Cartilage Transfer Procedures: OATS and Mosaicplasty Form

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Cartilage Transfer Procedures: Osteoarticular Transfer System (OATS) and Mosaicplasty Medical Guideline

Service: Cartilage Transfer Procedures: Osteoarticular Transfer System (OATS) and Mosaicplasty

PUM 250-0033-1812

Medical Guideline Committee Approval Q3-2025 Effective Date 03/01/2026

Related Medical Guidelines:

• Autologous Chondrocyte Implantation (ACI) and Matrix-induced Autologous Chondrocyte Implant (MACI®) Medical Guideline • Meniscal Allograft Transplantation Medical Guideline • Knee Replacement Surgery Medical Guideline • Non-covered Services and Procedures Medical Guideline

Coverage for Cartilage Transfer Procedures: Osteoarticular Transfer System (OATS) and Mosaicplasty may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

During a cartilage transfer procedure, healthy cartilage is taken from a normal non-weight bearing area of the knee and moved to the area of damaged cartilage.

Mosaicplasty transfers multiple small plugs of healthy hyaline cartilage to the damaged area, resulting in a mosaic tile appearance.

Osteoarticular Transfer System (OATS) transfers one or two larger healthy hyaline cartilage plugs to the defect. This may be referred to as an autograft, in which the bone and cartilage plug is taken from the same individual (typically taken from the less weight bearing portion of the femur), or allograft in which the cartilage and bone is taken from a cadaveric donor. The autograft system is typically used for smaller lesions, and allograft for larger defects.

Indications of Coverage:

Osteoarticular (autograft or allograft) transfer system (OATS) procedure or mosaicplasty of the knee is considered medically necessary when all of the following are met:

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1. The individual is between the ages of 15 and 55 years old. Documentation of closure of growth plate is required for individuals less than 18 years old.

2. Presence of focal full-thickness articular cartilage defect (Grade III or IV) caused by acute or repetitive trauma.

3. The individual experiences knee dysfunction or pain that affects ability to ambulate or complete activities of daily living.

4. The individual has completed a two-month trial of medication management.

5. The individual is not an appropriate candidate for a total knee replacement.

6. Absent or minimal degenerative changes (Outerbridge grade II or less) in

   surrounding articular cartilage, with only mild, if any, significant osteoarthritic

   changes elsewhere in the knee, as seen with MRI and/or radiographs.

7. Normal appearing hyaline cartilage surrounds the border of the defect.

8. Knee is aligned and stable with normal weight distribution within the joint, or

   procedure to ensure this is planned in combination with or prior to the OATS

   procedure or mosaicplasty.

9. BMI must be less than or equal to 35.

   Limitations of Coverage:

   Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

   A. Review contract and endorsements for exclusions and prior authorization or benefit requirements.

   B. If used for a condition/diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

   C. If used for a condition/diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

   D. Performance of any of the following will be considered experimental, investigational, and unproven to affect health outcomes:

10. Combined/hybrid OATS or mosaicplasty with autologous chondrocyte implantation (ACI or MACI)

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2. Combined/hybrid OATS or mosaicplasty with adipose-derived stem cell therapy

3. Non-autologous mosaicplasty using resorbable synthetic bone filler

4. Autologous cartilage chip transplantation

5. OATS or mosaicplasty on any joint other than the knee

6. OATS or mosaicplasty for an individual less than 15 years old or greater than 55 years old

7. OATS or mosaicplasty for an individual with uncorrected congenital blood coagulation disorder

8. OATS or mosaicplasty in the presence of malignancy in the area of cartilage harvest or defect

9. Subchondroplasty or Subchondral calcium phosphate injections

10. OATS or mosaicplasty of the proximal tibial cartilage

    E. Use of any of the following will be considered experimental, investigational, and unproven to affect health outcomes:

11. Minced cartilage or biopaste extracellular matrix products, either synthetic, autograft or allograft, (including, but not limited to BioCartilage®)

12. Synthetic resorbable polymers / synthetic grafts (including, but not limited to TruFit®, TruGraft®, PolyGraft® PGS)

13. Platelet rich plasma (PRP) injection/treatment

14. Stem cell therapy, injection, or transplant

15. Bone marrow aspirate concentrate (BMAC) injection/treatment

16. Microfragmented adipose tissue (MFAT) injection/treatment (such as, but not limited to Lipogems®)

17. Platelet Lysate (PL)

18. Viscosupplementation, hyaluronic acid injections (including, but not limited to Orthovisc®, Synvisc®)

19. Peripheral nerve block or ablation

20. Genicular nerve injections or genicular nerve radiofrequency ablation

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11. iovera® System

12. Coolief® Cooled RF (radiofrequency)

13. Cryotherapy

14. Juvenile cartilage allograft tissue implantation (such as, but not limited to, DeNovo NT® Natural Tissue Graft, DeNovo ET® engineered tissue graft)

15. Cryopreserved viable osteochondral allograft product (including, but not limited to Cartiform®)

    Documentation Required:

    • Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
    • Medical record information (including continued need/use if applicable) and medical necessity. Office visit notes
    • Correct coding for the item/service that meets all the coding guidelines.

    Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

    Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

    Cartilage transfer procedures: osteoarticular transfer system (OATS) and mosaicplasty are considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

    State mandates, laws or benchmark supersede this medical guideline.

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Guideline Review History:

Implemented 01/01/20, 04/01/21, 12/01/21, 03/01/23, 01/01/24, 11/01/24, 03/01/26 Medical Guideline Committee Approval 09/27/19, 11/19/20, 11/18/21, 12/15/22, 12/14/23, 10/31/24, Q3 2025 Reviewed

11/19/20, 11/18/21, 12/15/22, 12/14/23, 10/31/24, Q3 2025 Developed 09/27/19

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes. Code Description 0054T COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON FLUOROSCOPIC IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0055T COMPUTER-ASSISTED MUSCULOSKELETAL SURGICAL NAVIGATIONAL ORTHOPEDIC PROCEDURE, WITH IMAGE-GUIDANCE BASED ON CT/MRI IMAGES (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 0707T INJECTION(S), BONE-SUBSTITUE MATERIAL (E.G., CALCIUM PHOSPHATE) INTO SUBCHONDRAL BONE DEFECT (I.E., BONE MARROW LESION, BONE BRUISE, STRESS INJURY, MICROTRABECULAR FRACTURE), INCLUDING IMAGING GUIDANCE AND ARTHROSCOPIC ASSISTANCE FOR JOINT VISUALIZATION 20985 COMPUTER-ASSISTED SURGICAL NAVIGATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 27415 OSTEOCHONDRAL ALLOGRAFT, KNEE, OPEN 27416 OSTEOCHONDRAL AUTOGRAFT(S), KNEE, OPEN (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF AUTOGRAFT[S]) 28446 OPEN OSTEOCHONDRAL AUTOGRAFT, TALUS (INCLUDES OBTAINING GRAFT[S]) 29866 ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL AUTOGRAFT(S) (EG, MOSAICPLASTY) (INCLUDES HARVESTING OF THE AUTOGRAFT[S]) 29867 ARTHROSCOPY, KNEE, SURGICAL; OSTEOCHONDRAL ALLOGRAFT (EG, MOSAICPLASTY)

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J7330 AUTOLOGOUS CULTURED CHONDROCYTES, IMPLANT S2900 SURGICAL TECHNIQUES REQUIRING USE OF ROBOTIC SURGICAL SYSTEM (LIST SERPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)