Aetna · Clinical coverage policy

Aetna Knee Arthroscopy coverage criteria

Aetna CPB 0673 covers arthroscopic knee surgery (including partial meniscectomy or meniscal repair) and meniscal repair for traumatic tears or medial/lateral root tears only when the knee has no more than mild osteoarthritis (Kellgren-Lawrence or modified Outerbridge grade 0-2), there is radiologic/MRI confirmation of the pathology, and conservative therapy (at least 6 weeks of formal in-person physical therapy in the past year) has failed -- the conservative-therapy requirement is waived for a locked knee from a displaced bucket-handle tear. Intra-articular corticosteroid injections are covered for knee osteoarthritis, while diagnostic-only arthroscopy, isolated chondroplasty/debridement (especially for severe OA or pain-only OA), Zilretta, and a long list of regenerative/device/neuromodulation interventions (e.g., stem cell therapy, MISHA implant, subchondroplasty, genicular nerve RFA, PRP-adjacent orthobiologics) are not covered as not medically necessary or experimental/investigational.

Policy CPB 0673 · Effective · Verify against the current Aetna policy before submitting — view source policy.

Payer

Aetna

Policy

CPB 0673

Prior auth

Confirm

Effective

January 1, 2026

This page reflects the coverage criteria captured from Aetna policy CPB 0673 and may not include every criterion, exception, or code — verify the complete bulletin before submitting.

What this means for the claim

The covered path, the next step to get it approved, and the specific way it denies — built only from this policy.

When does Aetna cover Knee Arthroscopy (CPT 29881), and what gets it denied?

