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Definitions Autografts Grafts of bone and cartilage harvested from either the patient’s non-weight bearing surfaces (or surfaces that bear less weight), which is then implanted in the defect. Autografting is typically used to repair smaller defects. The advantages of using autograft material include graft availability, the absence of possible disease transmission risk, and that the procedure is a single-stage procedure. Disadvantages include donor site morbidity and limited available graft volume. In addition, tissue may have to be harvested from two different donor sites in order to provide enough material for a large defect without compromising the donor site.
The COR and COR2 systems (DePuy-Mitek) can be utilized for autograft or allograft transplantation. Allografts Grafts of bone and cartilage harvested from a cadaver joint (may be fresh or cryopreserved), which is then implanted in the defect. Allografting is typically used to repair larger defects of the knee (e.g., 10 cm2). The use of allograft cartilage has the advantage of providing osteochondral segments that are must be implanted within 72 hours of donor death, may be difficult to obtain (due to scarcity) and may also entail a concern of disease transmission.

Page 2 of 11 Application of osteochondral allografting is limited because cryopreserved allografts do not contain an acceptable level of cartilage viability, and cryopreservation may decrease the viability of the cartilage cells. A minimally processed osteochondral allograft (e.g., Chondrofix® [Zimmer]) is composed of decellularized hyaline cartilage and cancellous bone, which can be used “off the shelf” with precut cylinders of 7–15 mm. Multiple cylinders may be used to fill larger defects. The Osteochondral Autograft Transfer System (OATS) involves use of larger plugs usually filling the entire defect with a single plug. The COR and COR2 systems can be utilized for autograft or allograft transplantation. Mosaicplasty A technique of creating an osteochondral autograft by harvesting and transplanting multiple small cylindrical osteochondral plugs from the less weight-bearing periphery of the patellofemoral area and inserting them into drilled tunnels in the defective section of cartilage. (E.g., Mosaicplasty System) Guideline Osteochondral autografting and allografting have been investigated for full-thickness cartilage defects of weight bearing surfaces secondary to trauma or conditions such as osteochondritis dissecans. The goal of grafting is to re-establish the cartilage matrix with chondrocytes and support bone in order to improve joint function and decrease pain. Osteochondral autografting and allografting with one or more cores of osteochondral tissue is considered medically necessary for the treatment of cartilaginous defects caused by acute or repetitive trauma in the knee or ankle when all of the following criteria are met:

Presence of disabling, localized knee or ankle pain of ≥ 6 months duration that is refractory to conservative treatment, as well as abrasion arthroplasty and/or microfracture techniques
Mature skeletal growth achieved, or not a suitable candidate, for total joint replacement
Cartilage defect ≥ 1cm2
Focal, full thickness isolated defect of the weight bearing surface of any of the following areas: a. Talus
b. Medial or lateral femoral condyles
c. Trochlear region of the knee d. Patellar chondral defect
Defect is unipolar
Lesion is largely contained with near-normal surrounding articular cartilage and articulating cartilage (grades 0, 1, 2)
In the knee, meniscus is intact or has stable partial tears. (Partial meniscectomy may be indicated and does not preclude osteochondral grafting)
Normal or near-normal joint space with no > 15% joint space narrowing
No presence of active infection
No inflammation or osteoarthritis in the joint
Joint is stable with normal alignment. (A procedure to correct alignment may be performed in combination with, or prior to, grafting)
Member is willing and able to comply with post-operative weight-bearing restrictions and rehabilitation

