CommercialPrior AuthHigh impact
Osteochondral Grafting of the Knee - (Effective Date - 2026-10-15) 7.01.59
Excellus BlueCross BlueShield·Orthopedics, Sports Medicine·Bone & Joints (Orthopedic)
Effective date
Oct 15, 2026
We identified it
Jul 16, 2026
Summary
Excellus BlueCross BlueShield has established strict medical necessity criteria for osteochondral grafting (OATS/mosaicplasty) of the knee, effective October 15, 2026. Coverage requires patients to meet 10 specific criteria including BMI <35, age ≤49 years, Kellgren-Lawrence Grade II or less, specific defect sizes, failed conservative management for 3+ months, and stable knee anatomy. Hybrid ACI/OATS procedures are deemed investigational and not covered.
Action Required
By October 15, 2026: Billing team must implement prior authorization requirements for all osteochondral grafting procedures (OATS, mosaicplasty, and allograft transplantation) for Excellus BlueCross BlueShield members. Before submitting claims, obtain prior authorization and verify the following documentation from providers: (1) Patient BMI <35 and age ≤49; (2) Imaging confirmation (CT arthrogram, MRI with Modified Outerbridge Grade III-IV, or arthroscopy with Outerbridge Grade III-IV); (3) Defect size ≤2.5 cm² for autograft/mosaicplasty OR ≤10.0 cm² for allograft; (4) Absence of kissing lesions; (5) Evidence of stable knee with intact/reconstructed ligaments and normal alignment; (6) Documentation of function-limiting pain; (7) Proof of 3+ months failed conservative management. Update billing system to automatically flag claims that do not include all 10 criteria and route to compliance for denial. Add to encounter templates and provider education materials that Hybrid ACI/OATS procedures are investigational and should not be submitted for reimbursement. Failure to obtain prior authorization will result in claim denials.