Path
Aetna CPB 0673 covers arthroscopic knee surgery (including partial meniscectomy or meniscal repair) and meniscal repair for traumatic tears or medial/lateral root tears only when the knee has no more than mild osteoarthritis (Kellgren-Lawrence or modified Outerbridge grade 0-2), there is radiologic/MRI confirmation of the pathology, and conservative therapy (at least 6 weeks of formal in-person physical therapy in the past year) has failed -- the conservative-therapy requirement is waived for a locked knee from a displaced bucket-handle tear. Intra-articular corticosteroid injections are covered for knee osteoarthritis, while diagnostic-only arthroscopy, isolated chondroplasty/debridement (especially for severe OA or pain-only OA), Zilretta, and a long list of regenerative/device/neuromodulation interventions (e.g., stem cell therapy, MISHA implant, subchondroplasty, genicular nerve RFA, PRP-adjacent orthobiologics) are not covered as not medically necessary or experimental/investigational. Coverage criteria include: Arthroscopic knee surgery (with or without partial meniscectomy or meniscal repair) is medically necessary when ALL of the following are met: (1) significant knee pain PLUS mechanical symptoms; AND (2) no more than mild osteoarthritis (Kellgren-Lawrence grade 0, 1, or 2 OR modified Outerbridge grade 0, 1, or 2); AND (3) radiologic confirmation of pathology (X-ray for loose bodies; MRI for meniscal tears and/or loose bodies); AND (4) failure of conservative therapy (non-surgical medical management with at least 6 weeks of formal physical therapy in the past year, in-person as opposed to home or virtual physical therapy) -- WAIVED if the member's knee is 'locked' due to a displaced bucket handle tear of the meniscus.; Arthroscopic partial meniscectomy or meniscal repair for traumatic meniscal tears is medically necessary when ALL of the following are met: (1) traumatic meniscal tears; AND (2) significant symptoms; AND (3) no more than mild osteoarthritis (Kellgren-Lawrence grade 0, 1, or 2 OR modified Outerbridge grade 0, 1, or 2); AND (4) MRI confirmation of meniscal pathology; AND (5) failure of conservative therapy (at least 6 weeks of formal in-person physical therapy in the past year).; Arthroscopic meniscal repair for medial and/or lateral meniscal root tears is medically necessary when ALL of the following are met: (1) medial and/or lateral meniscal root tears; AND (2) significant symptoms; AND (3) no more than mild osteoarthritis (Kellgren-Lawrence grade 0, 1, or 2 OR modified Outerbridge grade 0, 1, or 2). Additional requirement: meniscal repair should only be considered where the vascular supply to the torn portion of the meniscus is adequate AND the meniscal tissue is not degenerated on imaging.; Intra-articular glucocorticoid (corticosteroid) injections are medically necessary for the treatment of osteoarthritis of the knee.; Minor synovectomy is considered integral to all other arthroscopic knee procedures and requires no separate justification.; Major synovectomy is medically necessary only when a disease of the synovium (e.g., pigmented villonodular synovitis, synovial osteochondromatosis) is identified pre-operatively.; Diagnostic knee arthroscopy may be billed and covered as medically necessary in the situation where the radiologically proven pathology is NOT confirmed at surgery (i.e., the arthroscopy was indicated by qualifying imaging findings but those findings were not borne out intra-operatively).; Imaging interpretation rule: Aetna will consider the official written report of complex imaging studies (e.g., CT, MRI). If the operating surgeon disagrees with the official written report, the surgeon should document that disagreement, discuss it with the provider who did the official interpretation, and there should be a written addendum to the official report indicating agreement or disagreement with the operating surgeon.. Applies to 11 codes: 29881, 29880, 29879, 29876, 29877, 29875, 29873, 29874, 29870, 29882, 29883.
Action
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin does not state a precertification submission process for knee arthroscopy generally. It references the pre-certification pathway only in the context of chondroplasty/debridement, stating that isolated chondroplasty/debridement cannot be approved on a pre-certification request but could be considered on a case-by-case basis post-operatively. Documentation: Conservative therapy must be confirmed by documentation: history of unsuccessful conservative therapy (non-surgical medical management with at least 6 weeks of formal physical therapy in the past year, in-person as opposed to home or virtual physical therapy), confirmed either by the actual physical therapy notes OR by documentation in the member's claims history.; Imaging interpretation: the official written report of complex imaging studies (e.g., CT, MRI) is required; if the operating surgeon disagrees with the official written report, there must be documented disagreement, discussion with the interpreting provider, and a written addendum to the official report indicating agreement or disagreement with the operating surgeon.
