BlueCross and BlueShield of Montana Medical Policy/Codes
Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
Chapter: Surgery: Procedures
Current Effective Date: September 24, 2013
Original Effective Date: June 24, 2013
Publish Date: September 24, 2013
Revised Dates: October 12, 2003; August 17, 2005; January 21, 2006; January 11, 2008; March 10, 2010; January 18, 2012; August 15, 2012; June 24, 2013
Description

Focal chondral defects of the knee, due to trauma or other conditions such as osteochondritis dissecans, often fail to heal on their own and may be associated with pain, loss of function, disability and the long-term complication of osteoarthritis.  The ideal resurfacing technique would eliminate the symptoms, restore normal biomechanics of the knee joint, and prevent the long-term emergence of osteoarthritis and the necessity for total knee replacement.  Various methods of cartilage resurfacing have been investigated including marrow-stimulation techniques, such as subchondral drilling, microfracture, and abrasion arthroplasty, all of which are considered standard therapies and all of which attempt to restore the articular surface by inducing the growth of fibrocartilage into the chondral defect. 

The use of both fresh and cryopreserved allogeneic osteochondral grafts has been encouraging.  Cryopreservation decreases the viability of cartilage cells and fresh allografts may be difficult to obtain.  There are concerns regarding infectious diseases when using allografts (from a donor other than the recipient).  For these reasons, autologous (one's own tissue from one location to another) grafts have been under investigation as an option to increase the survival rate of the grafted cartilage and to eliminate the risk of disease transmission.  Autografts have been limited by the small number of donor sites; thus allografts are typically used for larger lesions.  Single grafts have been harvested from the patella, femoral condyle, and proximal part of the fibula.  In an effort to extend the amount of available donor tissue, investigators have used multiple, small osteochondral cores harvested from various non-weight-bearing sites of the knee.  Several systems are available for performing this procedure, the MosaicPlasty System™ (Smith and Nephew) and Osteochondral Autograft Transfer System® (OATS®, Arthrex, Inc.), and the COR™ and COR2™ Systems (DePuy-Mitek).  Although MosaicPlasty and OATS may use different instrumentation, the underlying principle is similar; i.e., the use of multiple osteochondral cores harvested from a non-weight-bearing region of the femoral condyle and autografted into the chondral defect.  These terms have been used interchangeably to describe the procedure.  In contrast to autologous chondrocyte implantation (ACI), in which separate surgical procedures are required to harvest and then transplant the cultured chondrocytes, with osteochondral autografting the harvesting and transplantation can be performed during the same surgical procedure.

Preparation of the chondral lesion involves debridement and preparation of recipient tunnels. Multiple individual osteochondral cores are harvested from the donor site, typically from a peripheral non-weight-bearing area of the femoral condyle. Donor plugs range from six-mm to 10 mm in diameter. The grafts are press fit into the lesion in a mosaic-like fashion into the same-sized tunnels. The resultant surface consists of transplanted hyaline articular cartilage and fibrocartilage, which is thought to provide “grouting” between the individual autografts.

Although each system may use different instrumentation, the underlying principle to obtain the autografts is the same and to transfer the cartilage or bone plugs from one area to another damaged area.  These procedures may be performed with either an open approach or arthroscopically.  The resurfacing concept is similar to a hair transplant.  Clinical studies have begun by using osteochondral grafts to repair chondral defects of the hip, patella, tibia, and ankle.

Policy

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.

Medically Necessary

BCBSMT may consider osteochondral allografting medically necessary as a technique to repair large (e.g., 2-10 cm2) full-thickness chondral defects caused by acute or repetitive trauma. 

Osteochondral autografting, using one or more cores of osteochondral tissue, may be considered medically necessary for the treatment of symptomatic full-thickness cartilage defects caused by acute or repetitive trauma in the knee, when all of the following criteria are met:

  • The patient has persistent and localized knee pain of at least six months duration that has failed to respond to conservative treatment and has failed or inadequately responded to prior surgical treatment, such as, debridement or abrasion arthroplasty, and/or marrow-stimulating techniques, such as microfracture; AND
  • The lesion is discrete, single, unipolar (involving only one side of the joint), and full thickness (Outerbridge grade IV) and involves the weight bearing surface of the medial or lateral femoral condyles or trochlear region of the knee (“kissing lesions” [lesions on reciprocal surfaces] are excluded from coverage); AND
  • The cartilage defect size is ≥ 1 cm2 ≤ 2 cm in total area; AND
  • The lesion is largely contained with near normal surrounding articular cartilage and articulating cartilage (Outerbridge grades 0, I or II); AND
  • The affected knee joint is stable with normal biomechanics or alignment (corrective procedure may be performed in combination with or prior to transplantation); AND
  • There is an absence of meniscal pathology: AND
  • The adolescent patient should be skeletally mature with documented close of growth plates, ≥ 15 years of age; OR
  • The adult patient too young to be considered an appropriate candidate for total knee arthroplasty (TKA) or other reconstructive knee surgery, ≤ 55 years of age; AND
  • The body mass index (BMI) is ≤ 35; AND
  • There is no active infection present; AND
  • There is no inflammation or osteoarthritis present; AND
  • There is no history of cancer in the bones, cartilage, fat or muscle of the affected limb; AND
  • There is no alternative or better procedure, including total knee arthroplasty.

