Does J7330 require prior authorization?

Yes, J7330 requires prior authorization (high confidence). At least one active policy explicitly requires prior authorization.

What is the Medicare reimbursement rate for J7330?

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

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`J7330`, Autologous cultured chondrocytes, implant

HCPCS/CPT

Prior Authorization

Prior Auth Required

At least one active policy explicitly requires 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.
Documentation of skeletal maturity / documented closure of growth plates (e.g., radiographic evidence or age documentation).

Clinical baseline and follow-up outcome measures (as used in studies): KOOS, IKDC subjective score, VR-12, Tegner activity scale, pain VAS, FAAM, AOFAS scores where applicable to document functional change over time.

Postoperative imaging follow-up (MRI or second-look arthroscopy) to assess graft incorporation, defect fill, and repair tissue characteristics (e.g., MOCART score, OCAMRISS where applicable).

Documentation excluding contraindications used in trials when applicable: absence of severe axial malalignment, absence of knee instability, absence of systemic arthropathy for Agili-C knee indications.

For biologic augmentation (PRP/BMC): documentation of biologic product used (source, processing method, concentration/volume if available) given heterogeneity and the need for standardized reporting.

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 [...]
The member is skeletally mature with documented closure of growth plates (e.g., 15 years or older).
Osteochondral autografts (OATS or mosaicplasty) are considered medically necessary for symptomatic focal full-thickness articular cartilage defects of the knee when ALL of the following criteria are met:
The member has disabling symptoms limiting ambulation that have not been relieved by appropriate non-surgical therapies (e.g., medication, physical therapy).
The member is not considered a candidate for total knee replacement (i.e., member is under 55 years of age).
The member has focal, full thickness (Outerbridge grade III or IV) unipolar lesions on the weight bearing surface of the femoral condyles or trochlea.

15 Active Policies

EVICORE-HPLAN-CIGNA-AFCE721BA4F3, Cigna Comprehensive Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA-FE6FBAF45728, Cigna Commercial Joint Surgery Code List - Effective 03/07/2026

EVICORE-HPLAN-CIGNA_MEDICARE-86ECFFFC5A0A, Cigna Commercial & Medicare Advantage Joint Surgery Code List - Effective 01/01/2026

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

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

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

AETNA-CPB-0637, Osteochondral Autografts (Mosaicplasty, OATS)

BCBSIL-SUR705.035, Autologous Chondrocyte Implantation (ACI) for Focal Articular Cartilage Lesions

BCBSMT-SUR705.035, Autologous Chondrocyte Implantation (ACI) for Focal Articular Cartilage Lesions

BCBSNM-SUR705.035, Autologous Chondrocyte Implantation (ACI) for Focal Articular Cartilage Lesions

BCBSOK-SUR705.035, Autologous Chondrocyte Implantation (ACI) for Focal Articular Cartilage Lesions

REGENCE-SUR87, Autologous Chondrocyte Implantation for Focal Articular Cartilage Lesions

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

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

UHCMA-POL-UHC_MA-joint-procedures, Joint Procedures

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J7330, Autologous cultured chondrocytes, implant