Articular Cartilage Lesion Treatments (ACI and OATS)

Medical Policy: 07.01.01 
Original Effective Date: July 2002 
Reviewed: August 2011 
Revised: February 2010 

Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary based on contract, and individual member benefits must be verified. Wellmark determines medical necessity only if the benefit exists and no contract exclusions are applicable. This medical policy may not apply to FEP. Benefits are determined by the Federal Employee Program.

This Medical Policy document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy will be reviewed regularly and be updated as scientific and medical literature becomes available.

Description: 

Articular cartilage defects of lower extremity weight bearing joints, either due to trauma or other conditions often fail to heal on their own and may be associated with pain, loss of function, disability, and long -term complications such as osteoarthritis.

Traditional surgeries provide treatments to relieve symptoms of pain, locking and swelling. In contrast, several available procedures attempt to regenerate hyaline-like cartilage and thereby restore the function of the joint. While the underlying principle is similar in these procedures, different instrumentation may be involved.

ACI (Autologous Chondrocyte Implant): In this procedure knee arthroscopy is performed to identify and biopsy healthy articular tissue. Chondrocytes are filtered from the biopsied tissue and cultivated in culture media for 11-21 days. An arthrotomy is subsequently performed and the chondral lesion is excised up to the normal surrounding tissue. The previously cultured chondrocytes are then injected under a periosteal flap sutured to the area of the defect.

OATS (Osteochondral Autograft Transfer System) and Mosaicplasty are essentially the same procedure: This procedure is most often performed on chondral defect(s) that are associated with chronic tears of the anterior cruciate ligament (ACL).  Multiple small osteochondral cores are harvested from various non-weight bearing sites in the knee and autografted into the chondral defect.  Using an arthroscopic approach access to the knee joint is provided for both ACL reconstruction and performance of the autograft.  Autograft is considered a favorable alternative to allograft because the cartilage is more viable and there is decreased potential for infectious disease.  

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Prior Approval: 

Not applicable

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Policy: 

Autologous chondrocyte implantation may be considered medically necessary for the treatment of disabling full thickness articular cartilage defects of the knee caused by acute or repetitive trauma, in patients who have had an inadequate response to a prior surgical procedure, when ALL of the following criteria are met:

• Patient is between the ages of 15 and 55 years. Adolescent patients should be skeletally mature with documented closure of growth plates, and
• Body mass index of less than 35 kg/m², and
• Focal, full thickness grade III or IV unipolar lesions along the weight-bearing surface of the femoral condyle (medial or lateral) or the trochlear regions, and
• Lesions greater than 2 cm²  but less than or equal to 12 cm², and
• Absence of significant “kissing” lesions, defined as grade 3 or greater chondromalacia, and
• 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.

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

Matrix-induced autologous chondrocyte implantation is considered investigational.

Osteochondral allografting may be considered medically necessary as a technique to repair large (e.g., 10 cm²) full thickness chondral defects of the knee caused by acute or repetitive trauma.

Osteochondral autografting  for the treatment of ankle disease may be considered medically necessary when both of the following criteria are met:

• Patient has diagnosis of osteochondritis dissecans AND
• Documented persistent pain with joint defect of Grade 2, 3, or 4.

Osteochondral autografting for the treatment of ankle disease is considered investigational if the above criteria are not met.

Osteochondral autografting, using 1 or more cores of osteochondral tissue, may be considered medically necessary for the treatment of symptomatic full thickness cartilage defects of the knee caused by acute or repetitive trauma, in patients who have had an inadequate response to a prior surgical procedure, when ALL of the following criteria are met:

• Patient is between the ages of 15 and 55 years. Adolescent patients should be skeletally mature with documented closure of growth plates, and
• Body mass index of less than 35 kg/m², and
• Focal, full thickness (grade III or IV) uni-polar lesions on the weight bearing surface of the femoral condyles or trochlea, and
• Lesions that are less than or equal to 2 cm², and
• Absence of significant “kissing” lesions, defined as grade 3 or greater chondromalacia, and
• 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.

Osteochondral autografting for treatment of the knee is considered investigational if the above criteria are not met.

Osteochondral allografting or autografting for all other joints, including patellar and talar, and any indications other than those listed above, is considered investigational.

