Autologous Chondrocyte Implantation (CPB 0247, reviewed 2026-09-23)

IMMEDIATELY: Billing team must implement prior authorization review process for CPT 27412 and J7330 claims submitted to Aetna. Create internal checklist requiring verification of ALL 14 medical necessity criteria before claim submission, including: (1) age 15+ with documented growth plate closure OR <55 years; (2) BMI documentation ≤35; (3) evidence of 6-week minimum physical therapy failure within past year; (4) defect size 2-4 sq cm (arthroscopic) or 2-8 sq cm (open); (5) non-smoker status with lab-documented nicotine levels ≤10 ng/ml within 6 weeks of surgery; (6) imaging confirmation of focal full-thickness chondral defect (grade IV), opposing surface Modified Outerbridge 0-1, stable/aligned knee with intact meniscus and normal joint space; (7) documentation ruling out all alternative pain sources. Update billing software to flag any CPT 27412 or J7330 claims lacking complete documentation and hold for medical necessity verification before transmission. Instruct providers to document all 14 criteria elements in operative reports and submit with claims. Flag for DENIAL any claims combining CPT 27412 with CPT 27416, 29866, or 29868 (these combinations are experimental/not covered). Do NOT bill CPT 27412 for: ankle/talar lesions, prior total meniscectomy patients, osteoarthritis-associated defects, inflammatory arthropathy patients, first-line therapy, or patients with gentamicin anaphylaxis history or bovine material sensitivity. Consequences: Claims missing medical necessity documentation or meeting experimental criteria will be denied by Aetna.