Meniscal Allograft Transplantation Form

Page 1 of 5

Meniscal Allograft Transplantation Medical Guideline

Service: Meniscal Allograft Transplantation

PUM 250-0020-1812

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

Related Medical Guidelines:

• Non-covered Services and Procedures Guideline

Coverage for Meniscal Allograft Transplantation may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

A meniscus is a crescent-shaped piece of cartilage that provides a cushion between the bones of the knee joint. Each knee has an inner (medial) and outer (lateral) meniscus that act as shock absorbers for the knee by dispersing weight and reducing friction. During a meniscal allograft transplantation (MAT) surgery, the damaged meniscus is removed and a new meniscus that has been donated by a deceased person is placed in the knee.

Indications of Coverage:

A. Meniscal allograft transplantation using human cadaver meniscus is considered medically necessary when ALL of the following (1 through 8 below) are met:

1. Individual is skeletally mature.
2. Individual’s age is 55 years or younger.
3. Individual is ambulatory.
4. Presence of persistent knee pain that limits function and interferes with normal activities of daily living.
5. At least two weeks of provider-directed non-surgical management (such as analgesics, anti-inflammatory medication, exercise, bracing) has failed to improve pain symptoms and function.
6. Individual is not appropriate for a total knee arthroplasty.
7. Normal knee stability and alignment or plan to surgically correct at time of the allograft procedure.

8. Arthroscopy or imaging studies confirm ALL of the following (a. through d.):

   a. Meniscal loss after prior surgery or injury resulting in EITHER irreparable meniscal tear or prior meniscectomy with absence of at least 50% of the meniscus.

Page 2 of 5

b. Absent or only minimal degenerative changes present in the surrounding articular cartilage (Outerbridge Grade II or less) c. Absent or only minimal osteoarthritic change in the knee (Kellgren-Lawrence Scale as II or less) d. Closure of growth plates if individual is less than 18 years old (skeletal maturity)

B. Revision or repeat of meniscal allograft transplantation requires review by the Health Plan’s Medical Director.

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. Use of collagen meniscal implant or tissue-engineered meniscal implant (such as, but not limited to scaffold technology, Menaflex®, CMI®, Actifit®, NUsurface®, silk meniscal scaffold system) will be considered experimental, investigational, and unproven to affect health outcomes.

E. Use of meniscal prosthesis or polyurethane meniscal implant will be considered experimental, investigational, and unproven to affect health outcomes.

F. Xenotransplantation, xenografts (from a different species) will be considered experimental, investigational, and unproven to affect health outcomes.

G. Allograft transplantation for joints other than the knee will be considered experimental, investigational, and unproven to affect health outcomes.

H. All of the following will be considered experimental, investigational, and unproven to affect health outcomes:

1. Home use of CPM (continuous passive motion) devices and related equipment/supplies
2. iovera® System
3. Coolief® Cooled RF (radiofrequency)
4. Cryotherapy

Page 3 of 5

5. Viscosupplementation, hyaluronic acid injections
6. Stem cell therapy/injections
7. Peripheral nerve ablation
8. Platelet-rich plasma therapy/injections

9. Genicular nerve injections or genicular nerve radiofrequency ablation

   I. Zilretta (triamcinolone acetonide extended-release injectable suspension) injections are considered not medically necessary.

   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. History and physical notes (including documentation of physical/functional impairments and pain caused by knee). Imaging studies or arthroscopy report. Documentation of conservative provider-directed treatment (such as medication, physical therapy, home exercise, bracing, weight loss). • 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.

   Meniscal Allograft Transplantation is 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.

Page 4 of 5

Guideline Review History:

Implemented 10/01/19, 06/01/20, 03/01/21, 03/01/22, 03/01/23, 03/01/24, 03/01/26 Medical Guideline Committee Approval 06/21/19, 01/31/20, 02/25/21, 02/24/22, 02/23/23, 02/28/24, Q3 2025 Reviewed

01/31/20, 02/25/21, 02/24/22, 02/23/23, 02/28/24, Q3 2025 Developed 06/21/19

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 29868 ARTHROSCOPY, KNEE, SURGICAL; MENISCAL TRANSPLANTATION (INCLUDES ARTHROTOMY FOR MENISCAL INSERTION), MEDIAL OR LATERAL C8003 IMPLANTATION OF MEDIAL KNEE EXTRAARTICULAR IMPLANTABLE SHOCK ABSORBER SPANNING THE KNEE JOINT FROM DISTAL FEMUR TO PROXIMAL TIBIA, OPEN, INCLUDES MEASUREMENTS, POSITIONING AND ADJUSTMENTS, WITH IMAGING GUIDANCE (E.G., FLUOROSCOPY) G0428 COLLAGEN MENISCUS IMPLANT PROCEDURE FOR FILLING MENISCAL DEFECTS (E.G., CMI, COLLAGEN SCAFFOLD, MENAFLEX) 0SUC47Z SUPPLEMENT RIGHT KNEE JOINT WITH AUTOLOGOUS TISSUE SUBSTITUTE, PERCUTANEOUS ENDOSCOPIC APPROACH 0SUD47Z SUPPLEMENT LEFT KNEE JOINT WITH AUTOLOGOUS TISSUE SUBSTITUTE, PERCUTANEOUS ENDOSCOPIC APPROACH

Page 5 of 5