Meniscal allograft transplantation

Coverage decision

With prior authorization, the insurer will pay for meniscal allograft transplantation for selected patients. You will need to contact Qualis Health, see L&I's pre-authorizations site on how to do this.

Meniscal allograft transplantation involves surgically grafting a donor meniscus into the knee of a patient. Patients who have undergone meniscal repair procedures and meniscectomy may benefit from the procedure. The replacement meniscus may reestablish load bearing, shock absorption, and joint stability. Reducing stress on the tibial plateau may also help to prevent osteoarthrosis development. The options for graft preservation include freshly transplanting, fresh-freezing, cryopreserving, or lyophilizing the tissue.

When is this procedure covered?

Meniscal allograft transplantation in 1 or more compartments is covered if the patient and the affected compartment meet all the inclusion criteria, below:

1.	An acute, work-related trauma to the knee previously caused the need for a meniscectomy that removed at least two-thirds (2/3) of the menicus and
2.	The patient's knee pain has not responded to conservative treatment and
3.	The articular cartilage in the affected compartment demonstrates a chondrosis classified by the Modified Outerbridge Scale as: Grade I or Grade II, or Grade III - Debridement must first produce an articular surface sufficiently free of irregularities in order to maintain the integrity of the transplanted meniscus and
4.	Evidence shows that the knee is stable, has sufficient articular cartilage in the affected compartment to ensure the continued integrity of the allograft meniscus, intact ligaments, normal alignment and normal joint space and
5.	The patient meets all of the following characteristics: Too young or active for arthroplasty. The ideal patient age ranges from 20 to 45 years, Body Mass Index less than 35.2, and Capable and willing to follow the rehabilitation protocol.

When is this procedure not covered?

Meniscal allograft transplantation is not covered in the following circumstances:

1.	The patient has an arthritic condition that appears on standing X-rays as joint space narrowing, osteophytes or changes in the underlying bone. The insurer will exclude a patient if the inflammatory (rheumatoid or other) or degenerative (osteoarthritis) arthritis is any of these: Mild and diffuse, Moderate to severe and localized, or Moderate to severe and diffuse. or
2.	The articular cartilage in the affected compartment demonstrates a chondrosis classified by the Modified Outerbridge Scale as: Grade III and has not undergone debridement, Grade III and has undergone debridement that has not produced an articular surface sufficiently free of irregularities in order to maintain the integrity of the transplanced meniscus, or Grade IV.

Who gets reimbursed by the insurer?

Physicians who perform the procedure and meet the requirements below should bill for reimbursement:

Performed or assisted with this procedure 5 or more times, or
Perform the procedure under direct supervision and control of a surgeon who has also preformed this procedure 5 or more times.

What documentation does the physician submit?

Documentation needs to address all of the requirements for a covered procedure. The insurer may require physicians to submit the following documents to define the patient's knee condition: