CommercialPrior AuthHigh 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
Jul 16, 2026
Summary
Excellus BlueCross BlueShield established a new medical policy (effective October 15, 2025) establishing strict coverage criteria for osteochondral grafting procedures of the knee. The policy defines when OATS/mosaicplasty/allograft transplantation is medically appropriate, requiring meeting ALL criteria including BMI <35, age ≤49, specific imaging findings, defect size limits, and 3+ months of failed conservative management. Any procedures outside these criteria or using hybrid ACI/OATS techniques are considered investigational and non-covered.
Action Required
By October 15, 2025: Billing team must implement prior authorization process requiring verification of ALL policy criteria before processing claims for osteochondral grafting procedures. Update claim submission templates to capture: BMI documentation, patient age, imaging results (Kellgren-Lawrence Grade, Outerbridge Classification), defect size measurements (≤2.5 cm² for autograft/mosaicplasty; ≤10.0 cm² for allograft), documentation of 3+ months conservative management, and physical exam findings (knee stability, ligament/meniscal status, alignment). Providers must submit imaging reports and operative notes with claims. Reject claims that do not include complete documentation of all nine criteria (A-J). Flag any hybrid ACI/OATS procedures as investigational/non-covered for denial. Update provider communication materials to detail new requirements. No claims for osteochondral grafting procedures of the knee should be processed without prior authorization verification against these criteria.