Trap
Policy exclusions and limitations: Diagnostic knee arthroscopy is generally NOT medically necessary and NOT covered; knee arthroscopy is only covered for persons with radiologically proven pathology meeting the policy criteria (exception: it may be billed/covered when the radiologically proven pathology is not confirmed at surgery).; Chondroplasty/debridement as an isolated request is NOT medically necessary for minor chondral lesions, and NOT approvable for significant arthritis of the knee; therefore it cannot be approved on pre-certification request, but could be considered on a case-by-case basis post-operatively (it is otherwise integral to other arthroscopic knee procedures).; Arthroscopic debridement is experimental/investigational/unproven for persons with osteoarthritis presenting with knee pain ONLY, OR with severe osteoarthritis (Outerbridge classification III or IV).; Extended-release triamcinolone acetonide injectable suspension (Zilretta) is considered NOT medically necessary because it has not demonstrated significant improvement in osteoarthritis pain compared with the immediate-release formulation of triamcinolone acetonide.; Meniscectomy (arthroscopic or open; total or partial) for treatment of medial or lateral meniscal root tears is experimental/investigational/unproven.; Medial knee implanted shock absorber (MISHA) for management of knee osteoarthritis and subchondral insufficiency fractures is experimental/investigational/unproven.; Subchondroplasty for treatment of bone osteoarthritis and all other indications is experimental/investigational/unproven.; Sustained acoustic medicine (SAM) for treatment of knee pain and all other indications (including myofascial/soft tissue pain and injuries affecting ankle, back, elbow, neck, and shoulder) is experimental/investigational/unproven.; Adipose cell-based therapies (e.g., autologous lipoaspirate) for knee osteoarthritis are experimental/investigational/unproven.; Advanced Arthritis Relief Protocol (which includes stem cell therapy) for knee osteoarthritis is experimental/investigational/unproven.; Arthroscopic lavage for knee osteoarthritis is experimental/investigational/unproven.; Balneotherapy for knee osteoarthritis is experimental/investigational/unproven.; Bone marrow aspirate concentrate for knee osteoarthritis is experimental/investigational/unproven.; Combination of high tibial osteotomy and autologous bone marrow derived cell implantation for knee osteoarthritis is experimental/investigational/unproven.; Cryotherapy (e.g., Iovera cryoneurolysis) for knee osteoarthritis is experimental/investigational/unproven.; Extracorporeal shock wave therapy for knee osteoarthritis is experimental/investigational/unproven.; Genicular artery embolization for knee osteoarthritis is experimental/investigational/unproven.; Genicular nerve stimulation for treatment of knee osteoarthritis is experimental/investigational/unproven.; High-intensity laser therapy for knee osteoarthritis is experimental/investigational/unproven.; Intra-articular application of autologous, fat-derived orthobiologics for knee osteoarthritis is experimental/investigational/unproven.; Intra-articular botulinum toxin injections for knee osteoarthritis are experimental/investigational/unproven.; Intra-articular injections of autologous conditioned serum for knee osteoarthritis are experimental/investigational/unproven.; Iovera cryoneurolysis for pain management before and after total knee arthroplasty is experimental/investigational/unproven.; Leukotape for knee osteoarthritis is experimental/investigational/unproven.; Microfracture/abrasion arthroplasty and xeno-matrix-induced chondrogenesis for treatment of focal traumatic cartilage defects are experimental/investigational/unproven.; Patellar denervation for knee osteoarthritis is experimental/investigational/unproven.; Percutaneous autologous fat injections for knee osteoarthritis are experimental/investigational/unproven.; Percutaneous calcium phosphate injections for knee osteoarthritis are experimental/investigational/unproven.; Pulsed vibration therapy for knee osteoarthritis is experimental/investigational/unproven.; Radiofrequency ablation (RFA; including genicular nerve RFA) for knee osteoarthritis is experimental/investigational/unproven.; Stem cell therapy (e.g., intra-articular injections of adipose tissue-derived stem cells, bone marrow-derived mononuclear cells, infra-patellar fat pad-derived mesenchymal stem cells, or pre-cartilaginous stem cells) for knee osteoarthritis is experimental/investigational/unproven.; Stromal vascular fraction injection for knee osteoarthritis is experimental/investigational/unproven.; Transcranial direct current stimulation for knee osteoarthritis is experimental/investigational/unproven.; Transcutaneous electrical stimulation (TENS) for knee osteoarthritis is experimental/investigational/unproven. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source: Aetna CPB 0673 — Knee Arthroscopy

