254 Form

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Medical Policy Orthopedic Applications of Stem Cell Therapy (Including Allograft and Bone Substitute Products Used with Autologous Bone Marrow) Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 254 BCBSA Reference Number: 8.01.52 (For Plans internal use only) NCD/LCD: NA Related Policies
• Orthopedic Applications of Platelet-Rich Plasma, #737 • Prolotherapy, #183 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Mesenchymal stem cell therapy is considered INVESTIGATIONAL for all orthopedic applications, including use in repair or regeneration of musculoskeletal tissue.

Allograft bone products containing viable stem cells, including but not limited to demineralized bone matrix (DBM) with stem cells, are considered INVESTIGATIONAL for all orthopedic applications, including, but not limited to:
• AlloStem® (AlloSource) • Map3® (RTI Surgical) • Osteocel Plus® (NuVasive) • Trinity Evolution Matrix™ (Orthofix).

Allograft or synthetic bone graft substitutes that must be combined with autologous blood or bone marrow are considered INVESTIGATIONAL for all orthopedic applications, including, but not limited to:
• Fusion Flex™ (Wright Medical) • Ignite® (Wright Medical) • Vitoss® Bioactive Foam Bone Graft Substitute (Stryker) • NanOss BVF-E (Pioneer Surgical) • DBX® Putty (DePuy Synthes) • Integra MOZAIK™ Osteoconductive Scaffold (IsoTis OrthoBiologics) • Formagraft™ Collagen Bone Graft Matrix (R and L Medical)

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• CopiOs® Bone Void Filler (Kensey Nash) • OrthoBlast® II (Sea Spine) • DynaGraft® II (Sea Spine)

Supplemental Information
The purpose of the following information is to provide reference material. Inclusion of table 1, Demineralized Bone Matrix Products Cleared by FDA, does not indicate coverage. Orthopedic Applications of Stem Cell Therapy is considered investigational.

Tables 1 and 2 provide a representative sample of these products, differentiated by whether they must be mixed with autologous MSCs. Table 1. Examples of Demineralized Bone Matrix Products Cleared by FDA that Do Not Require Mixing with Autologous MSCs Product Matrix Type Manufacturer or Sponsor Vitoss® Bioactive Foam Bone Graft Substitute Type I bovine collagen Stryker NanOss BVF-E Nanocrystalline hydroxyapatite Pioneer Surgical OrthoBlast® II Demineralized bone matrix putty and paste Human (mixed allograft donor-derived) cancellous bone chips SeaSpine DBX® Demineralized bone matrix putty, paste and mix Processed human (single allograft donor-derived) bone and sodium hyaluronate Musculoskeletal Transplant Foundation Formagraft™ Collagen Bone Graft Matrix Bovine fibrillary collagen R and L Medical DynaGraft® II Gel and Putty Processed human (mixed allograft donor-derived) bone particles IsoTis Orthobiologics FDA: U.S. Food and Drug Administration; MSCs: mesenchymal stem cells.

Table 2. Examples of Demineralized Bone Matrix Products Cleared by FDA that Require Mixing with Autologous MSCs Product Matrix Type Manufacturer or Sponsor CopiOs® Bone Void Filler (sponge and powder disc) Type I bovine dermal collagen Kensey Nash Integra MOZAIK™ Osteoconductive Scaffold-Putty Collagen matrix with tricalcium phosphate granules IsoTis OrthoBiologics FDA: U.S. Food and Drug Administration; MSCs: mesenchymal stem cells.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient

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Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes
Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

According to the policy statement above, the following CPT code is considered investigational for the conditions listed for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue:

CPT Codes CPT codes:

Code Description 20930 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure).
NOTE: This is a generic graft add on injection code to spine surgery which could be used for stem cells injection.

