GoHealthcare Practice Solutions | MSK Specialty Procedure Library

ACL Reconstruction

Anterior Cruciate Ligament Reconstruction: Coverage, Medical Necessity, Prior Authorization, Graft and Device Selection, Documentation, Coding, Reimbursement, and Denial Prevention

A comprehensive healthcare-operations reference for clinical, prior authorization, utilization management, coding, revenue cycle, ASC, hospital, and executive teams.

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Educational and operational reference only. Verify the live member-specific benefit, payer policy, delegated utilization-management criteria, Medicare requirements, current code sets, NCCI edits, authorization details, contractual terms, and site-of-service rules before treatment, scheduling, billing, or appeal activity. Authorization does not guarantee coverage or payment.

Procedure FamilyOrthopedic Surgery / Sports Medicine | Knee

ProcedureAnterior Cruciate Ligament Reconstruction

Primary CPT Focus29888, with additional codes only when separately supported and reportable

Coding Year2026

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Procedure Navigation

Explore the Complete ACL Reconstruction Guide

Use the grouped links below to move directly to clinical, payer, authorization, coding, reimbursement, denial-prevention, and operational content.

Clinical Foundation

• Overview
• Evidence at a Glance
• Procedure Overview
• Relevant Anatomy (High-Level Overview)
• Clinical Indications
• Patient Selection
• Contraindications
• Imaging Requirements
• Medical Necessity

Coverage and Authorization

• Conservative Treatment Requirements
• Medicare and CMS Coverage
• CMS WISeR Model - Scope Boundary
• Commercial Payer and Utilization Management Comparison
• Documentation Requirements
• Prior Authorization Workflow
• Common Prior Authorization Denials
• Appeal Strategies

Coding and Revenue Integrity

• Coding and Billing Overview
• Applicable CPT Codes
• HCPCS Level II Codes
• Common ICD-10-CM Diagnosis Codes
• Applicable Modifiers
• Place of Service and Ambulatory Surgery Center Considerations

Operations, Insights, and Resources

• Clinical Documentation Checklist
• Procedure Comparison
• Device Manufacturers and System Considerations
• GoHealthcare Clinical Insights
• GoHealthcare Leadership Perspective
• GoHealthcare Prior Authorization Insight
• GoHealthcare Case Study
• GoHealthcare Best Practices
• Common Mistakes
• Pearls and Pitfalls
• Frequently Asked Questions
• Key Takeaways
• Future Outlook
• References
• Reading Recommendations
• Related GoHealthcare Resources
• Recommended Downloads
• Educational Disclaimer, Terms of Use, and Limitations

Procedure Guide

Overview

ACL reconstruction replaces a torn anterior cruciate ligament with a graft to restore stability. The core procedure is broadly accepted when criteria are met, but authorization and reimbursement risk concentrate in the reconstruction-versus-repair distinction, documented functional instability, conservative-care exceptions, graft and implant verification, adjunct procedures, and authorization-to-operative-note reconciliation.

This page is designed for physicians, advanced practice providers, practice administrators, prior authorization teams, utilization management nurses, coding and revenue cycle professionals, ambulatory surgery centers, hospitals, and healthcare executives. It focuses on healthcare operations rather than procedural technique.

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Procedure Guide

Evidence at a Glance

One-page executive summary for physicians, prior authorization specialists, utilization management teams, and revenue cycle leaders.

Domain	Summary Position
Medicare National Coverage Determination (NCD)	None. No NCD addresses anterior cruciate ligament reconstruction. NCD 150.9 governs only arthroscopic lavage and debridement for the osteoarthritic knee and does not reach ligament reconstruction. Coverage is therefore determined at Medicare Administrative Contractor discretion.
Medicare Local Coverage	Most contractors publish no full LCD for ACL reconstruction. Because Medicare criteria are not fully established, Medicare Advantage plans may apply internal medical necessity criteria under 42 CFR 422.101(b)(6). ACL reconstruction is a low-volume Medicare service; the operative payer environment is commercial, Medicaid, and workers' compensation.
CMS WISeR Model	Not applicable. ACL reconstruction is not a WISeR selected service. Only NCD 150.9 arthroscopic lavage and debridement for the osteoarthritic knee falls within the model from the knee code set. See Section 11 for the scope boundary and why it matters when ACL reconstruction is performed with concurrent debridement.
Commercial Payer Coverage	Broadly covered with conditions. Criteria converge on three requirements: imaging or arthroscopic confirmation of ACL tear or significant laxity, at least one positive instability test on examination, and documented functional instability. Conservative management is typically required but is waivable in the acute setting at most major vendors.
Evidence Level	Strong support for reconstruction over repair. The AAOS 2022 clinical practice guideline carries a strong-strength recommendation favoring reconstruction over repair based on lower revision rates. Strong recommendation for autograft over allograft, particularly in young and active patients. Moderate recommendation permitting anterolateral ligament reconstruction or lateral extra-articular tenodesis in selected patients. Early reconstruction preferred for acute isolated tears because the risk of additional cartilage and meniscal injury rises within three months.
Image Guidance	Not separately reportable. Intraoperative fluoroscopy used to confirm tunnel placement is integral to the arthroscopic procedure under National Correct Coding Initiative Chapter IV policy.
Prior Authorization	Required by essentially all commercial and Medicare Advantage plans. Commonly delegated to eviCore, Carelon, Evolent, Cohere, or TurningPoint. Frequently a separate authorization is required for allograft tissue.
Conservative Therapy	Typically 3 months of provider-directed non-surgical management, with named exceptions in the acute injury setting. eviCore waives the requirement where instability is documented together with a need to return to cutting, pivoting, or agility activity; a confirmed ACL tear with a repairable meniscus tear; or concomitant ligament injuries requiring reconstruction for stability.
Diagnostic Block Requirements	Not applicable to this procedure.
Key Documentation Requirements	MRI, CT arthrogram, or arthroscopic confirmation of ACL tear, disruption, or significant laxity; at least one positive instability test (Lachman, anterior drawer, pivot shift); documented subjective instability described as giving way, buckling, or subjective weakness; functional limitation against activities of daily living, occupational demands, or return-to-sport requirements; and either a conservative care record or a documented exception.
Typical Approval Considerations	ACL reconstruction is one of the more reliably approved knee procedures when documented correctly. Denials cluster in three places: instability documented as pain rather than as giving way, no positive instability test recorded, and conservative care neither completed nor affirmatively excepted. Adjunct procedures - lateral extra-articular tenodesis, allograft tissue, and bridge-enhanced repair devices - carry materially higher denial risk than the reconstruction itself.