Outerbridge Grading

Grade 0

Normal appearing cartilage

Grade I

Swelling and Softening or Articular Cartilage

Grade II

Fissuring within softened areas

Grade III

Fibrillation

Grade IV

Destruction of articular cartilage and exposed bone

Investigational

BCBSMT considers osteochondral autograft or allograft transplantation for joints other than the knee experimental, investigational and unproven, including but not limited to the patellar (knee cap) and talar (ankle).

Osteochondral autograft or allograft transplantation is considered experimental, investigational and unproven when the patient selection criteria cited above are not met.

Federal Mandate

Federal mandate prohibits denial of any drug, device, or biological product fully approved by the FDA as investigational for the Federal Employee Program (FEP). In these instances coverage of these FDA-approved technologies are reviewed on the basis of medical necessity alone.

Rationale

The current medical literature regarding osteochondral allografting of the knee shows that this procedure has demonstrated acceptable long-term results measured by reduction in pain, improved physical function, and sustained osteochondral graft viability.  Several long-term studies have demonstrated long-term donor osteochondral grafts viability up to 10-years and in one study as long as 14-years with a success rate reported at 63%.  Shorter term studies have reported success rates of between 75 to 80%.  The evidence indicates that osteochondral allografting has been highly successful in patients with chondral defects resulting from trauma or osteochondritis dissecans, but less so in patients with osteonecrosis or steroid induced lesions. Finally, the literature is unanimous in emphasizing the importance of proper patient selection including adequate joint stability and alignment.

Peer reviewed medical literature pertaining to osteochondral grafting and mosaicplasty of the knee consists mostly of single-institution case series focusing on chondral lesions of the knee.  These studies include heterogeneous populations of patients, some of whom are undergoing treatment for additional abnormalities such as ligament or meniscal repair.  Therefore, it is not known whether improvement in symptoms can be attributed to the osteochondral autografting or other components of the surgery.  In addition, there are very few studies currently available comparing the results of osteochondral autografting with other established therapies.  However, there is a large collection of small studies that demonstrated that osteochondral autografting procedures, including mosaicplasty, confer significant benefit in terms of both functional improvement and pain relief in a population where alternative therapies are limited.  Several studies have evaluated the long term viability of osteochondral autografts with histological examinations at up to three-years post-transplant.  The vast majority of these studies report finding stable hyaline cartilage at the operative site.  In almost all articles published, patients with misalignment, arthritis, unstable knees, and missing or compromised meniscus, were excluded from the studies due to concerns regarding suitability for the procedures.  Finally, there is little agreement on any limitations regarding the size of chondral defects that are appropriate for these procedures.  The medical literature suggests that mosaicplasty might be appropriate for lesions ranging from as little as 1.5 cm2 to as large as 16 cm2.  Most recent evidence supports the position that the larger the chondral defect, the higher the complication rate and rates of donor site morbidity.  Thus, at this time it may be appropriate to limit these procedures to small to moderate lesions, between 1.1 cm2 and 2.5 cm2, until further evidence is available to fully evaluate this issue.

Contraindications for osteochondral grafting and mosaicplasty of the knee include those patients with a systemic metabolic degenerative disease, arthritis of the knees, flattening of the femoral condyles or severe degenerative changes (greater than 50% joint space narrowing, bone on bone, or erosion to subchondral bone). Osteochondral grafting is not indicated for patients who have undergone partial or total meniscectomy and do not have symptoms or problems with their knee. It is evident that osteochondral grafting is a viable option for the treatment of symptomatic patients provided rigid inclusion criteria are met.  Patients with appropriate indications should expect to do well postoperatively in terms of a predictable reduction in pain and an ability to increase activity levels.  Only further study will clarify the long-term results of osteochondral grafting as well as their role in preventing the progression of secondary osteoarthritis in the involved compartment.

Wang reported the results of 15 patients with 16 knees undergoing osteochondral autograft to repair focal full thickness articular cartilage defects of the knee.  Minimum follow-up in this study was two-years.  Evaluations of patient outcomes were based on functional assessments, which included pain, giving way, locking, recurrent effusion, knee scores, functional scores, and Lysholm scores, statistically significant improvements were achieved in all.  The overall results were excellent in seven (43.75%), good in six (37.50%), fair in two (12.50%), and poor in one (6.25%).  The latter three had lesions larger than 600 mm2.  Radiographs showed mild degenerative changes in seven knees preoperatively and in eight knees postoperatively; however, seven of eight knees showed no progression of degenerative changes postoperatively.  No data was reported regarding the donor site.

Osteochondral allograft transplantation is appealing because it provides the ability to resurface larger and deeper defects with mature hyaline articular cartilage and addresses the underlying bone deficit in a single procedure.  The appropriate size and surface contour can be matched when the graft is obtained from an appropriately selected organ donor.  The biology of articular cartilage makes it ideal for transplantation.  It is both aneural and relatively avascular, receiving its nutrition by diffusion from synovial fluid.  Furthermore, it is a relative immuno-privileged tissue.  The chondrocytes are protected from the host immune surveillance by the surrounding matrix.  Therefore, this allows mature living chondrocytes to survive for many years after transplantation without the need for tissue matching or immunosuppression.

Williams and colleagues prospectively followed 19 patients with symptomatic chondral and osteochondral lesions of the knee who were treated with fresh osteochondral allografts between 1999 and 2002.  The mean age at the time of surgery was 34-years.  The mean duration of clinical follow-up was 48-months (range 21- to 68-months).  The mean score (and standard deviation) on the Activities of Daily Living Scale increased from a baseline of 56 +/- 24 to 70 +/- 22 at the time of the final follow-up (P< 0.05).  The mean Short Form-36 score increased from a baseline of 51 +/- 23 to 66 +/- 24 at the time of final follow-up (P < 0.005).  At a mean follow-up interval of 25-months, cartilage-sensitive magnetic resonance imaging demonstrated that the normal articular cartilage thickness was preserved in eight of the eighteen grafts.  The authors concluded that fresh osteochondral allografts that were hypothermically stored between seventeen and 42-days were effective in the short term both structurally and functionally in reconstructing symptomatic chondral and osteochondral lesions of the knee.

The indications for autografts are the small focal lesions that are 1 cm2 to 2.5 cm2 in size.  For larger defects, over 2.5 cm2 allografts are preferred.  The knee must be stable, not arthritic, and have normal alignment.  Current contradictions for the use of allografts include osteoarthritis that has advanced to Outerbridge grade IV, exposed subchondral bone, inflammatory arthritis, obesity, previous infection, multiple lesions, ligamentous instability, severe lower extremity malignancy and significant axial malalignment. 

2009 Update

A search of peer reviewed literature through August 2009 identified a number of small case series (five to 30 patients) describing use of osteochondral autografts for cartilage defects of the knee, elbow, and ankle, along with literature on uncontrolled case series with limited (e.g., two-years or less) follow-up.

A 2008 systematic review by Magnussen et al assessed whether “advanced” cartilage repair techniques (osteochondral transplantation or autologous chondrocyte transplantation) showed superior outcomes in comparison with traditional abrasive techniques for the treatment of isolated articular cartilage defects.  Finding a total of five randomized controlled trials and one prospective comparative trial that met their selection criteria, Magnussen and colleagues concluded that no one technique had been shown to produce superior clinical results for treatment of articular cartilage defects.  They stated that, “any differences in outcome based on the formation of articular rather than fibrocartilage in the defect may be quite subtle and only reveal themselves after many years of follow-up.  Similarly, complications such as donor site morbidity in osteochondral grafting may be late in their presentation and thus not be detected at short follow-up.” Relevant studies are described below.

