Blue Cross Blue Shield of Minnesota Medical Policy


Medical Policy:
Meniscal Allografts and Other Meniscal Implants
Effective Date:
March 2, 2020
Issued Date:
March 2, 2020
Last Revision Date:
December 2019
Annual Review:
December 2019

This policy version was replaced on July 1, 2021. To find the newest version, go to, read and accept the Blue Cross Medical Policy Statement, then select “Blue Cross and Blue Shield of Minnesota Medical Policies.” This will bring up the Medical Policy search screen. Enter the policy number without the version number (last 3 digits).

Meniscal cartilage is a structural component of the human knee, and functions to absorb shocks and provide load sharing, joint stability, congruity, proprioception, and lubrication of the joint. Meniscal injury is the most common pathology of the knee and results in pain, swelling, and dysfunction. Total and partial meniscectomy frequently result in degenerative osteoarthritis (OA).

Meniscal allograft transplantation is a surgical treatment intended for patients who have irreparable tears of the meniscus or who have undergone previous meniscectomy. There are three general groups of patients for whom meniscal allograft transplantation (MAT) is indicated:

  • Young patients with a history of meniscectomy who have symptoms of pain and discomfort associated with early OA 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 OA; due to the risks associated with this surgical procedure, prophylactic treatment is frequently not recommended.

Tissue engineering that grows new replacement tissue is also being investigated. The Collagen Meniscus Implant (CMI) is a resorbable collagen matrix composed primarily of type 1 collagen from bovine Achilles tendons. Other materials are being investigated, such as polyurethane.

As meniscal allograft transplantation is a surgical procedure, it is not subject to FDA regulation. The FDA does, however, regulate aspects of tissue banking under the Center for Biologics Evaluation and Research (CBER). According to the current rules, FDA premarket review or marketing approval is not required for minimally processed tissues transplanted from one person to another for their normal structural functions, and these criteria apply to meniscal allografts.

CMI (Ivy Sports Medicine) has received 510(k) clearance for use in surgical procedures for the reinforcement and repair of soft tissue injuries of the medial meniscus.

The polyurethane scaffold has not been approved for marketing in the United States.


Modified Outerbridge Classification is a method of determining the extent of cartilage damage, based on magnetic resonance imaging (MRI) or arthroscopy.

  • Grade 0: Normal
  • Grade I: Cartilage with softening and swelling by arthroscopy OR signal intensity alterations with an intact surface of the articular cartilage compared with the surrounding normal cartilage by MRI
  • Grade II: Partial-thickness defect with fissures on the surface that do not reach subchondral bone or exceed 1.5 centimeters (cm) in diameter
  • Grade III: Fissuring to the level of subchondral bone in an area with a diameter more than 1.5 cm
  • Grade IV: Exposed subchondral bone head. Subchondral bone is the bone underneath the joint cartilage.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Policy Position Coverage is subject to the specific terms of the member's benefit plan.

For applicable clinical criteria, see the following eviCore clinical guideline(s):

  •  Large Joint Services
    • CMM-312: Knee Surgery – Arthroscopic and Open Procedures,
    • CMM-312.3: Indications and Non-Indications for Meniscal Allograft Transplantation
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Denial Statements

No additional statements.


Blue Cross and Blue Shield of Minnesota medical policies apply generally to all Blue Cross and Blue Plus plans and products. Benefit plans vary in coverage and some plans may not provide coverage for certain services addressed in the medical policies.

Medicaid products and some self-insured plans may have additional policies and prior authorization requirements. As applicable, review the provisions relating to a specific coverage determination, including exclusions and limitations. Note that services with specific coverage criteria may be reviewed retrospectively to determine if criteria are being met. Retrospective denial of claims may result if criteria are not met.

For Medicare NCD and/or Medicare LCD, please consult CMS or National Government Services websites.

Blue Cross and Blue Shield of Minnesota reserves the right to revise, update and /or add to its medical policies at any time without notice. Codes listed on this policy are included for informational purposes only, and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. These guidelines are the proprietary information of Blue Cross and Blue Shield of Minnesota. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.