GoHealthcare Payer Intelligence Alert | Three current items that change ACL workflow

1. eviCore states plainly that ACL repair is not medically necessary. Under CMM-312 V2.0.2025, effective March 7, 2026, ACL reconstruction is approvable under criteria while ACL repair is designated not medically necessary as a categorical statement. Because CPT 29888 covers repair, augmentation, and reconstruction in a single descriptor, the code does not distinguish them - but the operative note and the authorization narrative must.

2. The BEAR Implant label expanded on January 14, 2026. The FDA granted 510(k) clearance for updated labeling of the Miach Orthopaedics BEAR (Bridge-Enhanced ACL Restoration) Implant to include a reduced risk of radiographically confirmed post-traumatic osteoarthritis compared with hamstring autograft reconstruction at six years. This is the first sports medicine product carrying a reduced-PTOA label claim. It sits in direct tension with vendor criteria that categorically exclude ACL repair, and it is a live coverage dispute rather than a settled question.

3. Guideline and payer timing has moved. eviCore CMM-312 took effect March 7, 2026; Carelon Joint Surgery MSK02-1125.1 took effect November 15, 2025 with annual-review updates announced for September 19, 2026, including a specifically noted change to posterior cruciate ligament criteria; and the UnitedHealthcare Surgery of the Knee policy took effect June 1, 2026.

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Procedure Guide

Procedure Overview

Anterior cruciate ligament reconstruction replaces a torn ACL with a graft passed through bone tunnels drilled in the femur and tibia and secured with fixation hardware. It is performed arthroscopically in the overwhelming majority of cases and is reported with CPT 29888. Approximately 200,000 ACL tears occur annually in the United States, and reconstruction is among the highest-volume sports medicine procedures performed in ambulatory surgery centers.

Unlike knee arthroscopy for degenerative disease, ACL reconstruction is not a contested procedure in principle. Payers accept the indication. What they scrutinize is whether functional instability has been documented, whether the specific graft and adjunct procedures selected are supported, and whether the intervention is a reconstruction rather than a repair. The operational risk in this service line sits in the details, not in the core procedure.

The reconstruction-versus-repair distinction

This distinction drives more ACL denials than any other single factor, and the coding structure obscures it. CPT 29888 reads arthroscopically aided anterior cruciate ligament repair, augmentation, or reconstruction - one code for three different operations. Payer criteria do not treat them as equivalent.

Approach	What It Is	Payer Posture
Reconstruction	The torn ligament is removed and replaced with an autograft or allograft passed through bone tunnels and fixed at both ends	The reference standard. Approvable under criteria at every major payer. AAOS 2022 carries a strong-strength recommendation favoring reconstruction over repair based on lower revision rates
Primary repair	The native ligament is reattached or sutured without graft replacement	Designated not medically necessary by eviCore CMM-312. Other payers vary. Historic primary repair fell out of favor decades ago because of high failure rates; the modern revival is technique-dependent and evidence remains limited
Bridge-enhanced restoration	A resorbable collagen scaffold saturated with autologous blood is placed between the torn ends to enable the native ligament to heal - the BEAR Implant approach	The live coverage frontier. FDA De Novo authorization December 2020, with expanded labeling cleared January 14, 2026. Several payers still treat it under repair exclusions or as investigational. Obtain written plan-specific confirmation before scheduling
Augmentation	Graft material supplements rather than replaces the native ligament	Assessed case by case. Document the residual native ligament quality and why augmentation rather than full reconstruction was selected

The adjunct procedures that generate denials

• Anterolateral ligament reconstruction or lateral extra-articular tenodesis - supported by a moderate-strength AAOS recommendation in selected patients and approvable under eviCore criteria only when performed to augment an ACL reconstruction that itself meets criteria. Standalone lateral extra-articular tenodesis is designated not medically necessary.
• Allograft tissue - covered by most payers, but AAOS recommends autograft over allograft in young and active patients. Expect scrutiny of allograft selection in a young athlete without a stated reason.
• Concurrent meniscal repair - strengthens rather than weakens the case; a confirmed ACL tear with a repairable meniscus tear is an explicit conservative-care exception under eviCore.
• Concurrent cartilage restoration - carries its own separate criteria set including defect size, containment, alignment, and body mass index thresholds.
• Revision reconstruction - no distinct CPT code exists. Reported with 29888 appended with modifier 22, or with unlisted code 29999, depending on payer preference. Requires a specific comparative narrative.

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Procedure Guide

Relevant Anatomy (High-Level Overview)

Limited to the anatomy required to understand indications, imaging correlation, coverage criteria, and graft and fixation decisions.