Hangody, who first reported use of the mosaicplasty technique in humans in 1992, has authored a number of summaries and case series.  It is likely that these reports contain overlapping populations of patients, and few details are reported.  In a 1997 article, Hangody and colleagues refer to a 1992 to 1994 comparison study of mosaicplasty and abrasion arthroplasty.  No details of this study are provided, except to note that the mosaicplasty patients had significantly improved Hospital for Special Surgery (HSS) knee scores, compared to those undergoing abrasion arthroplasty.  A 2008 summary paper includes descriptions of a prospective multicenter comparison of 413 resurfacing procedures and follow-up from 1,097 mosaicplasties at the author’s institution.  Although the authors report that the comparative study found hyaline-like resurfacing to result in a better clinical outcome than other techniques, the cited study is not available as a publicly available peer-reviewed publication.  For the retrospective analysis, Hangody and colleagues reported 789 implantations on the femoral condyles, 147 in the patellofemoral joint, 31 on the tibia condyles, 98 on talar domes, eight on the capitulum humeric, three on humeral heads, and 11 on femoral heads.  About two-thirds of the patients were reported to have had a localized cartilage lesion, and the remainder underwent surgery because of osteochondral defects.  In 81% of patients concomitant surgical interventions were performed; these included reconstruction of the ACL realignment osteotomies, meniscus surgery, and patellofemoral realignment procedures.  Clinical scores found good to excellent results in 92% of patients with femoral condylar implantations, 87% of tibial resurfacings, 74% of patellar and/or trochlear mosaicplasties, and in 93% of talar procedures.  Moderate and severe donor-site disturbances were reported in 3% of patients.  Ninety-eight second-look arthroscopies were done for persistent or recurrent pain, swelling or postoperative intraarticular bleeding (31 patients at two-months to 11-years), second trauma (26 patients at one- to nine-years) or to evaluate recovery in professional athletes (41 patients, four- to seven-months). Although at least 57 (58%) second-look arthroscopies were associated with clinical symptoms, the report indicates that 81 (83%) of the evaluations indicated good gliding surfaces, histologically proven survival of the transplanted hyaline cartilage, and acceptable fibrocartilage covering of the donor sites.  Slight or severe degenerative changes were seen at the recipient and/or donor sites in 17 cases (17%).  The association between clinical symptoms and histological results was not discussed.  Painful hemarthroses were observed in 56 (5%) of patients.  The authors note that although these results are encouraging for use of autologous osteochondral mosaicplasty as an alternative treatment for small- and medium-sized focal defects, postoperative bleeding from the empty donor tunnels represents a possible postoperative complication, and donor-site morbidity remains an open question.  Based on their extensive experience with this procedure, Hangody and colleagues consider the optimal indications to be a lesion size of 1 to 4 cm2, patient age of 50-years or younger (due to decreased repair capacity with aging), and correction of instability, malalignment, and meniscal or ligamental tears.

Osteochondral autografts in comparison with microfracture

One study from Lithuania was a well-controlled and blinded comparison of mosaic osteochondral autologous transplantation versus microfracture for lesions of the femoral condyle (one to 4 cm2) in 60 athletes between 15- and 40-years of age (mean, 24.3-years).  Follow-up on 95% of the athletes for up to three-years following surgery showed that more athletes returned to sports activities (mean, 6.5-months) following osteochondral autograft (93% versus 52%), and fewer required revision (one of 28 versus nine of 29).  Overall, 96% of patients treated by osteochondral autograft had an excellent or good result compared with 52% treated by microfracture.  At one-year follow-up, scores on the International Cartilage Repair Society (ICRS) cartilage grading system improved from a baseline of 51 to 86 in the osteochondral autograft group and 76 in the microfracture group.  At three-year follow-up, scores from Hospital for Special Surgery questionnaires improved from a baseline of 77 to 91 in the osteochondral group and 81 in the microfracture group.  No donor-site morbidity was observed.  Blinded arthroscopic and histological assessment in a subset of patients showed hyaline cartilage of normal appearance following transplantation, whereas microfracture was frequently observed to result in surface fibrillation and soft fibroelastic tissue.

Another group from Italy randomized 32 patients with osteochondral lesions of the talus to chondroplasty, microfracture, or osteochondral autograft.  This small study found similar improvements (approximately 40 points) for the three treatment groups as measured by the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score (baseline score of 31 to 37) and the Subjective Assessment Numeric Evaluation (baseline score of 35 to 36).  Complication rates were also similar, with persistent pain reported by one patient following chondroplasty, by two patients following microfracture, and by two patients following osteochondral autograft. Postoperative pain, measured by Numeric Pain Intensity Scores, was greater following osteochondral autograft (5.25) than chondroplasty (3.3) or microfracture (3.4).

Osteochondral autografts in comparison with chondrocyte implantation

Horas and colleagues reported two-year follow-up on a study of 40 patients (between 18 and 42 years of age) with an articular lesion of the femoral condyle (range of 3.2 to 5.6 cm2) who were randomly assigned to undergo either ACI or osteochondral autografting.  Eleven (28%) had received prior surgical treatment.  The authors reported that both treatments resulted in an improvement in symptoms (85% of each group), although those in the osteochondral autografting group responded more quickly.  Histomorphological evaluation of five biopsy specimens at two-years or less after transplantation indicated that the osteochondral cylinders had retained their hyaline character, although the investigators noted a persistent interface between the transplant and the surrounding original cartilage.  Evaluation of autologous chondrocyte implants indicated a rigid, elastic tissue, with partial roughening and the presence of fibrocartilage.

