CommercialPrior AuthHigh impact
Osteochondral Autografts (Mosaicplasty, OATS) (CPB 0637, reviewed 2026-01-16)
Aetna·Orthopedics, Sports Medicine·Medical Policy
Effective date
Jan 16, 2026
We identified it
Aug 13, 2026
Summary
Aetna has updated its Clinical Policy Bulletin 0637 for Osteochondral Autografts (OATS/Mosaicplasty), effective immediately (reviewed 2026-01-16). The policy establishes specific medical necessity criteria for knee OATS procedures including patient age (15+, under 55), BMI ≤35, non-smoker status with documented nicotine cessation, and strict lesion size/location requirements. Multiple combination therapies and procedures for other joints remain experimental/non-covered.
Action Required
Immediately effective (2026-01-16): (1) Billing team must update prior authorization workflows in billing software to require documentation of ALL nine medical necessity criteria before submitting claims for CPT 27416 and 29866 (OATS knee procedures). (2) Providers must document in operative reports: skeletal maturity confirmation, age under 55, failed conservative therapy (6+ weeks), lesion size (2-4 cm arthroscopic, 2-8 cm open), Outerbridge grade ≤II surrounding cartilage, knee stability/alignment/normal joint space on X-ray, opposing surface Modified Outerbridge 0-1, BMI ≤35, and nicotine-free status with lab verification (blood/urine nicotine ≤10 ng/ml or urinary cotinine ≤10 ng/ml within 6 weeks pre-surgery). (3) Update encounter forms and pre-op checklists to capture BMI, smoking/nicotine use status, and require lab documentation for nicotine screening. (4) Deny or request additional documentation for CPT 27412, 28446, and any billing codes for experimental procedures listed in policy (biologic augmentation, hybrid ACI/OATS, nuts-in-jelly mosaicplasty, OATS of non-knee joints). (5) Implement system rules to flag claims missing any required criteria elements. Failure to obtain/document medical necessity will result in claim denials.