Coverage criteria

  • Arthroscopic knee surgery (with or without partial meniscectomy or meniscal repair) is medically necessary when ALL of the following are met: (1) significant knee pain PLUS mechanical symptoms; AND (2) no more than mild osteoarthritis (Kellgren-Lawrence grade 0, 1, or 2 OR modified Outerbridge grade 0, 1, or 2); AND (3) radiologic confirmation of pathology (X-ray for loose bodies; MRI for meniscal tears and/or loose bodies); AND (4) failure of conservative therapy (non-surgical medical management with at least 6 weeks of formal physical therapy in the past year, in-person as opposed to home or virtual physical therapy) -- WAIVED if the member's knee is 'locked' due to a displaced bucket handle tear of the meniscus.
  • Arthroscopic partial meniscectomy or meniscal repair for traumatic meniscal tears is medically necessary when ALL of the following are met: (1) traumatic meniscal tears; AND (2) significant symptoms; AND (3) no more than mild osteoarthritis (Kellgren-Lawrence grade 0, 1, or 2 OR modified Outerbridge grade 0, 1, or 2); AND (4) MRI confirmation of meniscal pathology; AND (5) failure of conservative therapy (at least 6 weeks of formal in-person physical therapy in the past year).
  • Arthroscopic meniscal repair for medial and/or lateral meniscal root tears is medically necessary when ALL of the following are met: (1) medial and/or lateral meniscal root tears; AND (2) significant symptoms; AND (3) no more than mild osteoarthritis (Kellgren-Lawrence grade 0, 1, or 2 OR modified Outerbridge grade 0, 1, or 2). Additional requirement: meniscal repair should only be considered where the vascular supply to the torn portion of the meniscus is adequate AND the meniscal tissue is not degenerated on imaging.
  • Intra-articular glucocorticoid (corticosteroid) injections are medically necessary for the treatment of osteoarthritis of the knee.
  • Minor synovectomy is considered integral to all other arthroscopic knee procedures and requires no separate justification.
  • Major synovectomy is medically necessary only when a disease of the synovium (e.g., pigmented villonodular synovitis, synovial osteochondromatosis) is identified pre-operatively.
  • Diagnostic knee arthroscopy may be billed and covered as medically necessary in the situation where the radiologically proven pathology is NOT confirmed at surgery (i.e., the arthroscopy was indicated by qualifying imaging findings but those findings were not borne out intra-operatively).
  • Imaging interpretation rule: Aetna will consider the official written report of complex imaging studies (e.g., CT, MRI). If the operating surgeon disagrees with the official written report, the surgeon should document that disagreement, discuss it with the provider who did the official interpretation, and there should be a written addendum to the official report indicating agreement or disagreement with the operating surgeon.