Bentley and colleagues randomized 100 consecutive patients with symptomatic lesions of the knee (average 4.7 cm2, range of 1 to 12 cm2) to ACI or mosaicplasty.  Seventy-four percent of lesions were on the femoral condyle, and 25% of lesions were on the patella.  Ninety-four patients had undergone previous surgical interventions and the average duration of symptoms before surgery was seven-years. Clinical assessment at one-year showed excellent or good results in 98% of the ACI patients and 69% of the mosaicplasty patients.  The mosaicplasty plugs showed incomplete healing of the spaces between the grafts, fibrillation of the repair tissue, and disintegration of the grafts in some patients.  This finding may be related to both the relatively large lesion size and the unusual prominent placement of the plugs in this study, which was intended to allow contact with the opposite articular surface.

Dozin et al reported results from a multicenter randomized clinical trial in which ACI was compared to mosaicplasty.  Forty-four individuals (61% male, 39% female) age 16- to 40-years (mean 28.7 ± 7.8), who had a focal, symptomatic chondral injury of Outerbridge grade III or IV with no previous surgical treatment, were randomly assigned to ACI or mosaicplasty six-months after undergoing arthroscopic debridement.  The average lesion size was 1.9 cm.  Only 12 of 22 (54%) in the ACI group and 11 of 22 (50%) of the mosaicplasty group actually underwent the assigned procedure.  Dropouts comprised 14 patients (32%) who reported spontaneous improvement following arthroscopy and did not undergo subsequent surgery, five who did not show up at the pre-surgery examination and could not be further traced, and two who refused surgery for personal reasons.  Because of the substantial dropout rate, the original primary outcome measure, the mean Lysholm Knee Scoring Scale (LKSS) assessed 12-months post-surgery was converted into a scale in which improvement was categorized by proportions of responders (LKSS < 60, LKSS 60-90, LKSS 90-100).  With this scale, and including 10 patients who were cured by debridement (intention-to-treat analysis) the percentages of patients who achieved complete success were 89% (16 of 18 evaluable cases) in the mosaicplasty arm versus 68% (13 of 19 evaluable cases) in the ACI arm (test for trend P = 0.093).  The high rate of spontaneous improvement after simple debridement raises questions about the appropriateness of additional surgical intervention in patients with small lesions similar to those included in this trial.

Longer-term follow-up

Laprell and colleagues reported six- to 12-year follow-up from 29 of 35 patients (83%) with severe osteochondral defects (77% with osteochondritis dissecans) who were treated by autologous osteochondral transplantation.  The average age of the patients at the time of surgery was 26 years.  Clinical evaluation at an average eight-years after the procedure found 12 patients (41%) to be normal, 14 (48%) as nearly normal, and three (10%, all of whom refused correction of malalignment) as abnormal.  No patient was assessed as severely abnormal.  In contrast, no patients considered their functional status to be normal, three (10%) considered function to be nearly normal, 20 (69%) thought their function abnormal, and six (21%) considered their functional status to be severely abnormal.

Another report described seven-year follow-up on 30 patients who had been treated with osteochondral autologous transplantation for symptomatic Outerbridge grade III to IV chondral lesions (average 1.9 cm, range of 1.0 to 2.5 cm).  Nineteen patients received other procedures (ACL reconstruction, meniscectomy, medial collateral ligament repair) at the same time, and it is therefore not possible to assess the contribution of the osteochondral transplantation to the functional results reported.  Magnetic resonance imaging at seven-years showed complete bone integration in 96% of patients, complete integration of the grafted cartilage in 75% of cases, complete filling of the cartilage defect in 63% of the patients, and congruency of the articular surface in “some” patients.  Subchondral bone changes (edema or sclerosis) were noted in 71% of patients.  The donor sites were filled with a tissue of different density than the surrounding bone, presumed to be fibrous tissue.  No patients reported anterior knee pain.  Non-painful patellar crepitus was observed in three (10%) patients.

Adverse Events

One study reported donor site morbidity in 11 patients of 15 who had undergone graft harvest from the knee (mean of 2.9) for treatment of osteochondral lesions of the talus.  At an average 47-month follow-up (seven- to 77-month range), five patients were rated as having an excellent Lysholm score (95 to 100 points), two as good (84 to 94), and four as poor (64 or less).  Reported knee problems were instability in daily activities, pain after walking a mile or more, having a slight limp, and difficulty squatting.