Classification of Articular Cartilage Lesions by Severity

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Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• 28446 Open osteochondral autograft, talus (includes obtaining graft[s])
• 29866 Arthroscopy, knee, surgical; osteochondral graft(s) for treatment of articular surface defect; autografts for ACT.
• 29867 Arthroscopy, knee, surgical; osteochondral allograft (eg, mosaicplasty)  
• 29999 when OATS is performed for the ankle.
• 29885 drilling for osteochondritis dissecans with bone grafting, with or without internal fixation (including debridement of base of lesion) may also be appropriate with the OATS procedure.
• 27412 Autologous chondrocyte implantation, knee.
• 27415 Osteochondral allograft, knee, open
• 27416 Osteochondral autograft(s), knee, open (eg. mosalcplasty) (includes harvesting of autografts)
• J7330 Osteochondral allograft, knee, open
• S2112 Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)   

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Selected References: 

• Browne JE, Branch TP. Surgical alternatives for treatment of articular cartilage lesions. Journal of the American Academy of Orthopaedic Surgeons 2000;8:180-189.
• Hangody L, Feczko P, Bartha L, Bodo G, Kish G. Mosaicplasty for the treatment of articular defects of the knee and ankle. Clinical Orthopaedics and Related Research 2001;391:S328-S33.
• Jakob RP, Franz T, Gautier E, Mainil-Varlet P. Autologous osteochondral grafting in the knee: Indication, results and reflections. Clinical Orthopaedis and Related research 2002;# 401:170-184.
• Agneskirchner JD, Burcker P, Burkart A, Imhoff AB. Large osteochondral defects of the femoral condyle: press-fit transplantation of the posterior femoral condyle (MEGA-OATS). Knee Surgery, Sports Traumatology, Arthroscopy: official Journal of the ESSKA 2003;10:160-168.
• Al-Shaikh RA, Chou LB, Mann JA, Dreeben SM, Prieskorn D. Autologous osteochondral grafting for talar cartilage defect. Foot and Ankle International 2002; 23(5):381-389.
• Chevailer X, Autologous chondrocyte implantation for cartilage defects: development and applicability to osteoarthritis. Joint Bone Spine 2000;67:572-578.
• Technology Evaluation Center.  Autologous Chondrocyte Transplantation of the Knee.  Assessment Program Volume 18, No. 2. June 2003.
• Technology Evaluation Center. Autologous Chondrocyte Transplantation of the Knee. Assessment Program Volume 18, No. 2. June 2003.
• Bartha L; Vajda A; Duska Z; Rahmeh H; Hangody L. Autologous osteochondral mosaicplasty grafting. J Orthop Sports Phys Ther. 2006 Oct;36(10):739-50.
• Horas U, Pelinkovic D, Herr G et al. Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint. A prospective, comparative trial. J Bone Joint Surg Am 2003; 85-A(2):185-92.
• Klinger H, Baums M et al. Anterior cruciate reconstruction combined with autologous osteochondral transplantation. Knee Surg Sport Tramatol Arthroscopy 2003 Nov; 11(6):366-71.
• Karataglis d, Green m, et al. Autologous osteochondral transplantation for the treatment of chondral defects of the knee. The Knee 2006 Jan; 13(1):32-5.
• Bartha L, Vajda A, et al. Autologous osteochondral mosaicplasty grafting. The Journal of Orthopaedic and Sports Physical Therapy. 2006 Oct; 36(10): 739-50.
• Miura K, Ishibashi Y, et al. Results of arthroscopic fixation of osteochondritis dissecans lesionof the knee with cylindrical autogenous osteochondral plugs.The American Journal of Sports Medicine 2007 35(2) 216-22.
• Jones DG, Peterson, L. Autologous Chondrocyte Implantation. American Academy of Orthopaedic Surgeons Instructional Course Lectures 2007;56:429-445.
• ECRI. Autologous Chondrocyte Implantation for Knee Cartilage Defects. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 October 28. 13 p. (ECRI Hotline Response). Also available: http://www.ecri.org.
• ECRI. Osteochodral Autograft Transplantation in the Knee. Plymouth Meeting (PA): ECRI Health Technology Information Service; 2008 October 23. 8p. (ECRI Hotline Response). Also available: http://www.ecri.org.
• ECRI Institute. Osteochondral Autograft Transplantation for the Ankle. Plymouth Meeting (PA): ECRI Institute; 2009 October 27. 8 p. [ECRI hotline response]. Also available: http://www.ecri.org.   

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Policy History: 

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Wellmark medical policies address the complex issue of technology assessment of new and emerging treatments, devices, drugs, etc.   They are developed to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. Wellmark medical policies contain only a partial, general description of plan or program benefits and do not constitute a contract. Wellmark does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Wellmark or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. Our medical policies may be updated and therefore are subject to change without notice.

*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.