Covered codes

Codes listed in this Aetna policy. Check each one's prior-authorization verdict and Medicare rate:

Documentation required

  • Conservative therapy must be confirmed by documentation: history of unsuccessful conservative therapy (non-surgical medical management with at least 6 weeks of formal physical therapy in the past year, in-person as opposed to home or virtual physical therapy), confirmed either by the actual physical therapy notes OR by documentation in the member's claims history.
  • Imaging interpretation: the official written report of complex imaging studies (e.g., CT, MRI) is required; if the operating surgeon disagrees with the official written report, there must be documented disagreement, discussion with the interpreting provider, and a written addendum to the official report indicating agreement or disagreement with the operating surgeon.

Frequently asked questions

When does Aetna cover Knee Arthroscopy (CPT 29881), and what gets it denied?
Aetna CPB 0673 covers arthroscopic knee surgery (including partial meniscectomy or meniscal repair) and meniscal repair for traumatic tears or medial/lateral root tears only when the knee has no more than mild osteoarthritis (Kellgren-Lawrence or modified Outerbridge grade 0-2), there is radiologic/MRI confirmation of the pathology, and conservative therapy (at least 6 weeks of formal in-person physical therapy in the past year) has failed -- the conservative-therapy requirement is waived for a locked knee from a displaced bucket-handle tear. Intra-articular corticosteroid injections are covered for knee osteoarthritis, while diagnostic-only arthroscopy, isolated chondroplasty/debridement (especially for severe OA or pain-only OA), Zilretta, and a long list of regenerative/device/neuromodulation interventions (e.g., stem cell therapy, MISHA implant, subchondroplasty, genicular nerve RFA, PRP-adjacent orthobiologics) are not covered as not medically necessary or experimental/investigational. Coverage criteria include: Arthroscopic knee surgery (with or without partial meniscectomy or meniscal repair) is medically necessary when ALL of the following are met: (1) significant knee pain PLUS mechanical symptoms; AND (2) no more than mild osteoarthritis (Kellgren-Lawrence grade 0, 1, or 2 OR modified Outerbridge grade 0, 1, or 2); AND (3) radiologic confirmation of pathology (X-ray for loose bodies; MRI for meniscal tears and/or loose bodies); AND (4) failure of conservative therapy (non-surgical medical management with at least 6 weeks of formal physical therapy in the past year, in-person as opposed to home or virtual physical therapy) -- WAIVED if the member's knee is 'locked' due to a displaced bucket handle tear of the meniscus.; Arthroscopic partial meniscectomy or meniscal repair for traumatic meniscal tears is medically necessary when ALL of the following are met: (1) traumatic meniscal tears; AND (2) significant symptoms; AND (3) no more than mild osteoarthritis (Kellgren-Lawrence grade 0, 1, or 2 OR modified Outerbridge grade 0, 1, or 2); AND (4) MRI confirmation of meniscal pathology; AND (5) failure of conservative therapy (at least 6 weeks of formal in-person physical therapy in the past year).; Arthroscopic meniscal repair for medial and/or lateral meniscal root tears is medically necessary when ALL of the following are met: (1) medial and/or lateral meniscal root tears; AND (2) significant symptoms; AND (3) no more than mild osteoarthritis (Kellgren-Lawrence grade 0, 1, or 2 OR modified Outerbridge grade 0, 1, or 2). Additional requirement: meniscal repair should only be considered where the vascular supply to the torn portion of the meniscus is adequate AND the meniscal tissue is not degenerated on imaging.; Intra-articular glucocorticoid (corticosteroid) injections are medically necessary for the treatment of osteoarthritis of the knee.; Minor synovectomy is considered integral to all other arthroscopic knee procedures and requires no separate justification.; Major synovectomy is medically necessary only when a disease of the synovium (e.g., pigmented villonodular synovitis, synovial osteochondromatosis) is identified pre-operatively.; Diagnostic knee arthroscopy may be billed and covered as medically necessary in the situation where the radiologically proven pathology is NOT confirmed at surgery (i.e., the arthroscopy was indicated by qualifying imaging findings but those findings were not borne out intra-operatively).; Imaging interpretation rule: Aetna will consider the official written report of complex imaging studies (e.g., CT, MRI). If the operating surgeon disagrees with the official written report, the surgeon should document that disagreement, discuss it with the provider who did the official interpretation, and there should be a written addendum to the official report indicating agreement or disagreement with the operating surgeon.. Applies to 11 codes: 29881, 29880, 29879, 29876, 29877, 29875, 29873, 29874, 29870, 29882, 29883. Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin does not state a precertification submission process for knee arthroscopy generally. It references the pre-certification pathway only in the context of chondroplasty/debridement, stating that isolated chondroplasty/debridement cannot be approved on a pre-certification request but could be considered on a case-by-case basis post-operatively. Documentation: Conservative therapy must be confirmed by documentation: history of unsuccessful conservative therapy (non-surgical medical management with at least 6 weeks of formal physical therapy in the past year, in-person as opposed to home or virtual physical therapy), confirmed either by the actual physical therapy notes OR by documentation in the member's claims history.; Imaging interpretation: the official written report of complex imaging studies (e.g., CT, MRI) is required; if the operating surgeon disagrees with the official written report, there must be documented