Page 3 of 11

No history of cancer in the bones, cartilage, fat or muscle of the affected limb Limitations/Exclusions Osteochondral grafting is not considered medically necessary for any of the following due to insufficient evidence of therapeutic value:
Use in joints other than the knee and ankle (e.g., shoulder, elbow, hip)
Use of minced articular cartilage (autologous or allogeneic) (e.g., Cartilage Autograft Implantation System [CAIS], BioCartilage® [Arthrex], DeNovo NT Graft [natural tissue graft; ISTO Technologies]
Decellularized osteochondral allograft plugs (e.g., Chondrofix)
Reduced allograft discs (e.g., ProChondrix, Cartiform) Procedure Codes
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) Diagnosis Codes M22.40 Chondromalacia patellae, unspecified knee
M22.41 Chondromalacia patellae, right knee
M22.42 Chondromalacia patellae, left knee
M23.000 Cystic meniscus, unspecified lateral meniscus, right knee
M23.001 Cystic meniscus, unspecified lateral meniscus, left knee
M23.002 Cystic meniscus, unspecified lateral meniscus, unspecified knee
M23.003 Cystic meniscus, unspecified medial meniscus, right knee
M23.004 Cystic meniscus, unspecified medial meniscus, left knee
M23.005 Cystic meniscus, unspecified medial meniscus, unspecified knee
M23.006 Cystic meniscus, unspecified meniscus, right knee
M23.007 Cystic meniscus, unspecified meniscus, left knee
M23.009 Cystic meniscus, unspecified meniscus, unspecified knee
M23.011 Cystic meniscus, anterior horn of medial meniscus, right knee
M23.012 Cystic meniscus, anterior horn of medial meniscus, left knee
M23.019 Cystic meniscus, anterior horn of medial meniscus, unspecified knee

Page 4 of 11 M23.021 Cystic meniscus, posterior horn of medial meniscus, right knee
M23.022 Cystic meniscus, posterior horn of medial meniscus, left knee
M23.029 Cystic meniscus, posterior horn of medial meniscus, unspecified knee
M23.031 Cystic meniscus, other medial meniscus, right knee
M23.032 Cystic meniscus, other medial meniscus, left knee
M23.039 Cystic meniscus, other medial meniscus, unspecified knee
M23.041 Cystic meniscus, anterior horn of lateral meniscus, right knee
M23.042 Cystic meniscus, anterior horn of lateral meniscus, left knee
M23.049 Cystic meniscus, anterior horn of lateral meniscus, unspecified knee
M23.051 Cystic meniscus, posterior horn of lateral meniscus, right knee
M23.052 Cystic meniscus, posterior horn of lateral meniscus, left knee
M23.059 Cystic meniscus, posterior horn of lateral meniscus, unspecified knee
M23.061 Cystic meniscus, other lateral meniscus, right knee
M23.062 Cystic meniscus, other lateral meniscus, left knee
M23.069 Cystic meniscus, other lateral meniscus, unspecified knee
M23.2 Derangement of meniscus due to old tear or injury
M23.200 Derangement of unspecified lateral meniscus due to old tear or injury, right knee
M23.201 Derangement of unspecified lateral meniscus due to old tear or injury, left knee
M23.202 Derangement of unspecified lateral meniscus due to old tear or injury, unspecified knee
M23.203 Derangement of unspecified medial meniscus due to old tear or injury, right knee
M23.204 Derangement of unspecified medial meniscus due to old tear or injury, left knee
M23.205 Derangement of unspecified medial meniscus due to old tear or injury, unspecified knee
M23.206 Derangement of unspecified meniscus due to old tear or injury, right knee
M23.207 Derangement of unspecified meniscus due to old tear or injury, left knee
M23.209 Derangement of unspecified meniscus due to old tear or injury, unspecified knee
M23.211 Derangement of anterior horn of medial meniscus due to old tear or injury, right knee
M23.212 Derangement of anterior horn of medial meniscus due to old tear or injury, left knee
M23.219 Derangement of anterior horn of medial meniscus due to old tear or injury, unspecified knee
M23.221 Derangement of posterior horn of medial meniscus due to old tear or injury, right knee
M23.222 Derangement of posterior horn of medial meniscus due to old tear or injury, left knee
M23.229 Derangement of posterior horn of medial meniscus due to old tear or injury, unspecified knee
M23.231 Derangement of other medial meniscus due to old tear or injury, right knee
M23.232 Derangement of other medial meniscus due to old tear or injury, left knee
M23.239 Derangement of other medial meniscus due to old tear or injury, unspecified knee
M23.241 Derangement of anterior horn of lateral meniscus due to old tear or injury, right knee

