Medicare AdvantageCoverageHigh impact
Osteochondral and Subchondral Defects Surgery - Medicare Advantage (Revised)
Humana·Orthopedics, Sports Medicine·Medicare Advantage
Effective date
Jul 1, 2025
We identified it
Jun 24, 2026
Summary
Humana Medicare Advantage has updated their policy for osteochondral and subchondral defects surgery, effective July 1, 2025. The policy establishes specific medical necessity criteria for procedures like autologous chondrocyte transplantation, including requirements for BMI ≤35, focal defects 2-10 cm², and failure of 3 months conservative treatment.
Action Required
Before July 1, 2025: Billing and clinical teams must update prior authorization processes for osteochondral procedures to include new medical necessity documentation requirements: BMI documentation ≤35, MRI or arthroscopy reports showing focal defects 2-10 cm², and proof of 3 months failed conservative treatment. Update EMR templates and prior auth checklists to capture these specific criteria. Claims without proper documentation will likely be denied.