disagreement, discussion with the interpreting provider, and a written addendum to the official report indicating agreement or disagreement with the operating surgeon. Policy exclusions and limitations: Diagnostic knee arthroscopy is generally NOT medically necessary and NOT covered; knee arthroscopy is only covered for persons with radiologically proven pathology meeting the policy criteria (exception: it may be billed/covered when the radiologically proven pathology is not confirmed at surgery).; Chondroplasty/debridement as an isolated request is NOT medically necessary for minor chondral lesions, and NOT approvable for significant arthritis of the knee; therefore it cannot be approved on pre-certification request, but could be considered on a case-by-case basis post-operatively (it is otherwise integral to other arthroscopic knee procedures).; Arthroscopic debridement is experimental/investigational/unproven for persons with osteoarthritis presenting with knee pain ONLY, OR with severe osteoarthritis (Outerbridge classification III or IV).; Extended-release triamcinolone acetonide injectable suspension (Zilretta) is considered NOT medically necessary because it has not demonstrated significant improvement in osteoarthritis pain compared with the immediate-release formulation of triamcinolone acetonide.; Meniscectomy (arthroscopic or open; total or partial) for treatment of medial or lateral meniscal root tears is experimental/investigational/unproven.; Medial knee implanted shock absorber (MISHA) for management of knee osteoarthritis and subchondral insufficiency fractures is experimental/investigational/unproven.; Subchondroplasty for treatment of bone osteoarthritis and all other indications is experimental/investigational/unproven.; Sustained acoustic medicine (SAM) for treatment of knee pain and all other indications (including myofascial/soft tissue pain and injuries affecting ankle, back, elbow, neck, and shoulder) is experimental/investigational/unproven.; Adipose cell-based therapies (e.g., autologous lipoaspirate) for knee osteoarthritis are experimental/investigational/unproven.; Advanced Arthritis Relief Protocol (which includes stem cell therapy) for knee osteoarthritis is experimental/investigational/unproven.; Arthroscopic lavage for knee osteoarthritis is experimental/investigational/unproven.; Balneotherapy for knee osteoarthritis is experimental/investigational/unproven.; Bone marrow aspirate concentrate for knee osteoarthritis is experimental/investigational/unproven.; Combination of high tibial osteotomy and autologous bone marrow derived cell implantation for knee osteoarthritis is experimental/investigational/unproven.; Cryotherapy (e.g., Iovera cryoneurolysis) for knee osteoarthritis is experimental/investigational/unproven.; Extracorporeal shock wave therapy for knee osteoarthritis is experimental/investigational/unproven.; Genicular artery embolization for knee osteoarthritis is experimental/investigational/unproven.; Genicular nerve stimulation for treatment of knee osteoarthritis is experimental/investigational/unproven.; High-intensity laser therapy for knee osteoarthritis is experimental/investigational/unproven.; Intra-articular application of autologous, fat-derived orthobiologics for knee osteoarthritis is experimental/investigational/unproven.; Intra-articular botulinum toxin injections for knee osteoarthritis are experimental/investigational/unproven.; Intra-articular injections of autologous conditioned serum for knee osteoarthritis are experimental/investigational/unproven.; Iovera cryoneurolysis for pain management before and after total knee arthroplasty is experimental/investigational/unproven.; Leukotape for knee osteoarthritis is experimental/investigational/unproven.; Microfracture/abrasion arthroplasty and xeno-matrix-induced chondrogenesis for treatment of focal traumatic cartilage defects are experimental/investigational/unproven.; Patellar denervation for knee osteoarthritis is experimental/investigational/unproven.; Percutaneous autologous fat injections for knee osteoarthritis are experimental/investigational/unproven.; Percutaneous calcium phosphate injections for knee osteoarthritis are experimental/investigational/unproven.; Pulsed vibration therapy for knee osteoarthritis is experimental/investigational/unproven.; Radiofrequency ablation (RFA; including genicular nerve RFA) for knee osteoarthritis is experimental/investigational/unproven.; Stem cell therapy (e.g., intra-articular injections of adipose tissue-derived stem cells, bone marrow-derived mononuclear cells, infra-patellar fat pad-derived mesenchymal stem cells, or pre-cartilaginous stem cells) for knee osteoarthritis is experimental/investigational/unproven.; Stromal vascular fraction injection for knee osteoarthritis is experimental/investigational/unproven.; Transcranial direct current stimulation for knee osteoarthritis is experimental/investigational/unproven.; Transcutaneous electrical stimulation (TENS) for knee osteoarthritis is experimental/investigational/unproven. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.
Does Aetna require prior authorization for Knee Arthroscopy?
Confirm prior-authorization status with Aetna before scheduling — it is code- and plan-specific, and this policy is not an exact authorization source. The bulletin does not state a precertification submission process for knee arthroscopy generally. It references the pre-certification pathway only in the context of chondroplasty/debridement, stating that isolated chondroplasty/debridement cannot be approved on a pre-certification request but could be considered on a case-by-case basis post-operatively. Documentation: Conservative therapy must be confirmed by documentation: history of unsuccessful conservative therapy (non-surgical medical management with at least 6 weeks of formal physical therapy in the past year, in-person as opposed to home or virtual physical therapy), confirmed either by the actual physical therapy notes OR by documentation in the member's claims history.; Imaging interpretation: the official written report of complex imaging studies (e.g., CT, MRI) is required; if the operating surgeon disagrees with the official written report, there must be documented disagreement, discussion with the interpreting provider, and a written addendum to the official report indicating agreement or disagreement with the operating surgeon.
