CommercialCoverageHigh impact
Autologous Chondrocyte Implantation (CPB 0247, reviewed 2026-04-16)
Aetna·Orthopedics, Sports Medicine, General Surgery·Surgery
Effective date
Apr 16, 2026
We identified it
Aug 14, 2026
Summary
Aetna has updated its Clinical Policy Bulletin 0247 for Autologous Chondrocyte Implantation (ACI), establishing detailed medical necessity criteria for knee cartilage repair procedures. The policy covers CPT 27412 and HCPCS J7330/S2112 when strict patient and defect criteria are met, while explicitly designating numerous combination procedures and alternative joint treatments as experimental/non-covered. Billing teams must verify all 13 medical necessity requirements before submitting claims to avoid denials.
Action Required
By 2026-04-16, billing team must: (1) Update claim submission software to require verification of ALL 13 medical necessity criteria before CPT 27412 or HCPCS J7330/S2112 can be billed, including age (≥15 with closed growth plate or <55), BMI ≤35, 6+ weeks prior PT failure, defect size 2-4 sq cm (arthroscopic) or 2-8 sq cm (open), and documented nicotine cessation with lab confirmation if applicable; (2) Configure system to DENY claims for experimental procedures including: meniscal allograft combinations (CPT 29868), osteochondral autograft combinations (CPT 29866), AMIC procedures, ankle/talar lesions, and two-stage bone/meniscus allograft combinations; (3) Add pre-authorization checklist to encounter templates requiring provider documentation of defect grade (Grade IV only), opposing surface quality (Modified Outerbridge 0-1), knee stability/alignment, and absence of osteoarthritis/inflammatory disease; (4) Update claim denial messaging to reference specific CPB 0247 criteria for rejections. Providers must include specific documentation; claims lacking required criteria verification will be denied.