Structure	Operational Relevance
Anterior cruciate ligament	The primary restraint against anterior tibial translation and a secondary restraint against rotational load. Comprises the anteromedial and posterolateral bundles. Loss of function produces the giving-way and buckling that payer criteria require to be documented
Femoral and tibial footprints	Anatomic attachment sites determining tunnel placement. Non-anatomic tunnel position is a leading cause of graft failure and is a recurring finding in revision cases
Anterolateral ligament and iliotibial band	Contribute to rotatory control. The basis for anterolateral ligament reconstruction and lateral extra-articular tenodesis, both of which are authorized only as augmentation to a qualifying ACL reconstruction
Menisci, particularly the posterior horn of the medial meniscus	A secondary restraint to anterior translation. Concurrent meniscal pathology is common, influences the urgency of reconstruction, and is an explicit conservative-care exception when the tear is repairable
Articular cartilage	Chondral injury frequently accompanies ACL rupture and accumulates with delayed treatment. This is the clinical basis for the AAOS position favoring early reconstruction in acute isolated tears
Physes (growth plates)	Determinative in skeletally immature patients. Physeal-sparing and partial transphyseal techniques exist specifically to avoid growth disturbance. Skeletal maturity, not chronological age, drives technique selection and must be documented
Graft donor sites	Central third of the patellar tendon with bone blocks, the semitendinosus and gracilis tendons, and the quadriceps tendon. Donor-site morbidity differs by source and is relevant to the graft selection discussion
Posterolateral corner and collateral ligaments	Concomitant injury defines the multi-ligamentous knee, which is a recognized conservative-care exception and materially changes the surgical plan

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Procedure Guide

Clinical Indications

Strong and generally uncontested indications

• Complete ACL rupture with documented functional instability in a patient who requires return to activities involving cutting, pivoting, or agility.
• ACL insufficiency with recurrent episodes of giving way that limit activities of daily living or occupational demands.
• Confirmed ACL tear accompanied by a repairable meniscal tear, where reconstruction protects the meniscal repair.
• Multi-ligamentous knee injury requiring reconstruction to restore stability.
• ACL tear with a displaced bucket-handle meniscal tear or mechanical block.
• Tibial eminence (intercondylar spine) avulsion fracture requiring fixation, which is reported under distinct fracture codes rather than 29888.
• Failed prior ACL reconstruction with recurrent instability, appropriate tunnel assessment, and an identified failure mechanism.

Conditionally supported indications requiring careful documentation

• Partial ACL tear with objectively demonstrated instability. Document the specific bundle involved and the objective laxity finding; a partial tear without instability will be denied.
• ACL reconstruction in a low-demand patient, where the case rests on activities of daily living limitation rather than return to sport.
• Anterolateral ligament reconstruction or lateral extra-articular tenodesis as augmentation - approvable only when the underlying ACL reconstruction meets criteria and the augmentation rationale is documented, such as high-grade pivot shift, revision setting, generalized laxity, or young pivoting athlete.
• Reconstruction in the skeletally immature patient, where technique selection and physeal considerations must be explicitly documented.
• Reconstruction in the presence of early degenerative change, where the arthrosis grade should be stated and addressed rather than omitted.
• Bridge-enhanced ACL restoration, which requires plan-specific written confirmation and must be documented against the device's labeled indication, including the requirement for an ACL stump attached to the tibia and the timing window from injury.

Indications payers generally will not approve

• ACL primary repair as a categorical matter under eviCore CMM-312.
• Standalone anterolateral ligament reconstruction or lateral extra-articular tenodesis without a qualifying ACL reconstruction.
• Reconstruction for an incidentally imaged ACL tear in an asymptomatic patient without documented instability.
• Reconstruction where the documented complaint is pain alone, with no giving way, buckling, or subjective weakness.
• Reconstruction in advanced tricompartmental arthrosis where arthroplasty is the appropriate pathway.
• Biologic augmentation of the ACL graft, including bone marrow aspirate concentrate and platelet-rich plasma, which multiple payers designate experimental or investigational.

GoHealthcare Clinical Insight | Instability is a symptom, not an imaging finding

The recurring failure in ACL authorization is a technically perfect packet that documents the tear and omits the instability. An MRI showing complete ACL disruption is necessary but not sufficient at any major vendor. Every criteria set we work with requires reported instability - described as giving way, buckling, or subjective weakness - in addition to the imaging finding and in addition to a positive examination test.

Write it in the patient's words and date it. "Knee gave out twice descending stairs this month, once causing a fall" satisfies the criterion. "Persistent knee pain and swelling since injury" does not, no matter how complete the tear appears on MRI.

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Procedure Guide

Patient Selection

Selection Domain	What the Reviewer Is Looking For	Common Documentation Gap
1. Structural confirmation	MRI, CT arthrogram, or arthroscopy demonstrating tear, disruption, or significant laxity of the ACL	Report reads "ACL signal abnormality" or "attenuated ACL" without confirming tear, disruption, or laxity
2. Objective instability	At least one positive test: Lachman, anterior drawer, or pivot shift. Grading strengthens the record	Examination documents effusion and tenderness but records no ligamentous stability testing
3. Subjective instability	Reported giving way, buckling, or subjective weakness, in the patient's own words and dated	Instability inferred from the MRI rather than reported by the patient
4. Functional demand	Limitation of activities of daily living, occupational demands, or a documented need to return to cutting, pivoting, or agility activity	Functional impact stated generically as "unable to return to normal activity"
5. Conservative care or a documented exception	Three months of provider-directed non-surgical management, or an affirmatively stated acute-setting exception	Neither completed nor excepted - the case simply proceeds to surgery without either being addressed

Favorable selection factors

• Identifiable acute injury with a described mechanism, typically non-contact deceleration, pivoting, or landing.
• Documented instability episodes with dates and circumstances.
• High-grade objective laxity, including a Grade 2 or 3 Lachman or a positive pivot shift.
• Occupational or athletic demands requiring cutting, pivoting, or agility.
• Concurrent repairable meniscal pathology.
• Preserved articular cartilage and normal alignment.
• Skeletal maturity established, or physeal status documented where the patient is immature.