What does Aetna exclude for Knee Arthroscopy?
Policy exclusions and limitations: Diagnostic knee arthroscopy is generally NOT medically necessary and NOT covered; knee arthroscopy is only covered for persons with radiologically proven pathology meeting the policy criteria (exception: it may be billed/covered when the radiologically proven pathology is not confirmed at surgery).; Chondroplasty/debridement as an isolated request is NOT medically necessary for minor chondral lesions, and NOT approvable for significant arthritis of the knee; therefore it cannot be approved on pre-certification request, but could be considered on a case-by-case basis post-operatively (it is otherwise integral to other arthroscopic knee procedures).; Arthroscopic debridement is experimental/investigational/unproven for persons with osteoarthritis presenting with knee pain ONLY, OR with severe osteoarthritis (Outerbridge classification III or IV).; Extended-release triamcinolone acetonide injectable suspension (Zilretta) is considered NOT medically necessary because it has not demonstrated significant improvement in osteoarthritis pain compared with the immediate-release formulation of triamcinolone acetonide.; Meniscectomy (arthroscopic or open; total or partial) for treatment of medial or lateral meniscal root tears is experimental/investigational/unproven.; Medial knee implanted shock absorber (MISHA) for management of knee osteoarthritis and subchondral insufficiency fractures is experimental/investigational/unproven.; Subchondroplasty for treatment of bone osteoarthritis and all other indications is experimental/investigational/unproven.; Sustained acoustic medicine (SAM) for treatment of knee pain and all other indications (including myofascial/soft tissue pain and injuries affecting ankle, back, elbow, neck, and shoulder) is experimental/investigational/unproven.; Adipose cell-based therapies (e.g., autologous lipoaspirate) for knee osteoarthritis are experimental/investigational/unproven.; Advanced Arthritis Relief Protocol (which includes stem cell therapy) for knee osteoarthritis is experimental/investigational/unproven.; Arthroscopic lavage for knee osteoarthritis is experimental/investigational/unproven.; Balneotherapy for knee osteoarthritis is experimental/investigational/unproven.; Bone marrow aspirate concentrate for knee osteoarthritis is experimental/investigational/unproven.; Combination of high tibial osteotomy and autologous bone marrow derived cell implantation for knee osteoarthritis is experimental/investigational/unproven.; Cryotherapy (e.g., Iovera cryoneurolysis) for knee osteoarthritis is experimental/investigational/unproven.; Extracorporeal shock wave therapy for knee osteoarthritis is experimental/investigational/unproven.; Genicular artery embolization for knee osteoarthritis is experimental/investigational/unproven.; Genicular nerve stimulation for treatment of knee osteoarthritis is experimental/investigational/unproven.; High-intensity laser therapy for knee osteoarthritis is experimental/investigational/unproven.; Intra-articular application of autologous, fat-derived orthobiologics for knee osteoarthritis is experimental/investigational/unproven.; Intra-articular botulinum toxin injections for knee osteoarthritis are experimental/investigational/unproven.; Intra-articular injections of autologous conditioned serum for knee osteoarthritis are experimental/investigational/unproven.; Iovera cryoneurolysis for pain management before and after total knee arthroplasty is experimental/investigational/unproven.; Leukotape for knee osteoarthritis is experimental/investigational/unproven.; Microfracture/abrasion arthroplasty and xeno-matrix-induced chondrogenesis for treatment of focal traumatic cartilage defects are experimental/investigational/unproven.; Patellar denervation for knee osteoarthritis is experimental/investigational/unproven.; Percutaneous autologous fat injections for knee osteoarthritis are experimental/investigational/unproven.; Percutaneous calcium phosphate injections for knee osteoarthritis are experimental/investigational/unproven.; Pulsed vibration therapy for knee osteoarthritis is experimental/investigational/unproven.; Radiofrequency ablation (RFA; including genicular nerve RFA) for knee osteoarthritis is experimental/investigational/unproven.; Stem cell therapy (e.g., intra-articular injections of adipose tissue-derived stem cells, bone marrow-derived mononuclear cells, infra-patellar fat pad-derived mesenchymal stem cells, or pre-cartilaginous stem cells) for knee osteoarthritis is experimental/investigational/unproven.; Stromal vascular fraction injection for knee osteoarthritis is experimental/investigational/unproven.; Transcranial direct current stimulation for knee osteoarthritis is experimental/investigational/unproven.; Transcutaneous electrical stimulation (TENS) for knee osteoarthritis is experimental/investigational/unproven. Claims may be denied when the requested service falls under these. Some of these are conditional (note the stated exceptions) — confirm specifics against the bulletin.

Source

Aetna CPB 0673 — Knee Arthroscopy

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Coverage disclaimer

This page summarizes Aetna clinical-coverage criteria extracted from policy CPB 0673 for educational purposes. Coverage policies change and vary by individual plan. Always verify against Aetna's current policy before performing a procedure or submitting a claim. d3rx is not responsible for claim denials or reimbursement issues.