Page 5 of 11 M23.242 Derangement of anterior horn of lateral meniscus due to old tear or injury, left knee
M23.249 Derangement of anterior horn of lateral meniscus due to old tear or injury, unspecified knee
M23.251 Derangement of posterior horn of lateral meniscus due to old tear or injury, right knee
M23.252 Derangement of posterior horn of lateral meniscus due to old tear or injury, left knee
M23.259 Derangement of posterior horn of lateral meniscus due to old tear or injury, unspecified knee
M23.261 Derangement of other lateral meniscus due to old tear or injury, right knee
M23.262 Derangement of other lateral meniscus due to old tear or injury, left knee
M23.269 Derangement of other lateral meniscus due to old tear or injury, unspecified knee
M23.300 Other meniscus derangements, unspecified lateral meniscus, right knee
M23.301 Other meniscus derangements, unspecified lateral meniscus, left knee
M23.302 Other meniscus derangements, unspecified lateral meniscus, unspecified knee
M23.303 Other meniscus derangements, unspecified medial meniscus, right knee
M23.304 Other meniscus derangements, unspecified medial meniscus, left knee
M23.305 Other meniscus derangements, unspecified medial meniscus, unspecified knee
M23.306 Other meniscus derangements, unspecified meniscus, right knee
M23.307 Other meniscus derangements, unspecified meniscus, left knee
M23.309 Other meniscus derangements, unspecified meniscus, unspecified knee
M23.311 Other meniscus derangements, anterior horn of medial meniscus, right knee
M23.312 Other meniscus derangements, anterior horn of medial meniscus, left knee
M23.319 Other meniscus derangements, anterior horn of medial meniscus, unspecified knee
M23.321 Other meniscus derangements, posterior horn of medial meniscus, right knee
M23.322 Other meniscus derangements, posterior horn of medial meniscus, left knee
M23.329 Other meniscus derangements, posterior horn of medial meniscus, unspecified knee
M23.331 Other meniscus derangements, other medial meniscus, right knee
M23.332 Other meniscus derangements, other medial meniscus, left knee
M23.339 Other meniscus derangements, other medial meniscus, unspecified knee
M23.341 Other meniscus derangements, anterior horn of lateral meniscus, right knee
M23.342 Other meniscus derangements, anterior horn of lateral meniscus, left knee
M23.349 Other meniscus derangements, anterior horn of lateral meniscus, unspecified knee
M23.351 Other meniscus derangements, posterior horn of lateral meniscus, right knee
M23.352 Other meniscus derangements, posterior horn of lateral meniscus, left knee
M23.359 Other meniscus derangements, posterior horn of lateral meniscus, unspecified knee
M23.361 Other meniscus derangements, other lateral meniscus, right knee
M23.362 Other meniscus derangements, other lateral meniscus, left knee
M23.369 Other meniscus derangements, other lateral meniscus, unspecified knee

Page 6 of 11 M23.40 Loose body in knee, unspecified knee
M23.41 Loose body in knee, right knee
M23.42 Loose body in knee, left knee
M23.50 Chronic instability of knee, unspecified knee
M23.51 Chronic instability of knee, right knee
M23.52 Chronic instability of knee, left knee
M23.601 Other spontaneous disruption of unspecified ligament of right knee
M23.602 Other spontaneous disruption of unspecified ligament of left knee
M23.609 Other spontaneous disruption of unspecified ligament of unspecified knee
M23.611 Other spontaneous disruption of anterior cruciate ligament of right knee
M23.612 Other spontaneous disruption of anterior cruciate ligament of left knee
M23.619 Other spontaneous disruption of anterior cruciate ligament of unspecified knee
M23.621 Other spontaneous disruption of posterior cruciate ligament of right knee
M23.622 Other spontaneous disruption of posterior cruciate ligament of left knee
M23.629 Other spontaneous disruption of posterior cruciate ligament of unspecified knee
M23.631 Other spontaneous disruption of medial collateral ligament of right knee
M23.632 Other spontaneous disruption of medial collateral ligament of left knee
M23.639 Other spontaneous disruption of medial collateral ligament of unspecified knee
M23.641 Other spontaneous disruption of lateral collateral ligament of right knee
M23.642 Other spontaneous disruption of lateral collateral ligament of left knee
M23.649 Other spontaneous disruption of lateral collateral ligament of unspecified knee
M23.671 Other spontaneous disruption of capsular ligament of right knee
M23.672 Other spontaneous disruption of capsular ligament of left knee
M23.679 Other spontaneous disruption of capsular ligament of unspecified knee
M23.8X1 Other internal derangements of right knee
M23.8X2 Other internal derangements of left knee
M23.8X9 Other internal derangements of unspecified knee
M23.90 Unspecified internal derangement of unspecified knee
M23.91 Unspecified internal derangement of right knee
M23.92 Unspecified internal derangement of left knee
M25.861 Other specified joint disorders, right knee
M25.862 Other specified joint disorders, left knee
M25.869 Other specified joint disorders, unspecified knee
M25.871 Other specified joint disorders, right ankle and foot
M25.872 Other specified joint disorders, left ankle and foot

