CommercialCoverageHigh impact
Osteochondral Grafting of the Knee 7.01.59
Excellus BlueCross BlueShield·Orthopedics, Sports Medicine·Bone & Joints (Orthopedic)
Effective date
Oct 15, 2025
We identified it
Jun 20, 2026
Summary
Excellus BlueCross BlueShield has updated their medical policy for osteochondral grafting of the knee, establishing specific coverage criteria including BMI limits, age restrictions, imaging requirements, and mandatory 3-month conservative treatment failure. The policy considers certain hybrid procedures investigational and not covered.
Action Required
By October 15, 2025: Clinical staff must verify all osteochondral grafting cases meet ALL coverage criteria including BMI <35, age ≤49, specific imaging findings (Kellgren-Lawrence Grade II or less, Outerbridge Grade III-IV), defect size requirements (≤2.5 cm² for autograft, ≤10 cm² for allograft), stable knee anatomy, and documented 3-month conservative treatment failure. Update prior authorization requests to include all required documentation. Hybrid ACI/OATS procedures will be denied as investigational.