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Historically, the role of normal meniscal cartilage was greatly under appreciated, and up until some 30 years ago, torn and damaged menisci were routinely excised. However, it is now known that the menisci are an integral structural component of the human knee, functioning to absorb shocks, provide joint stability, congruity, and nutrition. In addition, total and partial meniscectomy are associated with altered load bearing across the joint, frequently resulting in degenerative osteoarthritis. The integrity of the menisci are particularly important in knees in which the anterior cruciate ligament (ACL) has been damaged; in these situations, the menisci act as secondary stabilizers of anteroposterior and varus-valgus translation. With this greater understanding, the surgical principles of treating torn or damaged menisci evolved to their repair and preservation whenever possible. 

Meniscal allograft transplantation has been investigated in patients with a previous meniscectomy or requiring total or near total meniscectomy for irreparable tears. There are three (3) general groups of patients who have been treated with meniscal allograft transplantation:  

• Young patients with a history of meniscectomy who have symptoms of pain and discomfort associated with early osteoarthrosis that is localized to the meniscus-deficient compartment
• Those who are undergoing ACL reconstruction in whom a concomitant meniscal transplant is intended to provide increased stability
• Young athletes with few symptoms in whom the allograft transplantation is intended to deter the development of osteoarthritis; due to risks associated with this surgical procedure, prophylactic treatment is not frequently recommended

The following different types of allografts have been investigated:

Fresh

Fresh implants, harvested under sterile conditions, typically are not a practical option. The grafts must be used within a couple of days to maintain viability. Also, there are concerns regarding infectious diseases, such as HIV, and the grafts must be appropriately sized.

Frozen

After sterile harvest, the meniscus can be frozen for storage until thawed for use. The freezing process may destroy donor cells and decrease the size of the graft.

Freeze Dried (Lyophilized)

In addition to freezing, the tissue may be dehydrated, permitting storage at room temperature. Before transplantation, the graft is thawed and rehydrated.  Lyophilized grafts have been shown to be prone to reduced tensile strength, graft shrinkage, poor rehydration, post-transplantation joint effusion and synovitis.  Thus these grafts are no longer used in the clinical setting.

Cryopreserved

Cryopreservation freezes the graft in glycerol, preserving the cell membrane integrity and donor fibrochondrocyte viability. Of all the above options, cryopreserved grafts are most commonly used; Cryolife (Marietta, Ga.) is a commercial supplier of such grafts.

Several secondary sterilization techniques may be used, with gamma irradiation the most common.  The dose of radiation considered effective has been shown to change the mechanical structure of the allograft; therefore, non-irradiated grafts from screened donors are most frequently used.

Tissue engineering that grows new replacement host tissue for individual patients is also being investigated.  For example, the ReGen Collagen Scaffold (ReGen Biologics), which may also be referred to as the Menaflex^TM collagen meniscus implant or CMI^TM, is a resorbable collagen matrix comprised primarily of bovine type I collagen.  The implant is provided in a semilunar shape and trimmed to size for suturing to the remaining meniscal rim.  The implant provides an absorbable collagen scaffold that is replaced by the patient's own soft tissue; it is not intended to replace normal body structure.  The ReGen Collagen Scaffold received 501(k) marketing clearance from the U.S. Food and Drug Administration (FDA) in 2008.  The FDA determined that this collagen scaffold was substantially equivalent to existing predicate absorbable surgical mesh devices.  This is the first resorbable collagen matrix to be intended for the reinforcement and repair of soft tissue injuries of the medial meniscus.  Other scaffold materials and cell-seeding techniques are being investigated.

The risk of infectious disease, particularly HIV or hepatitis, continues to be a concern. 

• Adolescent patients should be skeletally mature with documented closure of growth plates (e.g., 15 years or older).  Adult patients should be too young to be considered an appropriated candidate for total knee arthroplasty or other reconstructive knee surgery (e.g., younger than 55 years)
• Disabling knee pain with activity that is refractory to conservative treatment
• Absence or near absence (more than 50%) of the meniscus, established by imaging or prior surgery
• Documented minimal to absent degenerative changes in the surrounding articular cartilage (Outerbridge Grade II or less)
• Normal knee biomechanics, or alignment and stability achieved concurrently with meniscal transplantation

Meniscal allograft transplantation may be considered medically necessary when performed in combination, either concurrently or sequentially, with autologous chondrocyte implantation or osteochondral allografting or osteochondral autografting for focal articular cartilage lesions.

Collagen meniscus implants are considered investigational.

None

Severe obesity, e.g., body mass index (BMI) greater than 35 kg/m2, may affect outcomes due to increased stress on weight bearing surfaces of the joint.  Meniscal allograft transplantation is typically recommended for young, active patients who are too young for total knee arthroplasty.

Investigative service is defined as the use of any treatment procedure, facility, equipment, drug, device, or supply not yet recognized by certifying boards and/or approving or licensing agencies or published peer review criteria as standard, effective medical practice for the treatment of the condition being treated and as such therefore is not considered medically necessary.

The coverage guidelines outlined in the Medical Policy Manual should not be used in lieu of the Member's specific benefit plan language.

11/2001: Reviewed by MPAC; investigational status remains

2/21/2002: Investigational definition added, Code Reference section updated, CPT 0014T added, HCPCS S9085 deletion date of 12/31/2001 added

5/1/2002: Type of Service and Place of Service deleted

3/22/2005: Code Reference section updated, CPT code 0014T deletion date of 12/31/2004 and Note: "See CPT code 29868" added, CPT code 29868 with effective date of 1/1/2005 added, ICD-9 procedure code 81.47 added, HCPCS S9085 deleted

3/16/2006: Policy reviewed, no changes

1/9/2007: Policy reviewed, no changes

5/15/2007: Policy reviewed, description section rewritten. No change to policy statement

12/4/2008: Policy reviewed, policy section re-written with medically necessary conditions as noted

12/15/2008: Code Reference section updated, covered table added.

05/28/2010: Title changed from "Meniscal Allograft Transplantation" to "Meniscal Allografts and Collagen Meniscus Implants." Description section revised; Policy Statement revised to include "Collagen meniscus implants are considered investigational"; Policy Guidelines section revised; and Code Reference section revised to add the following ICD-9 diagnosis codes to the Covered Codes Table:  717.0 - 717.5; 836.0; 836.1 and 836.2.

06/21/2011:  Policy statement revised to state that meniscal allograft transplantation may be considered medically necessary when performed in combination, either concurrently or sequentially, with autologous chondrocyte implantation or osteochondral allografting or osteochondral autografting for focal articular cartilage lesions. Policy guidelines revised to remove "lasting at least 6 months" and to add information regarding uncorrected misalignment and instability of the joint.

04/26/2012: Policy reviewed; no changes.

Blue Cross Blue Shield policy # 7.01.15

The code(s) listed below are ONLY covered if the procedure is performed according to the "Policy" section of this document. 

Covered Codes

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