Page 7 of 11 M25.879 Other specified joint disorders, unspecified ankle and foot
M92.40 Juvenile osteochondrosis of patella, unspecified knee
M92.41 Juvenile osteochondrosis of patella, right knee
M92.42 Juvenile osteochondrosis of patella, left knee
M92.511 Juvenile osteochondrosis of proximal tibia, right leg
M92.512 Juvenile osteochondrosis of proximal tibia, left leg
M92.513 Juvenile osteochondrosis of proximal tibia, bilateral
M92.519 Juvenile osteochondrosis of proximal tibia, unspecified leg
M92.521 Juvenile osteochondrosis of tibia tubercle, right leg
M92.522 Juvenile osteochondrosis of tibia tubercle, left leg
M92.523 Juvenile osteochondrosis of tibia tubercle, bilateral
M92.529 Juvenile osteochondrosis of tibia tubercle, unspecified leg
M92.8 Other specified juvenile osteochondrosis
M92.591 Other juvenile osteochondrosis of tibia and fibula, right leg
M92.592 Other juvenile osteochondrosis of tibia and fibula, left leg
M92.593 Other juvenile osteochondrosis of tibia and fibula, bilateral
M92.599 Other juvenile osteochondrosis of tibia and fibula, unspecified leg
M93.261 Osteochondritis dissecans, right knee
M93.262 Osteochondritis dissecans, left knee
M93.269 Osteochondritis dissecans, unspecified knee
M93.271 Osteochondritis dissecans, right ankle and joints of right foot
M93.272 Osteochondritis dissecans, left ankle and joints of left foot
M93.279 Osteochondritis dissecans, unspecified ankle and joints of foot
M94.261 Chondromalacia, right knee
M94.262 Chondromalacia, left knee
M94.269 Chondromalacia, unspecified knee
M94.271 Chondromalacia, right ankle and joints of right foot
M94.272 Chondromalacia, left ankle and joints of left foot
M94.279 Chondromalacia, unspecified ankle and joints of foot

References Astur DC, et al. Autologous osteochondral transplantation for treating patellar chondral injuries: evaluation, treatment, and outcomes of a two-year follow-up study. J Bone Joint Surg Am 2014 May 21;96(10):816-23. Aubin PP, et al. Long-term follow-up of fresh femoral osteochondral allografts for posttraumatic knee defects. Clin Orthopaed Rel Res 2001;(2):S218-327.