Unfavorable selection factors

• Absence of subjective instability despite a complete tear on imaging.
• Advanced tricompartmental arthrosis.
• Active infection or open wound at the surgical or graft harvest site.
• Uncontrolled diabetes, active tobacco use, or a body mass index profile that jeopardizes graft incorporation.
• Inability or unwillingness to complete a structured postoperative rehabilitation program, which is essential to outcome and should be discussed and documented.
• Significant untreated malalignment in the revision setting, where osteotomy may be required first.
• Persistent effusion and motion loss at the time of proposed surgery, which increases arthrofibrosis risk and generally warrants prehabilitation.

GoHealthcare Prior Authorization Insight | The AAOS timing recommendation and the payer conservative care rule point in opposite directions

This is the central operational tension in ACL authorization and it is worth naming explicitly. The AAOS 2022 clinical practice guideline holds that when surgical treatment is indicated for an acute isolated ACL tear, early reconstruction is preferred, because the risk of additional cartilage and meniscal injury begins to rise within three months. Most payer criteria sets require three months of provider-directed non-surgical management before authorizing.

The reconciliation is the exception pathway, and practices that do not use it will spend three months accruing exactly the secondary damage the guideline warns about. Under eviCore CMM-312, the three-month requirement is waived in an acute injury setting where joint instability is documented together with any of: a need to return to activities requiring cutting, pivoting, or agility where ACL insufficiency may predispose to further instability episodes and new articular or meniscal injury; a confirmed ACL tear with a repairable meniscus tear; or concomitant ligament injuries requiring reconstruction to provide stability.

Operationally: identify the exception at intake, state it affirmatively in the request, and cite the clinical basis. Do not submit a standard request and wait for the pend.

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Procedure Guide

Contraindications

Absolute contraindications

• Active septic arthritis of the knee, or active infection at the surgical or graft harvest site.
• Active systemic bacteremia in an elective setting.
• Uncorrected coagulopathy that cannot be safely managed perioperatively.
• Medical instability precluding safe anesthesia.
• Skeletal immaturity where no appropriate physeal-sparing or physeal-respecting technique is available and deferral is the safer course.

Relative contraindications and coverage-defeating conditions

• Absence of documented functional instability - the most common practical contraindication and the most common cause of denial.
• Advanced tricompartmental osteoarthritis.
• Significant knee stiffness, persistent effusion, or extension loss at the time of proposed surgery, which increases arthrofibrosis risk.
• Poorly controlled diabetes mellitus and active tobacco use, both of which impair graft incorporation and are commonly addressed as preoperative optimization requirements.
• Documented non-adherence to rehabilitation after prior knee surgery.
• Untreated malalignment or tunnel malposition in the revision setting, which may require staged bone grafting or osteotomy before reconstruction.
• For bridge-enhanced restoration specifically, absence of a tibial-side ACL stump, or presentation outside the device's labeled timing window from injury.

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Procedure Guide

Conservative Treatment Requirements

ACL reconstruction is unusual among knee procedures in that the conservative care requirement is more often excepted than satisfied. Practices that treat the three-month rule as fixed will delay indicated surgery, accrue secondary meniscal and chondral injury, and generate avoidable authorization friction. Practices that treat the exception as automatic will be denied. The discipline is in documenting which pathway applies and why.

Duration expectations and exception pathways by governing policy

Reviewing Entity	Standard Requirement	Exception Pathway
eviCore (CMM-312, V2.0.2025, effective March 7, 2026)	Failure of provider-directed non-surgical management for at least 3 months	Waived in an acute injury setting where joint instability is documented together with any of: need to return to cutting, pivoting, or agility activity where ACL insufficiency may predispose to further instability and new articular or meniscal injury; confirmed ACL tear with a repairable meniscus tear; or concomitant ligament injuries requiring reconstruction for stability
Carelon (Joint Surgery, MSK02-1125.1, effective November 15, 2025)	Conservative management defined as physical therapy plus at least one complementary strategy, with a documented reevaluation showing no meaningful improvement	Acute traumatic presentations and documented instability follow shortened pathways. Note that the announced September 19, 2026 update adds a criterion regarding persistent instability despite conservative treatment on the posterior cruciate ligament side; verify whether parallel language reaches ACL
Evolent / NIA (CG-316)	Documented failure of conservative management with clinical correlation of subjective complaints to objective findings and imaging	Acute instability presentations. Note the separate constraint prohibiting intra-articular cortisone injection within four weeks of surgery
Aetna	Documented conservative therapy consistent with the governing bulletin	Acute traumatic instability follows a more direct pathway. Allograft tissue is addressed under Clinical Policy Bulletin 0364, Allograft Transplants of the Extremities
UnitedHealthcare (Surgery of the Knee, effective June 1, 2026)	Conservative management consistent with the current coverage rationale	Acute traumatic and multi-ligamentous presentations
Original Medicare	No national conservative care mandate; contractor discretion applies	Not applicable. Low-volume population for this procedure

What conservative management means when it is required

• Structured physical therapy emphasizing quadriceps and hamstring strengthening, neuromuscular control, and progressive return to function - delivered by a qualified provider or as a documented supervised home program.
• Activity modification, including avoidance of cutting and pivoting activity during the trial.
• Functional bracing where used, with the indication documented.
• Anti-inflammatory or analgesic medication as clinically appropriate.
• A documented reevaluation demonstrating persistent instability rather than merely persistent pain. This is the element that converts a completed conservative trial into an approval. A patient who completes therapy and still gives way has, by definition, failed non-operative management for ACL insufficiency.

