Allograft Transplants of the Extremities (CPB 0364, reviewed 2026-05-15)

Immediately (by 2026-05-15): Billing team must implement prior authorization process for all allograft extremity claims submitted to Aetna. (1) Update billing system to flag CPT codes 20932-20934, 27427-27429, and 29888-29889 for mandatory pre-service review. (2) Create verification checklist for medical necessity criteria: for osteochondral knee allografts, verify documentation includes lesion size (≥3 sq cm), grade (III-IV), BMI (≤35), non-smoker status with nicotine labs if applicable, 6+ weeks conservative treatment, and imaging confirmation; for meniscal allografts, verify age (<55), degenerative changes (Outerbridge ≤II), conservative treatment failure, and MRI/arthroscopy confirmation; for ankle instability, verify 6 months failed conservative treatment. (3) Coding and prior auth staff must deny or request documentation for any claims matching experimental/investigational procedures (BEAR implant, BMAC augmentation, DeNovo grafts, osteochondral talus procedures, OAT for talus, TruFit/PolyGraft synthetics, vascularized bone grafts for avascular necrosis). (4) Update encounter templates to require surgeon documentation of all selection criteria before procedure authorization. (5) Train providers on non-covered indications per policy Experimental section. (6) For claims submitted without prior auth meeting criteria, obtain retroactive documentation or deny claim. Failure to implement prior auth will result in increased claim denials and potential overpayments.