Does G0428 require prior authorization?

No, G0428 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for G0428?

Medicare facility rate: N/A. Non-facility rate: N/A. Work RVU: 0.00.

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`G0428`, Collagen meniscus implant procedure for filling meniscal defects (e.g., cmi,

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Medicare Pricing

Work RVU

0.00

Facility

N/A

Non-Facility

N/A

Documentation Required

Documentation: Medical records may be required to determine if the member meets the clinical criteria for coverage for knee surgery.
None specified in this Clinical Policy Bulletin.

Product-specific application details: documentation of product lot, size, number of applications, fixation method (sutures, staples, adhesives), and whether single or multiple applications were performed (many devices are single-use and dosage is per cm2 or per mg for particulates).

For use of biologic implants/allografts/xenografts: documentation of patient allergies or sensitivities (e.g., known porcine sensitivity excludes Mediskin), informed consent noting product source (human, porcine, bovine, ovine), and rationale for selection.

When using investigational or off-label applications (e.g., TTAX01 for Wagner grade 3-4 DFUs in trials), document enrollment in clinical trial or detailed justification for off-label use, including prior therapies and expected benefit.

For nerve conduit/wrap use (NeuroMatrix/NeuroMend): documentation of nerve injury characteristics demonstrating suitability (no substantial loss of nerve tissue; ability to achieve gap closure by flexion) and surgical details.

Key Coverage Criteria

Covered when the patient meets the medical necessity clinical coverage criteria for knee arthroscopy or arthroscopically assisted surgery, knee diagnostic arthroscopy with or without synovial biopsy, knee arthrotomy, total knee replacement (TJR), unicondylar or patellofemoral knee replacement as outlined in InterQual CP: Procedures: Arthroscopy or Arthroscopically Assisted Surgery, Knee Arthroscopy or Arthroscopically Assisted Surgery, Knee (Pediatric) Arthroscopy, Diagnostic, +/- Synovial Biops [...]
Aetna considers the Menaflex device (previously known as the Collagen Meniscal Implant and the Collagen Scaffold device) experimental and investigational for repair and reinforcement of the medial meniscus of the knee and all other indications because of insufficient evidence of its effectiveness.
Use of acellular human dermal allograft in rhinoplasty
Healing septal perforations using acellular dermis as bioscaffold
Artiss is approved for attachment of skin grafts onto burn patients (clinical trial basis described).
AlloSkin: As an allogeneic human, cadaver-derived skin graft for the management of traumatic skin wounds and burn wounds if the wound is too large for autograft. (Note: not AlloSkin AC or AlloSkin RT, which are different products).

11 Active Policies

UHC-POL-surgery-knee, Surgery of the Knee

AETNA-CPB-0786, Menaflex

AETNA-CPB-0244, Skin and Soft Tissue Substitutes

BCBSIL-SUR705.034, Meniscal Allografts and Other Meniscal Implants

BCBSMT-SUR705.034, Meniscal Allografts and Other Meniscal Implants

BCBSNM-SUR705.034, Meniscal Allografts and Other Meniscal Implants

BCBSOK-SUR705.034, Meniscal Allografts and Other Meniscal Implants

UMR-POL-UMR-surgery-knee, Surgery of the Knee

SUREST-POL-SUREST-surgery-knee, Surgery of the Knee

CARELON-joint-surgery-2024-11-17-updated-2025-01-01, Joint Surgery

CARELON-joint-surgery-2025-11-15, Joint Surgery

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G0428, Collagen meniscus implant procedure for filling meniscal defects (e.g., cmi,