GoHealthcare Best Practice | Two templates, not one

Build two distinct ACL authorization narratives and select at intake rather than at submission.

• Acute exception template - leads with the injury date and mechanism, the objective instability finding, and the specific named exception being invoked, with the clinical rationale stated. Used when the patient presents acutely with a qualifying feature.
• Completed conservative care template - leads with the dated conservative care ledger and the reevaluation documenting persistent instability despite therapy. Used for chronic or delayed presentations.

Practices that maintain only one template inevitably force acute cases through the chronic pathway, which is both a clinical and an administrative loss.

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Procedure Guide

Imaging Requirements

Radiographs

• Weight-bearing anteroposterior, lateral, and axial patellofemoral views, with a posteroanterior flexion view where degenerative change is a consideration.
• Purpose in the ACL setting is to exclude fracture, identify a Segond fracture as an indirect sign of ACL injury, assess physeal status in the skeletally immature patient, assess alignment, and establish the degree of any degenerative change.
• Where arthrosis is present, state the Kellgren-Lawrence grade. Arthrosis does not defeat an ACL reconstruction request in the way it defeats a meniscectomy request, but an unaddressed advanced grade invites a pend.
• In the revision setting, add long-leg alignment views and consider computed tomography for tunnel position and osteolysis assessment.

Magnetic resonance imaging

• The reference standard and the modality named in essentially every criteria set.
• The report should state tear, disruption, or significant laxity of the ACL. Descriptive language such as "increased signal," "attenuated," or "indistinct" does not clearly satisfy the criterion and should be clarified.
• Where the tear is partial, the report should identify the bundle involved and comment on the integrity of the remaining fibers.
• The report should address concurrent pathology: meniscal tears with location and repairability features, collateral and posterolateral corner injury, chondral injury with a modified Outerbridge grade, and bone contusion pattern.
• For bridge-enhanced restoration candidacy specifically, the presence and quality of a tibial-side ACL stump is a labeled requirement and must be documented.
• Computed tomography arthrography is an accepted alternative where MRI is contraindicated and is named as acceptable in the eviCore criteria alongside MRI and arthroscopy.

Report Language That Supports Approval	Report Language That Invites Denial
"Complete disruption of the anterior cruciate ligament with fiber discontinuity"	"Increased intrasubstance signal within the anterior cruciate ligament"
"High-grade partial tear of the anteromedial bundle with residual posterolateral bundle fibers intact"	"Partial-thickness ACL abnormality, clinical correlation recommended"
"Peripheral vertical longitudinal tear of the posterior horn of the medial meniscus, red-red zone, amenable to repair"	"Meniscal signal abnormality"
"Tibial-side ACL stump remains attached with preserved fiber bulk"	"ACL not visualized"
"Segond fracture of the lateral tibial plateau"	"Small cortical irregularity, likely incidental"
"Grade 3 Lachman with soft endpoint; pivot shift positive" documented on examination alongside imaging	Imaging findings reported with no corresponding stability testing on examination

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Procedure Guide

Medical Necessity

Framed for insurance approval rather than clinical theory alone.

Medical necessity for ACL reconstruction rests on five linked elements. Unlike degenerative knee procedures, radiographic arthrosis is not the gating factor. Instability is.

1 Structural confirmation of ACL tear, disruption, or significant laxity on MRI, computed tomography arthrogram, or arthroscopy.

2 Objective instability on physical examination - positive Lachman, anterior drawer, or pivot shift, ideally graded.

3 Subjective instability reported by the patient as giving way, buckling, or subjective weakness.

4 Functional limitation stated against activities of daily living, occupational demands, or a documented need to return to cutting, pivoting, or agility activity.

5 Failed conservative management, or an affirmatively documented exception naming the qualifying acute-setting feature.

Model medical necessity statement - acute exception pathway

Template | Adapt to the specific clinical facts; do not use verbatim

This 23-year-old collegiate soccer midfielder sustained a non-contact pivoting injury to the left knee on [date] with immediate hemarthrosis and inability to continue play. She reports three subsequent episodes of the knee giving way, including one during level walking that caused a fall on [date]. Examination demonstrates a Grade 3 Lachman with a soft endpoint, a positive pivot shift, and a positive anterior drawer, with a 5-degree extension lag and a moderate effusion. MRI obtained [date] demonstrates complete disruption of the anterior cruciate ligament with fiber discontinuity, bone contusion of the lateral femoral condyle and posterior lateral tibial plateau, and a peripheral vertical longitudinal tear of the posterior horn of the medial meniscus in the red-red zone that is amenable to repair.

Arthroscopically aided anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft, with concurrent medial meniscal repair, is recommended. Three months of provider-directed non-surgical management is not indicated in this acute setting. Joint instability is objectively documented, and two qualifying conditions are present: a confirmed ACL tear with a repairable meniscus tear, and a need to return to activities requiring cutting and pivoting in which ACL insufficiency predisposes to further instability episodes and new articular or meniscal cartilage injury. Current guidance favors early reconstruction in acute isolated tears because the risk of additional cartilage and meniscal injury increases within three months; delay in this patient would also jeopardize the repairability of the meniscal tear.