Page 8 of 11 Bekkers JE, et al. Treatment selection in articular cartilage lesions of the knee: a systematic review. Am J Sports Med 2009 Nov;37 Suppl 1:148S-55S. Bekkers JE, et al. Articular cartilage evaluation after TruFit plug implantation analyzed by delayed gadolinium-enhanced MRI of cartilage (dGEMRIC). Am J Sports Med 2013 Jun;41(6):1290-5. Bentley G, et al. Minimum ten-year results of a prospective randomized study of autologous chondrocyte implantation versus mosaicplasty for symptomatic articular cartilage lesions of the knee. J Bone Joint Surg Br 2012 Apr;94(4):504-9. BlueCross BlueShield Association. Osteochondral autografts and allografts in the treatment of focal articular cartilage lesions. Medical Policy Reference Manual Policy #7.01.78. 2015 Jun 11. Bugbee WD, et al. Bipolar fresh osteochondral allografting of the tibiotalar joint. J Bone Joint Surg Am 2013 Mar 6;95(5):426-32. Camp CL, et al. Transplantation of a tibial osteochondral allograft to restore a large glenoid osteochondral defect. Orthopedics 2015 Feb;38(2):e147-52. Chahal J, et al. Outcomes of osteochondral allograft transplantation in the knee. Arthroscopy 2013 Mar;29(3):575-88. Chambers HG, et al. American Academy of orthopedic Surgeons clinical practice guideline on: the diagnosis and treatment of osteochondritis dissecans. J Bone Joint Surg Am 2012 Jul 18;94(14):1322-4. De Caro F, et al. Large fresh osteochondral allografts of the knee: a systematic clinical and basic science review of the literature. Arthroscopy 2015 Apr;31(4):757-65. Duif C, Koutah MA, Ackermann O, et al. Combination of autologous chondrocyte implantation (ACI) and osteochondral autograft transfer system (OATS) for surgical repair of larger cartilage defects of the knee joint. A review illustrated by a case report. Technol Health Care. 2015;23(5):531-537. El-Rashidy H, et al. Fresh osteochondral allograft for the treatment of cartilage defects of the talus: a retrospective review. J Bone Joint Surg Am 2011 Sep 7;93(7):1634-40. Emre TY, et al. Open mosaicplasty in osteochondral lesions of the talus: a prospective study. J Foot Ankle Surg 2012 Sep- Oct;51(5):556-60. Erdil M, et al. Osteochondral autologous graft transfer system in the knee; mid-term results. Knee 2013 Jan;20(1):2-8. Farr J, et al. Clinical, radiographic, and histological outcomes after cartilage repair with particulated juvenile articular cartilage: A 2-year prospective study. Am J Sports Med 2014 Jun;42(6):1417-25. Figueroa D, et al. Osteochondral autografts in full thickness patella cartilage lesions. Knee 2011 Aug;18(4):220-3. Galli MM, et al. Role of demineralized allograft subchondral bone in the treatment of shoulder lesions of the talus: clinical results with two-year follow-up. J Foot Ankle Surg 2014 Jul 9 [Epub ahead of print]. Gobbi A, et al. Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation. Arthroscopy 2006 Oct;22(10):1085-92. Gracitelli GC, et al. Fresh osteochondral allograft transplantation for isolated patellar cartilage injury. Am J Sports Med 2015 Apr;43(4):879-84. Gracitelli GC, et al. Fresh osteochondral allografts in the knee: comparison of primary transplantation versus transplantation after failure of previous subchondral marrow stimulation. Am J Sports Med 2015 Apr;43(4):885-91. Gudas R, et al. A prospective, randomized clinical study of osteochondral autologous transplantation versus microfracture for the treatment of osteochondritis dissecans in the knee joint in children. J Pediatr Orthop 2009 Oct-Nov;29(7):741-8. Gudas R, et al. ten-year follow-up of a prospective, randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint of athletes. Am J Sports Med 2012 Nov;40(1):2499-508. Gudas R, et al. Comparison of osteochondral autologous transplantation, microfracture, or debridement techniques in articular cartilage lesions associated with anterior cruciate ligament injury: a prospective study with a 3-year follow-up. Arthroscopy 2013 Jan;29(1):89-97.