The following CPT codes are considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: CPT Codes CPT codes:

Code Description 0263T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure including unilateral or bilateral bone marrow harvest 0264T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; complete procedure excluding bone marrow harvest 0265T Intramuscular autologous bone marrow cell therapy, with preparation of harvested cells, multiple injections, one leg, including ultrasound guidance, if performed; unilateral or bilateral bone marrow harvest only for intramuscular autologous bone marrow cell therapy 0489T Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; adipose tissue harvesting, isolation and preparation of harvested cells including incubation with cell dissociation enzymes, removal of non-viable cells and debris, determination of concentration and dilution of regenerative cells 0490T Autologous adipose-derived regenerative cell therapy for scleroderma in the hands; multiple injections in one or both hands 0565T Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; tissue harvesting and cellular implant creation 0566T Autologous cellular implant derived from adipose tissue for the treatment of osteoarthritis of the knees; injection of cellular implant into knee joint including ultrasound guidance, unilateral

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Description Mesenchymal Stem Cells Mesenchymal stem cells (MSCs) are multipotent cells (also called multipotent stromal cells) that can differentiate into various tissues including organs, trabecular bone, tendon, articular cartilage, ligaments, muscle, and fat. MSCs are associated with the blood vessels within the bone marrow, synovium, fat, and muscle, where they can be mobilized for endogenous repair as occurs with the healing of bone fractures. Tissues such as cartilage, tendon, ligaments, and vertebral discs show limited capacity for endogenous repair because of the limited presence of the triad of functional tissue components: vasculature, nerves, and lymphatics. Orthobiologics is a term introduced to describe interventions using cells and biomaterials to support healing and repair. Cell therapy is the application of MSCs directly to a musculoskeletal site. Tissue engineering techniques use MSCs and/or bioactive molecules such as growth factors and scaffold combinations to improve the efficiency of repair or regeneration of damaged musculoskeletal tissues.1, Bone marrow aspirate is considered the most accessible source and, thus, the most common place to isolate MSCs for the treatment of musculoskeletal disease. However, harvesting MSCs from bone marrow requires a procedure that may result in donor-site morbidity. Also, the number of MSCs in bone marrow is low, and the number and differentiation capacity of bone marrow-derived MSCs decreases with age, limiting their efficiency when isolated from older patients. In vivo, the fate of stem cells is regulated by signals in the local 3-dimensional microenvironment from the extracellular matrix and neighboring cells. It is believed the success of tissue engineering with MSCs will also require an appropriate 3-dimensional scaffold or matrix, culture conditions for tissue-specific induction, and implantation techniques that provide appropriate biomechanical forces and mechanical stimulation. The ability to induce cell division and differentiation without adverse effects, such as the formation of neoplasms, remains a significant concern. Given that each tissue type requires different culture conditions, induction factors (signaling proteins, cytokines, growth factors), and implantation techniques, each preparation must be individually examined. Summary Description Mesenchymal stem cells (MSCs) have the capability to differentiate into a variety of tissue types, including various musculoskeletal tissues. Potential uses of MSCs for orthopedic applications include treatment of damaged bone, cartilage, ligaments, tendons, and intervertebral discs.

Summary of Evidence For individuals who have cartilage defects, meniscal defects, joint fusion procedures, or osteonecrosis who receive stem cell therapy, the evidence includes systematic reviews, randomized controlled trials (RCTs) and observational studies. Relevant outcomes are symptoms, morbid events, functional outcomes, quality of life, and treatment-related morbidity. Use of mesenchymal stem cells (MSCs) for orthopedic conditions is an active area of research. Despite continued research into the methods of harvesting and delivering treatment, there are uncertainties regarding the optimal source of cells and the delivery method. Studies have included MSCs from bone marrow, adipose tissue, and peripheral blood. Recent systematic reviews have reported that intra-articular MSCs offer little to no pain relief for knee osteoarthritis (OA), with possible slight functional improvement and increased adverse events. For hip OA, MSCs show some benefit in pain and function but evidence is limited by small studies and inconsistent protocols. Overall, the quality of evidence is low and there is a possibility of publication bias. The strongest evidence to date is on autologous MSCs expanded from bone marrow, which includes several phase 1/2 RCTs and a phase 3 RCT (which also evaluated other cell therapies). The phase 3 trial did not indicate significant improvements with the cell therapy modalities relative to active-control intra-articular corticosteroid injections for patients with knee OA after 12 months of follow-up. Another recent phase 3 RCT evaluated autologous MSCs expanded from abdominal adipose tissue for treatment of knee OA; this trial indicated autologous adipose-derived MSCs were more effective than matching placebo injections in improving pain, function, and other patient- reported outcomes after 6 months of follow-up. These phase 3 trials' mixed findings may be related to

