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Medical Policy: 07.01.16
Original Effective Date: September 2001
Reviewed: September 2011
Revised: September 2011
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:
Meniscal allograft transplantation is a surgical procedure for the treatment of patients with irreparable meniscus tears or who have undergone a complete or near-complete meniscectomy. The procedure involves the grafting of donor meniscus into the knee and can be accomplished arthroscopically or by open technique. The goal of the procedure is restoration of knee function and prevention of further degeneration. Other reconstructive procedures, such as anterior cruciate ligament (ACL) repair may be performed concomitantly.
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Prior Approval:
Not applicable
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Policy:
Meniscal allograft transplant may be considered medically necessary in patients meeting all of the following criteria:
- Physically active and under age 55
- Missing more than half of the meniscus due to surgery or injury or has a tear that cannot be repaired
- Continues to have activity-related pain in the knee
- Has little or no evidence of arthritis in the knee
- BMI ≤ 35
- Stable ligaments and normal alignment of knee
Meniscal allograft transplantation may be considered medically necessary when performed in combination, either concurrently or sequentially, with autologous chondrocyte implantation or osteochondral allografting.
All other indications for meniscal allograft transplant are considered investigational.
Meniscal allograft transplantation, performed in combination with other surgical interventions, appears to improve symptoms in some patients with a prior meniscectomy who are considered too young to undergo total knew replacement. Evidence consisting primarily of retrospective case series indicates the procedure may produce short- to intermediate-term pain relief in selected patients. Although short- to intermediate-term results are promising, the literature does not permit conclusions concerning the effect to meniscal transplantation on the long-term progression of degenerative changes and joint space narrowing.
Meniscal allograft transplantation is associated with a high number of complications, including tears of the transplanted meniscus, displacement, or arthrofibrosis. Careful selection of patients and surgical technique appear critical for success of this procedure.
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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.
- 29868 Meniscal transplantation, medical or lateral, knee [any method].
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Selected References:
- Stollsteimer, G.T., Shelton, W.R., Dukes, A., Bomboy, A.L. Meniscal allograft transplantation: A 1-5 year follow-up of 22 patients. The Journal of Arthroscopic and Related Surgery 2000; 16(4):343-347.
- Rodeo, S.A. Meniscal Allografts-Where do we stand?. The American Journal of Sports Medicine 2001; 29(2):246-261.
- Rath, E., Richmond, J.C. The menisci: basic science and advances in treatment. British Journal of Sports Medicine 2000; 34:252-257.
- Maitra, R.S, Miller, M.D, Johnson, D.L. A review paper; Meniscal Reconstruction Part II: Outcome potential complications, and future directions. The American Journal of Orthopedics 1999 May; 28(5):280-286.
- Verdonk, R. Meniscal transplantation. Acta Orthopaedica Belgica 2002 April;68(2):118-7.
- Graf KW, Sekiya JK, Wojtys EM et al. Long-term results after combined meniscal allograft transplantation and anterior cruciate ligament reconstruction: minimum 8.5-year follow-up study. Arthroscopy. 2004 Feb;20(2):129-40.
- Sekiya JK, Giffin JR, Irrgang JJ et al. Clinical outcomes after combined allograft transplantation and anterior cruciate ligament reconstruction. Am J Sports Med. 2003 Nov-Dec; 31(6):896-906.
- Verdonk PC, Bemurie A, et al. Transplantation of viable meniscal allograft. Survivorship analysis of one hundred cases. J Bone Joint Surg Am 2005 Apr; 87(4):715-24.
- Matava MJ. Meniscal allograft transplantation: a systematic review. Clin Orthop Relat Res. 2007 Feb;445:142-57.
- Kim JM, Bin SI. Meniscal allograft transplantation after total meniscectomy of torn discoid lateral meniscus. Arthroscopy. 2006 Dec;22(12):1344-1350.
- Verdonk PC, Verstraete KL, Almqvist KF et al. Meniscal allograft transplantation: long-term clinical results with radiological and magnetic resonance imaging correlations. Knne Surg Sports Traumatol Arthrosc. 2006 Aug; 14(8):694-706.
- Sekiya JK, West RV, Groff YJ et al. Clinical outcomes following isolated lateral meniscal allograft transplantation. Arthroscopy. 2006 Jul;22(7):771-80.
- Rue JP, Yanke AB, Busam ML, McNIckle AG, Cole BJ. Perspective Evaluation of Concurrent Meniscus Transplantation and Articular Cartilage Repair: Minimum 2-years Follow-Up. Am J Sports Med. 2008 May 15.[Epub ahead of print]
- Chang HC, The KL, Leong KL, Mak SL, Karim SA. Clinical Evaluation of Arthroscopic-assisted Allograft Meniscal Transplant. Ann Acad Ned Singapore.2008 Apr;37(4):266-7.
- ECRI Institute. [Windows report] 2008. Meniscal Allograft Transplantation for Damaged or Removed Meniscus. ECRI Institute.
- ECRI Institute. Meniscal Allograft Transplantation for Damaged or Removed Meniscus. Plymouth Meeting (PA): ECRI Institute; 2009 Dec 18. 13 p. [ECRI hotline response]. Also available: http://www.ecri.org.
- Stone KR, Adelson WS, Peissis JR et al. Long-term survival of concurrent meniscus allograft transplantation and repair of the articular cartilage: a prospective two- to 12-year follow-up report. J Bone Joint Surg Br 2010;92(7):941-8.
- Bulgheroni P, Murena L, Ratti C et al. Follow-up of collagen meniscus implant patients: clinical, radiological, and magnetic resonance imaging results at 5 years. Knee. 2010;17(3):224-9.
- Amendola A. Knee osteotomy and meniscal transplantation: indications, technical considerations, and results. Sports Med Arthrosc 2007;15(5):476-92.
- Zaffagnini S, Marcheggiani Mucciolo GM, Lopomo N et al. Prospective long-term outcomes of the medial collagen meniscus implant versus partial medial meniscectomy: a minimum 10-year follow-up study. Am J Sports Med. 2011 May;39(5):977-85. Epub 2011 Feb 4.
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Policy History:
Date Reason Action
September 2011 Annual review Policy revised
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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.
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