Note the four features that make this work: the exception is named, the qualifying conditions are enumerated, instability is documented subjectively and objectively, and the clinical cost of delay is stated specifically rather than generically.

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Procedure Guide

Medicare and CMS Coverage

No National Coverage Determination applies

There is no National Coverage Determination addressing anterior cruciate ligament reconstruction. NCD 150.9, Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee, is frequently miscited in this context; it governs only arthroscopic lavage and debridement performed for osteoarthritis and does not reach ligament reconstruction. Coverage for ACL reconstruction is therefore determined at Medicare Administrative Contractor discretion under the general reasonable and necessary standard at Section 1862(a)(1)(A) of the Social Security Act.

Local coverage

• Most Medicare Administrative Contractors publish no full Local Coverage Determination for ACL reconstruction. Verify contractor-specific articles for the applicable jurisdiction before assuming coverage posture.
• Because Medicare coverage criteria are not fully established, Medicare Advantage plans may apply internal medical necessity criteria consistent with the transparency and evidence requirements at 42 CFR 422.101(b)(6). In practice, Medicare Advantage ACL authorization is governed by delegated vendor criteria rather than by Medicare policy.
• CPT 29888 is on the Medicare ambulatory surgery center covered procedures list. Confirm current-year status.

Practical Medicare operating notes

• ACL reconstruction is a low-volume service in the Original Medicare population; the dominant payer environment is commercial, Medicaid managed care, and workers' compensation.
• Where a Medicare beneficiary undergoes ACL reconstruction with concurrent debridement for osteoarthritis, the debridement component may implicate NCD 150.9 even though the reconstruction does not. Code and document the two components distinctly.
• Intraoperative fluoroscopy used for tunnel placement is integral and is not separately reportable.
• Graft harvest from the operative knee is included in 29888 and is not separately payable.

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Procedure Guide

CMS WISeR Model - Scope Boundary

Why ACL reconstruction is outside the model, and where the boundary still matters.

The CMS Wasteful and Inappropriate Service Reduction (WISeR) Model introduced prior authorization into Original Medicare for a defined list of services beginning January 1, 2026, in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington. From the knee code set, only NCD 150.9 - arthroscopic lavage and arthroscopic debridement for the osteoarthritic knee - is a selected service. ACL reconstruction is not.

Question	Answer
Is CPT 29888 subject to WISeR prior authorization?	No. ACL reconstruction is not among the WISeR selected services. Verify the current Appendix A code set in the WISeR Model Provider and Supplier Operational Guide, since the list may change across performance years
Does WISeR affect Medicare Advantage ACL cases?	No. WISeR applies only to Original Medicare fee-for-service beneficiaries. Medicare Advantage members remain subject to plan-level prior authorization, which for ACL reconstruction is typically required
Where does the boundary still matter?	When ACL reconstruction is performed in an Original Medicare beneficiary in a model state with concurrent debridement or lavage for osteoarthritis. The reconstruction is outside the model; the debridement component may fall within it. Document and code the components distinctly, and verify code-level applicability using the MAC prior authorization look-up tool before scheduling
Could ACL reconstruction be added later?	The selected service list is subject to change by CMS across the six performance years running through December 31, 2031. GoHealthcare recommends quarterly verification rather than a one-time build

Operational note. Practices in the six model states have reported staff applying WISeR screening to all knee arthroscopy codes indiscriminately, which delays ACL cases unnecessarily. Build the code-level distinction into the front-end workflow explicitly rather than relying on the procedure family name.

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Procedure Guide

Commercial Payer and Utilization Management Comparison

Synthesized operational guidance. Policy language is not reproduced. Always verify the version and effective date governing the specific member.

Utilization management vendor comparison

Vendor / Policy	Current Version and Date	Distinguishing Operational Features
eviCore by Evernorth CMM-312, Knee Surgery - Arthroscopic and Open Procedures	Comprehensive Musculoskeletal Management Guidelines V2.0.2025; Cigna-administered version effective March 7, 2026	The most explicit ACL criteria in the market. Requires MRI, CT arthrogram, or arthroscopy showing tear, disruption, or significant laxity; any one of positive Lachman, anterior drawer, or pivot shift; both function-limiting pain or loss of function and reported instability described as subjective weakness or buckling; and 3 months of provider-directed non-surgical management with three named acute exceptions. States categorically that ACL repair is not medically necessary. Treats anterolateral ligament reconstruction and lateral extra-articular tenodesis as approvable only as augmentation to a qualifying ACL reconstruction
Carelon Medical Benefits Management Clinical Appropriateness Guidelines: Joint Surgery	Doc ID MSK02-1125.1, effective November 15, 2025. Annual-review updates announced effective September 19, 2026	Applies a consistent general framework across joints: conservative management defined as physical therapy plus at least one complementary strategy; significant pain defined as at least 3 out of 10 with documented impact on activities of daily living; imaging within 12 months; provider interpretation of radiographs expressly permitted where a graded radiology report is unavailable. The announced September 2026 update adds a criterion for persistent instability despite conservative treatment on the posterior cruciate ligament side - verify whether parallel language reaches the ACL section
Evolent Health (National Imaging Associates) Clinical Guideline: Knee Arthroscopy, NIA CG 316 _ _	Verify plan-specific implementation date	Groups ACL and PCL reconstruction within the knee ligament reconstruction and repair code family alongside 27405, 27407, 27409, 27427, 27428, and 27429. Requires clinical correlation of subjective complaints with objective findings and imaging. Applies the distinct constraint of no intra-articular cortisone injection within four weeks of surgery. Publishes a utilization management matrix governing allowable billed groupings, which directly affects multi-code ACL requests
Cohere Health	Plan-specific; verify at the health plan level	Episode and care-pathway oriented. ACL cases frequently benefit from submitting the full anticipated procedure set, including meniscal repair contingencies, at initial request
TurningPoint Healthcare Solutions	Plan-specific; verify at the health plan level	Emphasizes site-of-service appropriateness and implant and graft selection alongside medical necessity. Allograft selection in a young active patient may draw specific review