In summary, only one relatively small randomized controlled trial from Europe has demonstrated improved clinical outcomes when compared with microfracture.  Data regarding the long-term viability of the transplanted osteochondral hyaline cartilage is also limited.  However, controlled studies demonstrate similar benefit to other cartilage resurfacing procedures in appropriately selected patients, and a number of uncontrolled studies indicate that osteochondral autografts can improve symptoms in some patients with lesions of the femoral condyle who have failed prior surgical treatment.  These patients have limited options.  Therefore, based on the clinical input received and additional literature reviewed, it is concluded that osteochondral autografts may be considered an option for symptomatic full-thickness chondral lesions of the femoral condyle caused by acute or repetitive trauma, in patients who have had an inadequate response to a prior arthroscopic or other surgical repair procedure.  Evidence is currently insufficient to evaluate the efficacy of osteochondral autografts in comparison with other surgical repair procedures as a primary treatment of small lesions, or to evaluate the efficacy of osteochondral autografts for joints other than the knee.  Questions also remain about the natural history of asymptomatic lesions found incidentally during other surgical procedures.  Additional controlled trials with longer follow-up are needed to demonstrate that use of osteochondral autografts as a primary treatment results in improved clinical outcomes in comparison with traditional marrow-stimulating procedures.

Other Guidelines

The Interventional Procedures Advisory Committee of the United Kingdom’s National Institute for Health and Clinical Excellence (NICE) conducted a 2005 review of mosaicplasty for knee cartilage defects.  The corresponding NICE Guidance on mosaicplasty, released in 2006, is in agreement with conclusions listed above, stating that “There is some evidence of short-term efficacy, but data on long-term efficacy are inadequate.”

An additional search of peer reviewed literature through August 2009 identified no new clinical trial publications or any additional information that would that would alter or change the conclusions reached above.

Coding

Disclaimer for coding information on Medical Policies

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps. 

