical policies can be highly technical and are designed for use by the Horizon BCBSNJ professional staff in making coverage determinations. Members referring to this policy should discuss it with their treating physician, and should refer to their specific benefit plan for the terms, conditions, limitations and exclusions of their coverage.

The Horizon BCBSNJ Medical Policy Manual is proprietary. It is to be used only as authorized by Horizon BCBSNJ and its affiliates. The contents of this Medical Policy are not to be copied, reproduced or circulated to other parties without the express written consent of Horizon BCBSNJ. The contents of this Medical Policy may be updated or changed without notice, unless otherwise required by law and/or regulation. However, benefit determinations are made in the context of medical policies existing at the time of the decision and are not subject to later revision as the result of a change in medical policy
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