National commercial payer comparison

Payer	Governing Policy	Operational Notes
Cigna Healthcare	Cigna Medical Coverage Policies - Musculoskeletal; CMM-312 developed by eviCore, effective March 7, 2026	Administers ACL criteria through eviCore CMM-312. Confirm against the Cigna CPT code list which procedures eviCore actually reviews for the specific plan; presence of a code in the guideline table does not establish that it is under management
UnitedHealthcare	Surgery of the Knee - Commercial and Individual Exchange Medical Policy, effective June 1, 2026; Joint Procedures for Medicare Advantage; state-specific Community Plan versions including a distinct New Jersey policy	Applicable code set includes 29888 and 29889 together with 0737T, 27412-27447, 27486, 27487, 27664, 27665, G0428, J7330, and S2112. Maintains separate commercial, Medicare Advantage, and Medicaid variants with differing criteria. For Oxford and certain arrangements, outpatient procedures may route through eviCore
Aetna	Clinical Policy Bulletin 0364, Allograft Transplants of the Extremities, addresses knee ligament reconstruction with allograft tendon; related bulletins address knee arthroscopy and adjunct technologies	Recognizes allograft tendon for ACL, PCL, and collateral ligament reconstruction, and specifically for primary reconstruction of combined ligament injuries where an adequate autologous graft is not available. Designates bone marrow aspirate concentrate augmentation of ACL graft reconstruction as not covered. Verify the current bulletin set governing the specific member
Humana	Medical coverage policies; delegated arrangements vary by market	Verify whether the plan delegates musculoskeletal review. Medicare Advantage products apply internal criteria where Medicare criteria are not fully established
Elevance Health (Anthem) and affiliated Blue plans	Carelon Clinical Appropriateness Guidelines: Joint Surgery	Most Anthem and affiliated Blue plans delegate to Carelon. Guideline changes are published in advance through provider news bulletins with defined dates of service; the September 19, 2026 update is already announced
Blue Cross Blue Shield plans (independent licensees)	Plan-specific medical policy; several use MCG care guidelines or delegate to Carelon or eviCore	Build a plan-level matrix. Independent licensees vary materially on adjunct procedures and on bridge-enhanced restoration in particular
Medicaid managed care and state Medicaid	State-specific; prior authorization commonly required	Verify both medical necessity criteria and fee schedule inclusion. Some state fee schedules exclude codes that appear on commercial policy lists
Workers' compensation and auto/no-fault	State treatment guidelines and jurisdiction-specific utilization review	ACL reconstruction is a high-volume workers' compensation procedure. Causation documentation carries weight equal to medical necessity. Document mechanism, temporal relationship, and the distinction between acute traumatic rupture and pre-existing degenerative attenuation explicitly

GoHealthcare Payer Intelligence | Where payers genuinely diverge on ACL

The core reconstruction criteria are largely harmonized. Divergence concentrates in four places, and all four are adjuncts rather than the primary procedure:

• ACL repair and bridge-enhanced restoration. eviCore excludes repair categorically. Other payers vary from silence to investigational designation to case-by-case review. This is the single largest divergence in the service line and it is actively moving following the January 2026 BEAR label expansion.
• Lateral extra-articular tenodesis and anterolateral ligament reconstruction. Approvable as augmentation under eviCore when the ACL reconstruction qualifies; standalone performance is excluded. Other payers may not address it at all, which in practice often means denial as unproven.
• Allograft in young active patients. Covered broadly, but AAOS recommends autograft in this population. Where allograft is selected for a young athlete, state the reason - revision setting, multi-ligamentous injury, inadequate autograft, or patient-specific factors.
• Biologic augmentation. Bone marrow aspirate concentrate and platelet-rich plasma augmentation of ACL graft are designated not covered or investigational by multiple payers, including expressly by Aetna. Do not include them in the request without written plan confirmation.

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Procedure Guide

Documentation Requirements

Core clinical documentation

• Injury date and mechanism, stated specifically (non-contact pivoting, deceleration, landing, hyperextension, contact)
• Immediate symptoms including audible pop, immediate swelling or hemarthrosis, and inability to continue activity
• Instability episodes described in the patient's own words, with dates - giving way, buckling, subjective weakness
• Functional limitation stated against activities of daily living, occupational demands, or specific return-to-sport requirements
• Activity level and sport or occupational demands, including cutting, pivoting, and agility requirements
• Prior knee injury or surgery on the ipsilateral and contralateral knee, with dates
• Skeletal maturity status where the patient is an adolescent
• Relevant comorbidities: diabetes with most recent hemoglobin A1c, body mass index, tobacco use, anticoagulation

Physical examination

• Lachman test with grade and endpoint quality
• Anterior drawer test
• Pivot shift test with grade
• Posterior drawer, posterior sag, and quadriceps active test to exclude PCL involvement
• Valgus and varus stress testing at 0 and 30 degrees
• Dial test or posterolateral corner assessment where indicated
• Range of motion in degrees, including any extension lag or flexion loss
• Effusion grade
• Joint line tenderness and meniscal provocative testing
• Gait, alignment, and quadriceps bulk or atrophy
• Instrumented laxity measurement where obtained

