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It specifies eligibility requirements for knee defects, including age, trauma-related symptom interference, failure of conservative therapy, imaging confirmation of defect size and full-thickness grade, lesion containment, and knee alignment considerations. It also outlines criteria for ankle talus lesions and distinguishes medical necessity versus non-medical necessity based on whether listed conditions are met.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/osteochondral-allografts-and-autografts-for-cartilaginous-defects-medical-policy-number-149-coverage-criteria/292841/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/osteochondral-allografts-and-autografts-for-cartilaginous-defects-medical-policy-number-149-coverage-criteria/292841.png","ImageObject",300,407,{"name":92,"@type":93},"Margaret","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-21","2026-09-17",true,{"@type":102,"interactionType":103,"userInteractionCount":44},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"哪些膝关节软骨缺损情形符合骨软骨异体移植的医学必要性？","Question",{"text":112,"@type":113},"当症状来源于急性或慢性外伤并影响日常活动，且保守治疗至少3个月无改善；同时需MRI/CT/关节镜确认缺损面积≥1cm²、为局灶全层缺损（Outerbridge分级III或IV），病灶周围软骨接近正常，膝关节对线正常或将在移植同期通过截骨纠正，且关节内无炎症性关节炎或骨关节炎。","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"踝关节（距骨）骨软骨异体移植在什么条件下可被认为是医学必要？",{"text":117,"@type":113},"当距骨骨软骨病灶为较大病灶且自体移植会因病灶大小、深度或部位不足以满足需求时，可考虑医学必要；或在曾因较大/囊性病灶失败接受骨髓刺激（marrow stimulation）后的修正手术中，若自体移植仍会因大小、深度或部位不足而不充分，也可考虑。",{"name":119,"@type":110,"acceptedAnswer":120},"不满足上述条件时，政策如何界定骨软骨异体或自体移植的覆盖？",{"text":121,"@type":113},"若未满足针对相应关节与适应证列出的全部（或特定）条件，政策将其判定为不具备医学必要性，从而不满足覆盖标准。","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},292841,1790194800,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":44,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":139,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":145},137451207643,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","Medical Policy  \nOsteochondral Allografts and Autografts for Cartilaginous Defects  \nMEDICAL POLICY NUMBER: 149  \nEffective Date: 4/1/2026 COVERAGE CRITERIA ................................................................... 2  \nLast Review Date: 2/2026 POLICY CROSS REFERENCES ......................................................... 4  \nNext Annual Review: 10/2026 POLICY GUIDELINES ..................................................................... 4  \nREGULATORY STATUS.................................................................. 8  \nCLINICAL EVIDENCE AND LITERATURE REVIEW ............................ 8  \nHEALTH EQUITY CONSIDERATIONS ............................................ 21  \nBILLING GUIDELINES AND CODING ............................................ 21  \nREFERENCES.............................................................................. 23  \nPOLICY REVISION HISTORY......................................................... 26  \nINSTRUCTIONS FOR USE: Company Medical Policies serve as guidance for the administration of plan benefits. Medical policies do not constitute medical advice nor a guarantee of coverage. Company Medical Policies are reviewed annually and are based upon published, peer-reviewed scientific evidence and evidence-based clinical practice guidelines that are available as of the last policy update. The Company reserves the right to determine the application of medical policies and make revisions to medical policies at any time. The scope and availability of all plan benefits are determined in accordance with the applicable coverage agreement. Any conflict or variance between the terms of the coverage agreement and Company Medical Policy will be resolved in favor of the coverage agreement. Coverage decisions are made on the basis of individualized determinations of medical necessity and the experimental or investigational character of the treatment in the individual case. In cases where medical necessity is not established by policy for specific treatment modalities, evidence not previously considered regarding the efficacy of the modality that is presented shall be given consideration to determine if the policy represents current standards of care.  \nSCOPE: Providence Health Plan, Providence Health Assurance, and Providence Plan Partners as applicable (referred to individually as “Company” and collectively as “Companies”) .  \nPLAN PRODUCT AND BENEFIT APPLICATION  \n☒ Commercial ☐ Medicaid/OHP * ☐ Medicare **  \n* Medicaid/OHP Members  \nOregon: Services requested for Oregon Health Plan (OHP) members follow the OHP Prioritized List and Oregon Administrative Rules (OARs) as the primary resource for coverage determinations. Medical policy criteria below may be applied when there are no criteria available in the OARs and the OHP Prioritized List.  \nOsteochondral Allografts and Autografts: Guideline Note 220  \n**Medicare Members  \nThis Company policy may be applied to Medicare Plan members only when directed by a separate Medicare policy. Note that investigational services are considered “not medically necessary” for Medicare members.  \nCOVERAGE CRITERIA  \nOsteochondral Allografting of the Knee  \nI. Osteochondral allografting of the knee may be considered medically necessary for the treatment of symptomatic articular cartilage defects of the knee (medial, lateral or trochlear femoral condyle, or patella) when ALL of the following criteria (A.– G. ) are met:  \nA. Age of \u003C55 years; and  \nB. Symptoms from acute or chronic trauma interfere with age-appropriate activities of daily living; and  \nC. Symptoms have failed to improve after 3 months of conservative treatment, including physical therapy, as part of pre-operative planning for surgery; and  \nD. The following must be confirmed by MRI, CT or arthroscopy:  \n1. Defect size of 1cm2 in total area or greater; and  \n2. It must be a focal, full thickness defect (grade III or IV on the Outerbridge  \nscale) . Please see Policy Guidelines section for scale; and","cbCaiadCm0Gzthj3","https://ap.wps.com/l/cbCaiadCm0Gzthj3","pdf",517623,26,"English","# COVERAGE CRITERIA\n## Osteochondral Allografting of the Knee\n## Osteochondral Allografting of the Ankle\n## Osteochondral Autografting of the Knee (Mosaicplasty or Osteochondral Autograft Transplant [OATS])","[{\"question\":\"哪些膝关节软骨缺损情形符合骨软骨异体移植的医学必要性？\",\"answer\":\"当症状来源于急性或慢性外伤并影响日常活动，且保守治疗至少3个月无改善；同时需MRI/CT/关节镜确认缺损面积≥1cm²、为局灶全层缺损（Outerbridge分级III或IV），病灶周围软骨接近正常，膝关节对线正常或将在移植同期通过截骨纠正，且关节内无炎症性关节炎或骨关节炎。\"},{\"question\":\"踝关节（距骨）骨软骨异体移植在什么条件下可被认为是医学必要？\",\"answer\":\"当距骨骨软骨病灶为较大病灶且自体移植会因病灶大小、深度或部位不足以满足需求时，可考虑医学必要；或在曾因较大/囊性病灶失败接受骨髓刺激（marrow stimulation）后的修正手术中，若自体移植仍会因大小、深度或部位不足而不充分，也可考虑。\"},{\"question\":\"不满足上述条件时，政策如何界定骨软骨异体或自体移植的覆盖？\",\"answer\":\"若未满足针对相应关节与适应证列出的全部（或特定）条件，政策将其判定为不具备医学必要性，从而不满足覆盖标准。\"}]","Osteochondral Allografts and Autografts for Cartilaginous Defects - Medical Policy Number 149 - Coverage Criteria | PDF",1789656456,66]