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differences in the cell therapy modalities used, baseline cohort characteristics, and/or the use of an active vs placebo control.

Alternative methods of obtaining MSCs have been reported in a smaller number of trials and with mixed results. Current evidence regarding the application of allografts combined with stem cells for bone fusion in the extremities or spine, as well as for the treatment of nonunion, remains limited. Several early-phase, industry-sponsored trials have been reported. Clinical studies involving moldable cellular bone allografts have demonstrated high fusion rates at 12 months in lumbar, cervical, and foot and ankle procedures. These studies also note significant improvements in disability and pain scores, with few serious graft-related adverse events. However, the data are drawn primarily from nonrandomized, small-scale, and largely retrospective studies. Additional study with longer follow-up is needed to evaluate the long-term efficacy and safety of these procedures. Also, expanded MSCs for orthopedic applications are not U.S. Food and Drug Administration approved (concentrated autologous MSCs do not require agency approval). Overall, there is a lack of clear evidence that clinical outcomes are improved. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Policy History Date Action 2/2026 Annual policy review. References updated. Policy statements unchanged. 11/2025 Policy updated with literature review through July 24, 2025; references added. Clinical evidence for Trinity Elite cellular bone allograft in joint fusion procedures has been added. Policy statements unchanged. 3/2025 Annual policy review. References updated. Policy statements unchanged. 3/2024 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 9/2023 Policy clarified. Table 1. Demineralized Bone Matrix Products Cleared by FDA added. 5/2023 Clarified coding information 3/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 12/2022 Policy clarified. Allograft and bone substitute products used with autologous bone marrow added. Policy statements unchanged. 2/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 3/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 3/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 3/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 2/2018 Annual policy review. New references added. 8/2017 Annual policy review. New references added. 9/2015 Annual policy review. New investigational indications described; title changed. Clarified coding information. Effective 9/1/2015. 7/2014 Annual policy review. New references added. 10/2013 Annual policy review. New investigational indications described. Effective 10/1/2013. 12/2012 Updated to add new CPT code 38243. 6/2011 Reviewed - Medical Policy Group – Orthopedics, Rehabilitation and Rheumatology,
No changes to policy statements. 12/01/2010 New policy, effective 12/01/2010.
Information Pertaining to All Blue Cross Blue Shield Medical Policies

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Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Goldberg A, Mitchell K, Soans J, et al. The use of mesenchymal stem cells for cartilage repair and regeneration: a systematic review. J Orthop Surg Res. Mar 09 2017; 12(1): 39. PMID 28279182
2. U.S. Food & Drug Administration. Regulatory Considerations for Human Cells, Tissues, and Cellular and Tissue-Based Products: Minimal Manipulation and Homologous Use. Updated July 21, 2020. Accessed November 23, 2025.
3. Jin WS, Yin LX, Sun HQ, et al. Mesenchymal Stem Cells Injection Is More Effective Than Hyaluronic Acid Injection in the Treatment of Knee Osteoarthritis With Similar Safety: A Systematic Review and Meta-analysis. Arthroscopy. Feb 2025; 41(2): 318-332. PMID 39154667
4. Sadeghirad B, Rehman Y, Khosravirad A, et al. Mesenchymal stem cells for chronic knee pain secondary to osteoarthritis: A systematic review and meta-analysis of randomized trials. Osteoarthritis Cartilage. Oct 2024; 32(10): 1207-1219. PMID 38777213
5. Giorgino R, Alessandri Bonetti M, Migliorini F, et al. Management of hip osteoarthritis: harnessing the potential of mesenchymal stem cells-a systematic review. Eur J Orthop Surg Traumatol. Dec 2024; 34(8): 3847-3857. PMID 39254726
6. Borakati A, Mafi R, Mafi P, et al. A Systematic Review And Meta-Analysis of Clinical Trials of Mesenchymal Stem Cell Therapy for Cartilage Repair. Curr Stem Cell Res Ther. Feb 23 2018; 13(3): 215-225. PMID 28914207
7. Kim SH, Djaja YP, Park YB, et al. Intra-articular Injection of Culture-Expanded Mesenchymal Stem Cells Without Adjuvant Surgery in Knee Osteoarthritis: A Systematic Review and Meta-analysis. Am J Sports Med. Sep 2020; 48(11): 2839-2849. PMID 31874044
8. Jin L, Yang G, Men X, et al. Intra-articular Injection of Mesenchymal Stem Cells After High Tibial Osteotomy: A Systematic Review and Meta-analysis. Orthop J Sports Med. Nov 2022; 10(11):
9. PMID 36452339
10. Wong KL, Lee KB, Tai BC, et al. Injectable cultured bone marrow-derived mesenchymal stem cells in varus knees with cartilage defects undergoing high tibial osteotomy: a prospective, randomized controlled clinical trial with 2 years' follow-up. Arthroscopy. Dec 2013; 29(12): 2020-8. PMID 24286801
11. Emadedin M, Labibzadeh N, Liastani MG, et al. Intra-articular implantation of autologous bone marrow-derived mesenchymal stromal cells to treat knee osteoarthritis: a randomized, triple-blind, placebo-controlled phase 1/2 clinical trial. Cytotherapy. Oct 2018; 20(10): 1238-1246. PMID 30318332
12. Lamo-Espinosa JM, Mora G, Blanco JF, et al. Intra-articular injection of two different doses of autologous bone marrow mesenchymal stem cells versus hyaluronic acid in the treatment of knee osteoarthritis: long-term follow up of a multicenter randomized controlled clinical trial (phase I/II). J Transl Med. Jul 31 2018; 16(1): 213. PMID 30064455
13. Lamo-Espinosa JM, Mora G, Blanco JF, et al. Intra-articular injection of two different doses of autologous bone marrow mesenchymal stem cells versus hyaluronic acid in the treatment of knee osteoarthritis: multicenter randomized controlled clinical trial (phase I/II). J Transl Med. Aug 26 2016; 14(1): 246. PMID 27565858
14. Mautner K, Gottschalk M, Boden SD, et al. Cell-based versus corticosteroid injections for knee pain in osteoarthritis: a randomized phase 3 trial. Nat Med. Dec 2023; 29(12): 3120-3126. PMID 37919438
15. Loke RYJ, Chu Z, Liang J, et al. Allogenic MSCs are a safe and efficacious treatment for knee osteoarthritis: A systematic review of randomised controlled trials. J Exp Orthop. Jul 2025; 12(3): e70437. PMID 40980258
16. Shapiro SA, Kazmerchak SE, Heckman MG, et al. A Prospective, Single-Blind, Placebo-Controlled Trial of Bone Marrow Aspirate Concentrate for Knee Osteoarthritis. Am J Sports Med. Jan 2017; 45(1): 82-90. PMID 27566242