Page 9 of 11 Haasper C, et al. No mid-term difference in mosaicplasty in previously treated versus previously untreated patients with osteochondral lesions of the talus. Arch Orthop Trauma Surg 2008 May;128(5):499-504. Haene R, et al. Intermediate outcomes of fresh talar osteochondral allografts for treatment of large osteochondral lesions of the talus. J Bone Joint Surg Am 2012 Jun 20;94(12):1105-10. Hangody L, et al. Mosaicplasty for the treatment of articular defects of the knee and ankle. Clin Orthopaed Rel Res 2001 Oct;1(391):S328-36. Hangody L, et al. Mosaicplasty for the treatment of osteochondritis dissecans of the talus: two to seven year results in 36 patients. Foot Ankle Internat 2001 Jul;22(7):552-8. Hangody L, et al. Autologous osteochondral grafting- technique and long-term results. Injury 2008 Apr;39(Suppl)1:S32-9. Harris JD, et al. Biological knee reconstruction: a systematic review of combined meniscal allograft transplantation and cartilage repair or restoration. Arthroscopy 2011;27(3):409-18. Hettrich CM, et al. Cartilage repair: third-generation cell-based technologies- basic science, surgical techniques and clinical outcomes. Sports Med Arthrosc 2008 Dec;16(4):230-5. Hindle P, et al. Autologous osteochondral mosaicplasty or TruFitTM plugs for cartilage repair. Knee Surg Sports Traumatol Arthrosc 2014 Jun;22(6):1235-40. Hu Y, et al. Treatment of large cystic medial osteochondral lesions of the talus with autologous osteoperiosteal cylinder grafts. Arthroscopy 2013 Aug;29(8):1372-9. Imhoff AB, et al. Osteochondral transplantation of the talus: long-term clinical and magnetic resonance imaging evaluation. Am J Sports Med 2011 Jul;39(7):1487-93. Iwasaki N, et al. Autologous osteochondral mosaicplasty for osteochondritis dissecans of the elbow in teenage athletes. J Bone Joint Surg Am 2009 Oct;91(10):2359-66. Li Z, Zhu T, Fan W. Osteochondral autograft transplantation or autologous chondrocyte implantation for large cartilage defects of the knee: A meta-analysis. Cell Tissue Bank. 2016;17(1):59-67.Lynch TS, Patel RM, Benedick A, et al. Systematic review of autogenous osteochondral transplant outcomes. Arthroscopy. 2015;31(4):746-754.
Jeng CL, et al. Fresh osteochondral total ankle allograft transplantation for the treatment of ankle arthritis. Foot Ankle Int 2008 Jun;29(6):554-60. Joshi N, et al. Synthetic resorbable scaffolds for the treatment of isolated patellofemoral cartilage defects in young patients: magnetic resonance imaging and clinical evaluation. Am J Sports Med 2012 Jun;40(6):1289-95. Kim YS, et al. Clinical comparison of the osteochondral autograft transfer system and subchondral drilling in the osteochondral defects of the first metatarsal head. Am J Sports Med 2012 Aug;40(8):1824-33. Kim YS, et al. Factors associated with the clinical outcomes of the osteochondral autograft system in osteochondral lesions of the talus: second-look arthroscopic evaluation. Am J Sports Med 2012 Dec;40(12):2709-19. Kircher J, et al. Osteochondral autologous transplantation for the treatment of full-thickness cartilage defects of the shoulder: results at nine years. J Bone Joint Surg Br 2009 Apr;91(4):499-503. Kon E, et al. How to treat osteochondritis dissecans of the knee: surgical techniques and new trends: AAOS exhibit selection. J Bone Joint Surg Am 2012 Jan 4;94(1):e1(1-8). Kreuz P, et al. Mosaicplasty with autogenous talar autograft for osteochondral lesions of the talus after failed primary arthroscopic management – a prospective study with a 4-year follow-up. Am J Sports Med 2006:34(1):55-63. Kyrch AJ, et al. Return to athletic activity after osteochondral allograft transplantation in the knee. Am J Sports Med 2012 May;40(5):1053-9. Kyrch AJ, et al. Activity levels are higher after osteochondral autograft transfer mosaicplasty than after microfracture for articular cartilage defects of the knee: a retrospective comparative study. J Bone Joint Surg Am 2012 Jun 6;94(11):971-8. Lim HC, et al. Current treatments of isolated articular cartilage lesions of the knee achieve similar outcomes. Clin Orthop Relat Res 2012 Aug;470(8):2261-7.