ICD-9 Codes

81.96, 717.7, 717.7, 732.7

ICD-10 Codes
M12.561-M12.569, M17.0-M17.9, M23.8x1-M23.92, M25.861-M25.869, M89.8x6, M89.9, M93.261-M93.269, M94.261-M94.269, M94.8x6, M94.9, S89.81xA-S98.119S, S89.90xA-S89.92xS, 0SQC0ZZ, 0SQC3ZZ, 0SQC4ZZ, 0SQD0ZZ, 0SQD3ZZ, 0SQD4ZZ 
Procedural Codes: 27415, 27416, 28446, 29866, 29867
References
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  2. Convery, F.R., Botte, M.J., et al.  Chondral defects of the knee.  Contemporary Orthopedics (1994 February) 28(2):101-7.
  3. Garrett, J.C.  Fresh Osteochondral allografts for treatment of articular defects in osteochondritis dissecans of the lateral femoral condyle in adults.  Clinical Orthopedics and Related Research (1994 June) 303:33-7.
  4. Bobic, V.   Arthroscopic osteochondral autograft transplantation in anterior cruciate ligament reconstruction: a preliminary clinical study.  Knee Surgery, Sports Traumatology, Arthroscopy (1996) 3(4):262-4.
  5. Hangody, L., Kish, G., et al.  Arthroscopic autogenous osteochondral mosaicplasty for the treatment of femoral condylar articular defects.  A preliminary report.  Knee Surgery, Sports Traumatology, Arthroscopy (1997) 5 (4):262-7.
  6. Hangody, L., Kish, G., et al.  Mosaicplasty for the treatment of articular cartilage defects: Application in clinical practice (see comments).  Orthopedics (1998 July) 21(7):751-6.
  7. Hangody, L., Kish, G., et al.  Treatment of osteochondritis dissecans of the talus: Use of the mosaicplasty technique – a preliminary report.  Foot Ankle International (1997 October) 18 (10):628-34.
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  9. Bugbee, W.D., and F.R. Convery.  Osteochondral allograft transplantation.  Clinics in Sports Medicine (1999 January) 18(1):67-95.
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  11. Horas, U., Schnettler, R., et al.  Osteochondral transplantation versus autogenous chondrocyte transplantation.  A prospective comparative clinical study.  (Article in German).  Chirug (2000 September) 71 (9):1090-7.
  12. Kim, S.J. and S.J. Shin.  Loose bodies after arthroscopic osteochondral autograft in osteochondral dissecans of the knee.  Arthroscopy (2000 October) 16 (7):E16.
  13. Cain, E.L. and W.G. Clancy.  Treatment algorithm for osteochondral injuries of the knee. Clinical Sports Medicine (2001 April) 20 (2):321-42.
  14. Laprell, H., and W. Petersen.  Autologous osteochondral transplantation using the diamond bone-cutting system (DBCS): 6-12 years’ follow-up of 35 patients with osteochondral defects at the knee joint.  (2001 May) 121(5):248-53.
  15. Matsusue, Y., Kotake, T., et al.  Arthroscopic osteochondral autograft transplantation for chondral lesion of the tibial plateau of the knee.  Arthroscopy (2001 July) 17 (6):653-9.
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  21. Agneskirchner, J.D., Brucker, P., et al.  Large osteochondral defects of the femoral condyle: Press-fit transplantation of the posterior femoral condyle (MEGA-OATS).  Knee Surgery, Sports Traumatology, Arthroscopy (2002 May) 10 (3):160-8.
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  24. Jakob, R.P., Franz, T., et al.  Autologous osteochondral grafting in the knee: Indication, results, and reflections.  Clinical Orthopaedics and Related Research (2002 August) (401):170-84.
  25. Bugbee, W.D.  Fresh Osteochondral allografts.  Journal of Knee Surgery (2002 Summer): 191-5.
  26. Shasha, N., Aubin, P.P., et al.  Long-term clinical experience with fresh Osteochondral allografts for articular knee defects in high demand patients.  Cell Tissue Bank (2002) 3(3):175-82.
  27. Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions. Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 January) Surgery 7.01.78.
  28. Horas, U., Pelinkovic, D., et al.  Autologous chondrocyte implantation and osteochondral cylinder transplantation in cartilage repair of the knee joint.  A prospective comparative trial. Journal of Bone and Joint Surgery – American Volume (2003 February) 85-A (2):185-92.
  29. Bentley, G., Biant, L.C., et al.  A prospective, randomized comparison of autologous chondrocyte implantation versus mosaicplasty for osteochondral defects in the knee.  Journal of Bone and Joint Surgery.  British Volume (2003 March) 85(2):223-30.
  30. Lee, C.H., Chao, K.H., et al.  Osteochondral autografts for osteochondritis dissecans of the talus. Foot and Ankle International (2003 November) 24(11):815-22.
  31. Klinger, H.M., Baums, M.H., et al.  Anterior cruciate reconstruction combined with autologous osteochondral transplantation.  Knee Surgery, Sports Traumatology, Arthroscopy (2003 November) 11(6):366-71.
  32. Ueblacker, P., Burkart, A., et al.  Retrograde cartilage transplantation on the proximal and distal tibias.  Arthroscopy (2004 January) 20 (1):73-8.
  33. Knutsen, G., Engebretsen, L., et al.  Autologous chondrocyte implantation compared with microfracture in the knee.  A randomized trial.  Journal of Bone and Joint Surgery (2004 March) 86-A (3):455-64.
  34. LaPrade, R.F. and J.C. Botker.  Donor-site morbidity after osteochondral autograft transfer procedures.  Arthroscopy (2004 September) 20 (7):e69-73.
  35. Chow, J.C., Hantes, M.E., et al.  Arthroscopic autogenous osteochondral transplantation for treating knee cartilage defects: a 2- to 5-year follow-up study.  Arthroscopy (2004 September) 20(7):681-90.
  36. Scheibel, M., Bartl, C., et al.  Osteochondral autologous transplantation for the treatment of full-thickness articular cartilage defects of the shoulder.  Journal of Bone and Joint Surgery.  British Volume (2004 September) 86(7):991-7.