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16. Tangkanjanavelukul P, Khuangsirikul S, Heebthamai D, et al. Cartilage Regeneration Potential in Early Osteoarthritis of the Knee: A Prospective, Randomized, Open, and Blinded Endpoint Study Comparing Adipose-Derived Mesenchymal Stem Cell (ADSC) Therapy Versus Hyaluronic Acid. Int J Mol Sci. Aug 31 2025; 26(17). PMID 40943401
17. Koh YG, Kwon OR, Kim YS, et al. Comparative outcomes of open-wedge high tibial osteotomy with platelet-rich plasma alone or in combination with mesenchymal stem cell treatment: a prospective study. Arthroscopy. Nov 2014; 30(11): 1453-60. PMID 25108907
18. Zaffagnini S, Andriolo L, Boffa A, et al. Microfragmented Adipose Tissue Versus Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis: A Prospective Randomized Controlled Trial at 2-Year Follow-up. Am J Sports Med. Sep 2022; 50(11): 2881-2892. PMID 35984721
19. Kim KI, Lee MC, Lee JH, et al. Clinical Efficacy and Safety of the Intra-articular Injection of Autologous Adipose-Derived Mesenchymal Stem Cells for Knee Osteoarthritis: A Phase III, Randomized, Double-Blind, Placebo-Controlled Trial. Am J Sports Med. Jul 2023; 51(9): 2243-2253. PMID 37345256
20. Saw KY, Anz A, Siew-Yoke Jee C, et al. Articular cartilage regeneration with autologous peripheral blood stem cells versus hyaluronic acid: a randomized controlled trial. Arthroscopy. Apr 2013; 29(4): 684-94. PMID 23380230
21. Lim HC, Park YB, Ha CW, et al. Allogeneic Umbilical Cord Blood-Derived Mesenchymal Stem Cell Implantation Versus Microfracture for Large, Full-Thickness Cartilage Defects in Older Patients: A Multicenter Randomized Clinical Trial and Extended 5-Year Clinical Follow-up. Orthop J Sports Med. Jan 2021; 9(1): 2325967120973052. PMID 33490296
22. Xiao Z, Wang X, Li C, et al. Effects of the umbilical cord mesenchymal stem cells in the treatment of knee osteoarthritis: A systematic review and meta-analysis. Medicine (Baltimore). Nov 15 2024; 103(46): e40490. PMID 39560593
23. Whitehouse MR, Howells NR, Parry MC, et al. Repair of Torn Avascular Meniscal Cartilage Using Undifferentiated Autologous Mesenchymal Stem Cells: From In Vitro Optimization to a First-in-Human Study. Stem Cells Transl Med. Apr 2017; 6(4): 1237-1248. PMID 28186682
24. Vangsness CT, Farr J, Boyd J, et al. Adult human mesenchymal stem cells delivered via intra- articular injection to the knee following partial medial meniscectomy: a randomized, double-blind, controlled study. J Bone Joint Surg Am. Jan 15 2014; 96(2): 90-8. PMID 24430407
25. Orthofix Announces Full Market Release and Launch of Trinity ELITE. Published July 1, 2013. Accessed November 21, 2025.
26. Wind J, Park D, Lansford T, et al. Twelve-Month Results from a Prospective Clinical Study Evaluating the Efficacy and Safety of Cellular Bone Allograft in Subjects Undergoing Lumbar Spinal Fusion. Neurol Int. Oct 26 2022; 14(4): 875-883. PMID 36412692
27. Lansford T, Park DK, Wind JJ, et al. High Lumbar Spinal Fusion Rates Using Cellular Bone Allograft Irrespective of Surgical Approach. Int J Spine Surg. Sep 12 2024; 18(4): 355-364. PMID 39054302
28. Park DK, Wind JJ, Lansford T, et al. Twenty-four-month interim results from a prospective, single-arm clinical trial evaluating the performance and safety of cellular bone allograft in patients undergoing lumbar spinal fusion. BMC Musculoskelet Disord. Nov 17 2023; 24(1): 895. PMID 37978378
29. Russo A, Park DK, Lansford T, et al. Impact of surgical risk factors for non-union on lumbar spinal fusion outcomes using cellular bone allograft at 24-months follow-up. BMC Musculoskelet Disord. May 03 2024; 25(1): 351. PMID 38702654
30. Sayeed A, Jawad A, Zakko P, et al. Radiographic Fusion Outcomes for Trinity Cellular Based Allograft versus Local Bone in Posterolateral Lumbar Fusion. J Am Acad Orthop Surg Glob Res Rev. Apr 01 2024; 8(4). PMID 38648399
31. Goldman SN, Paschal GK, Mani K, et al. Efficacy of an allograft cellular bone matrix as an alternative to autograft in anterior cervical discectomy and fusion: radiological results safety. J Spine Surg. Sep 23 2024; 10(3): 372-385. PMID 39399080
32. Donaghue P. Radiographical outcomes of a cellular based allograft following foot/ankle arthrodesis in patients with risk for non-union. Orthop Rev (Pavia). 2024; 16: 115603. PMID 38562146
33. Vanichkachorn J, Peppers T, Bullard D, et al. A prospective clinical and radiographic 12-month outcome study of patients undergoing single-level anterior cervical discectomy and fusion for symptomatic cervical degenerative disc disease utilizing a novel viable allogeneic, cancellous, bone matrix (trinity evolution™) with a comparison to historical controls. Eur Spine J. Jul 2016; 25(7): 2233-
34. PMID 26849141