Page 10 of 11 Liu W, et al. Osteochondral autograft transplantation for acute osteochondral fractures associated with an ankle fracture. Foot Ankle Int 2011 Apr;32(4):437-42. Lynch TS, et al. Systematic review of autogenous osteochondral transplant outcomes. Arthroscopy 2015 Apr;31(4):746-54. Ma HL, et al. Osteochondral autografts transfer for post-traumatic osteochondral defect of the knee- 2-5 years follow-up. Injury 2004 Dec;35(12):1286-92. Maruyama M, et al. Outcomes of an open autologous osteochondral plug graft for capitellar osteochondritis dissecans: time to return to sports. Am J Sports Med 2014 Sep;42(9):2122-77. Meric G, et al. Fresh osteochondral allograft transplantation for bipolar reciprocal osteochondral lesions of the knee. Am J Sports Med 2015 Mar;43(3):709-14. Murphy RT, et al. Osteochondral allograft transplantation of the knee in the pediatric and adolescent population. Am J Sports Med 2014 Mar;42(3):635-40. National Institute for Health and Clinical Excellence. Mosaicplasty for symptomatic articular cartilage defects of the knee. March 2018. https://www.nice.org.uk/guidance/ipg607. Accessed January 23, 2026. Ollat D, et al. Mosaic osteochondral transplantations in the knee joint, midterm results of the SFA multicenter study. Orthop Traumatol Surg Res 2011 Dec;97(8 Suppl):S160-6. Ovesen J, et al. The clinical outcomes of mosaicplasty in the treatment of osteochondritis dissecans of the distal humeral capitellum of young athletes. J Shoulder Elbow Surg 2011 Jul;20(5):813-8. Pearce CJ, et al. Synthetic osteochondral grafting of ankle osteochondral lesions. Foot Ankle Surg 2012 Jun;18(2):114-8. Peterson W, et al. Osteochondral transplantation for the treatment of osteochondral defects at the talus with the Diamond twin system® and graft harvesting from the posterior femoral condyles. Arch Orthop Trauma Surg 2014 Jun;134(6):843-52. Raikin SM. Fresh osteochondral allografts for large-volume cystic osteochondral defects of the talus. J Bone Joint Surg Am 2009 Dec;91(12):2818-26. Richter DL, Schenck RC Jr, Wascher DC, Treme G. Knee articular cartilage repair and restoration techniques: A review of the literature. Sports Health. 2016;8(2):153-160. Sagstetter PJ, et al. Donor-site morbidity after osteochondral autologous transplantation for lesions of talus. J Bone Joint Surg Am 2009 Jul;91(17):1683-8. Shimada K, et al. Cylindrical costal osteochondral autograft for reconstruction of large defects of the capitellum due to osteochondritis dissecans. J Bone Joint Surg Am 2012 Jun 6;94(11):992-1002. Solheim E, et al. Results at 10 to 14 years after osteochondral autografting (mosaicplasty) in articular cartilage defects in the knee. Knee 2013 Aug;20(4):287-90. Spak RT, et al. Fresh osteochondral allografts for patellofemoral arthritis – long-term followup. Clin Ortho Rel Res 2006 Mar;(444):193-200. Ulstein S, et al. Microfracture technique versus osteochondral autologous transplantation mosaicplasty in patients with articular chondral lesions of the knee: a prospective randomized trial with long-term follow-up. Knee Surg Sports Traumatol Arthrosc 2014 Jun;22(6):1207-15. Valderrabano V, et al. Reconstruction of osteochondral lesions of the talus with autologous spongiosa grafts and autologous matrix-induced chondrogenesis. Am J Sports Med 2013 Mar;41(3):519-27. Vogt S, et al. Osteochondral transplantation in the elbow leads to good clinical and radiologic long-term results: An 8-to 14-year follow-up examination. Am J Sports Med 2011 Dec;39(12):2619-25. Wang CJ. Treatment of focal articular cartilage lesions of the knee with autogenous osteochondral grafts – a 2 to 4 year follow-up study. Arch Orthoped Trauma Surg 2002;122:169-72. Woelfe JV, et al. Indications and limitations of osteochondral autologous transplantation in osteochondritis dissecans of the talus. Knee Surg Sports Traumatol Arthrosc 2013 Aug;21(8):1925-30.

Page 11 of 11 Wu WC, et al. Autologous osteochondral graft for traumatic defects of finger joints. J Hand Surg Eur Vol 2012 Mar;37(3):251-7. Yoon HS, et al. Osteochondral autologous transplantation is superior to repeat arthroscopy for the treatment of osteochondral lesions of the talus after failed primary arthroscopic treatment. Am J Sports Med 2014 Jun 6;42(8):18961903. Solheim E, et al. Results at 10-14 years after microfracture treatment of articular cartilage defects in the knee. Knee Surg Sports Traumatol Arthrosc 2014 Nov 23 [Epub ahead of print]. Specialty matched clinical peer review. Revision History Company(ies)

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REVISION EmblemHealth Feb 14, 2025 Transferred policy content to individual company branded template EmblemHealth ConnectiCare Feb. 10, 2023 Added patellar chondral defect indication to coincide with covered diagnostic coding listed in policy ConnectiCare Jan. 14, 2022 Retired MCG criteria for this service and adopted the clinical criteria of parent corporation EmblemHealth EmblemHealth Jan. 11, 2019 Added decellularized osteochondral allograft plugs (e.g., Chondrofix) and reduced allograft discs (e.g., ProChondrix, Cartiform) to Limitations/Exclusions section as investigational

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