  37. Sgaglione, N.A.  Biologic approaches to articular cartilage surgery: future trends.  Orthopedic Clinics of North American (2005):485-95.
  38. Gross, A.E., Shasha, N., et al.  Long-term follow-up of the use of fresh Osteochondral allografts for posttraumatic knee defects.  Clinical Orthopedics and Related Research (2005 June) 435:79-87.
  39. Lang, P., Noorbakhsh, F., et al.  MR Imaging of articular cartilage: Current state and recent developments.  Radiological Clinics of North America (2005):629-39.
  40. NHS – Interventional Procedure Overview of Mosaicplasty for Knee Cartilage Defects.  National Institute for Health and Clinical Excellence (2005 April) Interventional Procedures Programme 283:1-13.  Available at http://www.nice.org.uk (accessed on 2009 August 24). 
  41. Shimada, K., Yoshida, T., et al.  Reconstruction with an osteochondral autograft for advanced osteochondritis dissecans of the elbow.  Clinical Orthopaedics and Related Research (2005 June) (435):140-7.
  42. Dozin, B., Malpeli, M., et al.  Comparative evaluation of autologous chondrocyte implantation and mosaicplasty: a multicentered randomized clinical trial.  Clinical Journal of Sport Medicine (2005 July) 15(4):220-6.
  43. Gudas, R., Kalesinskas, R.J., et al.  A prospective randomized clinical study of mosaic osteochondral autologous transplantation versus microfracture for the treatment of osteochondral defects in the knee joint in young athletes.  Arthroscopy (2005 September) 21(9):1066-75.
  44. NHS – Mosaicplasty for Knee Cartilage Defects.  National Institute for Health and Clinical Excellence (2006 March) Interventional Procedure Guidance 162:1-2.  Available at http://www.nice.org.uk (accessed on 2009 August 24). 
  45. Gobbi, A., Francisco, R.A., et al.  Osteochondral lesions of the talus: randomized controlled trial comparing chondroplasty, microfracture, and osteochondral autograft transplantation.  Arthroscopy (2006 October) 22(10):1085-92.
  46. Gortz, S., and W.D. Bugbee.  Allografts in articular cartilage repair.  Instructional Course Lectures (2007) 56:469-81.
  47. Miniacis, A., and P.A. Martineau.  Technical aspects of osteochondral autograft transplantation.  Instructional Course Lectures (2007) 56:447-55.
  48. Reddy, S., Pedowitz, D.I., et al.  The morbidity associated with osteochondral harvest from asymptomatic knees for the treatment of osteochondral lesions of the talus.  American Journal of Sports Medicine (2007 January) 35(1):80-5.
  49. Williams, R.J., Ranawat, A.S., et al.  Fresh stored allografts for the treatment of Osteochondral defects of the knee.  Journal of Bone and Joint Surgery, American Volume (2007 April) 89(4):718-26.
  50. McCullooch, P.C., Kang, R.W., et al.  Prospective evaluation of prolonged fresh Osteochondral allograft transplantation of the femoral condyle.  Minimum 2-year follow-up.  American Journal of Sports Medicine (2007 March) 35(3):411-20.
  51. McCulloch, P.C., Lattermann, C., et al.  An illustrated history of anterior cruciate ligament surgery.  Journal of Knee Surgery (2007 April) 20(2):95-104.
  52. Emmerson, B.C., Gortz, S., et al.  Fresh Osteochondral Allografting in the treatment of osteochondritis dissecans of the femoral condyle.  American Journal of Sports Medicine (2007 June) 35(6):907-14.
  53. Marcacci, M., Kon, E., et al.  Arthroscopic autologous osteochondral grafting for cartilage defects of the knee: prospective study results at a minimum 7-year follow-up.  American Journal of Sports Medicine (2007 December) 35(12):2014-21.
  54. Magnussen, R.A., Dunn, W.R., et al.  Treatment of focal articular cartilage defects in the knee: a systematic review.  Clinical Orthopaedics and Related Research (2008 April) 466(4):952-62.
  55. Hangody, L., Vasarhelyli, G., et al.  Autologous osteochondral grafting – technique and long-term results.  Injury (2008 April) 39(Supplement):S32-9.
  56. Gross, A.E., Kim, W., et al.  Fresh osteochondral allografts for posttraumatic knee defects: long-term follow-up.  Clinical Orthopaedics and Related Research (2008 August) 466(8):1863-70.
  57. Rue, J.P., Yanke, A.B., et al.  Prospective evaluation of concurrent meniscus transplantation and articular cartilage repair: minimum 2-year follow-up.  American Journal of Sports Medicine (2008 September) 36(9):1770-8.
  58. Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2008 November) Surgery 7.01.78.
  59. Van Bergen, C.J., De Leeuw, P.A., et al.  Treatment of osteochondral defects of the talus.  Revue De Chirurgie Orthopedique Et  Reparatrice De L Appareil Moteur (2008 December) 94(8 Supplement):398-408.
  60. Birman, M.V., Le Dan, T., et al.  The humeral head as a potential donor source for osteochondral allograft transfer to the knee.  Journal of Knee Surgery (2009 April) 22(2):99-105.
History
January 2012 Policy reviewed: updated policy statement and medical necessity criteria, rationale, and references. Name change from Osteochondral grafts: Osteochondral Autograft Transfer System (OATS) and to Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions
August 2012 Policy updated with literature search through April 2012; references added and reordered; policy statements unchanged.
June 2013 Policy formatting and language revised.  Criteria revised in the Medically Necessary statement for osteochondral autografting.  Removed Outerbridge grade III lesions from coverage.  Cartilage defect size changed from between 1 and 2.5 square cm to between 1 and 2 square cm.  Added statement "There is an absence of meniscal pathology".
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Osteochondral Autografts and Allografts in the Treatment of Focal Articular Cartilage Lesions