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34. Peppers TA, Bullard DE, Vanichkachorn JS, et al. Prospective clinical and radiographic evaluation of an allogeneic bone matrix containing stem cells (Trinity Evolution® Viable Cellular Bone Matrix) in patients undergoing two-level anterior cervical discectomy and fusion. J Orthop Surg Res. Apr 26 2017; 12(1): 67. PMID 28446192
35. Jones CP, Loveland J, Atkinson BL, et al. Prospective, Multicenter Evaluation of Allogeneic Bone Matrix Containing Viable Osteogenic Cells in Foot and/or Ankle Arthrodesis. Foot Ankle Int. Oct 2015; 36(10): 1129-37. PMID 25976919
36. Eastlack RK, Garfin SR, Brown CR, et al. Osteocel Plus cellular allograft in anterior cervical discectomy and fusion: evaluation of clinical and radiographic outcomes from a prospective multicenter study. Spine (Phila Pa 1976). Oct 15 2014; 39(22): E1331-7. PMID 25188591
37. Li J, Su P, Li J, et al. Efficacy and Safety of Stem Cell Combination Therapy for Osteonecrosis of the Femoral Head: A Systematic Review and Meta-Analysis. J Healthc Eng. 2021; 2021: 9313201. PMID 34608416
38. American Academy of Orthopaedic Surgeons. Management of Glenohumeral Joint Osteoarthritis Evidence-Based Clinical Practice Guideline. Updated March 23, 2020. Accessed Novmeber 25, 2025. https://www.aaos.org/globalassets/quality-and-practice-resources/glenohumeral/gjo-cpg.pdf
39. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non- Arthroplasty). Updated August 31, 2021. Accessed November 25, 2025.https://www.aaos.org/globalassets/quality-and-practice-resources/osteoarthritis-of-the- knee/oak3cpg.pdf
40. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Hip. Updated December 1, 2023. Accessed November 25 , 2025. https://www.aaos.org/globalassets/quality-and- practice-resources/osteoarthritis-of-the-hip/oah-cpg.pdf
41. American Academy of Orthopaedic Surgeons. Orthobiologics (Regenerative Medicine) FAQ. Updated May 2023. Accessed November 25, 2025. https://orthoinfo.aaos.org/en/treatment/orthobiologics- faq/?_ga=2.204926547.238005081.1753987110-2061571831.1753987110
42. Kaiser MG, Groff MW, Watters WC, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 16: bone graft extenders and substitutes as an adjunct for lumbar fusion. J Neurosurg Spine. Jul 2014; 21(1): 106-32. PMID 24980593
43. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Care Res (Hoboken). Feb 2020; 72(2): 149-162. PMID 31908149
44. Department of Veterans Affairs/Department of Defense. VA/DoD Clinical Practice Guideline for the Non-Surgical Management of Hip & Knee Osteoarthritis. Published 2020. Accessed November 24,
45. https://www.healthquality.va.gov/HEALTHQUALITY/guidelines/cd/oa/index.asp