Articular Cartilage Lesion Treatments (ACI and OATS) Printer-Friendly Version   

Medical Policy: 07.01.01 
Original Effective Date: July 2002 
Reviewed: April 2007 
Revised: October 2007 

This policy applies to all products unless specific contract limitations, exclusions or exceptions apply. Please refer to the member's coverage manual for benefit availability. Managed care guidelines related to referral authorization, and precertification of inpatient hospitalization, home health, home infusion and hospice services apply.

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.  

Policy: 

• Patient has the diagnosis of traumatic osteoarthropathy of the knee joint
• Hyaline cartilage lesions of 1-10 cm²
• Patient is between the ages of 15 and 55 years
• Failed response to prior arthroscopy or other surgical interventions
• Significant symptoms of pain, swelling, catching, and limitation of daily or recreational activities are documented

ACI is considered investigational if the above criteria are not met. 

The OATS procedure 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
  

The OATS procedure for treatment of the knee may be considered medically necessary when the following criteria are met:

• Patient has the diagnosis of traumatic osteoarthropathy of the knee joint
• Hyaline cartilage lesions of ≤ 2 cm²
• Patient is between the ages of 15 and 55 years
• Significant symptoms of pain, swelling, catching and limitation of daily or recreational activities are documented

The OATS procedure for treatment of the knee is considered investigational if the above criteria are not met.

Top

Procedure Codes and Billing Guidelines: 

• To report provider services, use appropriate CPT* codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
• CPT 29866; Arthroscopy, knee, surgical; osteochondral graft(s) for treatment of articular surface defect; autografts for ACT.
• CPT code 29999 when OATS is performed for the ankle.
• CPT code 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.
• CPT code 27412, Autologous chondrocyte implantation, knee.
• CPT code 27416 Osteochondral autograft(s), knee, open (eg. mosalcplasty) (includes harvesting of autografts) 

Top

Selected References: 

• The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on Technology Evaluation Center (TEC) criteria.
• A review of the medical literature and recommendations from Wellmark's Medical Policy Advisory Council (MPAC), a council of practicing physicians who advise and assist Wellmark in the development and implementation of medical policies. The council is comprised of primary care and specialty physicians from Iowa and South Dakota.
• 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.  

Top

Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309

*Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.

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.