Imaging

• Weight-bearing radiographs with views specified; Kellgren-Lawrence grade where degenerative change is present
• MRI or CT arthrogram report stating tear, disruption, or significant laxity of the ACL
• Bundle involvement and residual fiber integrity where the tear is partial
• Concurrent meniscal pathology with location, pattern, and repairability features
• Collateral, posterolateral corner, and chondral findings with grading
• Tibial-side ACL stump status where bridge-enhanced restoration is contemplated
• Long-leg alignment views and tunnel assessment in the revision setting
• Explicit imaging-to-examination-to-symptom correlation statement

Conservative management or documented exception

• Either: dated conservative care ledger with therapy provider, start and end dates, visits, medications, bracing, activity modification, and documented reevaluation showing persistent instability
• Or: an affirmative statement naming the acute-setting exception invoked and the qualifying condition present
• Where an exception is invoked, the clinical rationale for not delaying, including risk to meniscal repairability or risk of additional articular injury
• Intra-articular injection dates, verified against the applicable preoperative window

Surgical planning and administrative

• Named intended procedure, laterality, and whether reconstruction, augmentation, or repair
• Graft selection and the rationale, particularly where allograft is chosen in a young active patient
• Planned adjunct procedures, including meniscal repair, cartilage procedures, and anterolateral ligament reconstruction or lateral extra-articular tenodesis with rationale
• Anticipated intraoperative contingencies stated in advance
• Explicit medical necessity statement linking all elements
• Shared decision-making documentation including graft options and rehabilitation commitment
• Site of service with rationale where a hospital outpatient department is selected
• Separate verification for allograft tissue, implants, and any device on an investigational list

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Procedure Guide

Prior Authorization Workflow

Stage	Owner	Actions and Operational Standards
1. Intake triage	PA specialist / Clinical staff	Determine at first contact whether this is an acute-exception case or a chronic conservative-care case. This single decision determines the template, the timeline, and the documentation set. Acute cases with a repairable meniscal tear should be flagged for expedited handling
2. Initial evaluation	Physician / APP	Document mechanism and date, instability episodes in the patient's words, full ligamentous examination with Lachman grade and endpoint, and functional demand. Order radiographs and MRI
3. Pathway determination	Physician	Either initiate and date conservative management, or document the acute exception and the specific qualifying condition. Do not leave this ambiguous
4. Surgical decision	Physician	Name the procedure and specify reconstruction rather than repair. State graft selection and rationale. Identify adjunct procedures and contingencies. Draft the medical necessity statement. Document shared decision-making
5. Benefit and vendor determination	PA specialist	Verify eligibility. Determine the reviewing entity and the governing guideline version. Determine separately whether allograft tissue and any implant require independent verification
6. Packet assembly	PA specialist	Fixed order: medical necessity statement, then either the conservative care ledger or the exception statement, then imaging reports, then office notes with the instability history highlighted, then therapy notes. Include a criteria-mapped cover page with page references
7. Submission	PA specialist	Submit 29888 with anticipated adjunct codes - meniscal repair, meniscectomy, cartilage procedures, and any planned augmentation. Record the reference number, date, time, and reviewing entity
8. Pend management	PA specialist	Respond within 24 hours. Track the specific criterion cited. For ACL the most common citation is absence of documented instability
9. Peer-to-peer	Physician + PA specialist	Prepare a one-page brief: criterion at issue, record page satisfying it, clinical argument. For acute cases, state the time-dependent risk to meniscal repairability explicitly
10. Determination and scheduling	PA specialist / Scheduling	Record the authorization number, approved code set, units, and validity window. Confirm graft and implant coverage separately. Communicate the approved code set to the operating room and facility
11. Post-operative reconciliation	Coding / Revenue cycle	Compare the operative note to the authorized code set. Confirm the note describes reconstruction where reconstruction was authorized. Initiate retrospective review where the procedure differs materially

GoHealthcare Prior Authorization Insight | Expedite the meniscal repair case

An ACL tear with a repairable meniscal tear is a time-limited surgical opportunity. Meniscal tears that are repairable at four weeks may not be repairable at twelve. This is not a theoretical concern; it is the clinical rationale that both justifies the acute exception and supports an expedited authorization request.

When the MRI describes a peripheral vertical longitudinal tear in a vascularized zone, flag the case for expedited review at intake, state the repairability risk explicitly in the request, and request expedited handling where the plan offers it. This is one of the few genuinely defensible expedite requests in elective orthopedic surgery, and reviewers respond to it when it is documented rather than asserted.

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Procedure Guide

Coding and Billing Overview

Operational overview only. Fee schedules, payment rates, relative value units, and detailed revenue cycle analysis are addressed in the GoHealthcare Revenue Cycle Knowledge Center.

ACL coding is deceptively simple at the primary code and genuinely complex at the margins. One code covers three different operations, graft harvest is bundled in most circumstances but not all, adjunct arthroscopic procedures are separately reportable but only under compartment rules, and no distinct code exists for revision.

Seven rules that govern most ACL claims

1 29888 covers repair, augmentation, and reconstruction. The descriptor does not distinguish them. The operative note and the authorization narrative must, because payer criteria treat them differently and at least one major vendor excludes repair categorically.

2 Graft harvest from the operative knee is included in 29888. This applies whether the graft is bone-patellar tendon-bone, hamstring, or quadriceps tendon. Do not report a separate harvest code for same-knee harvest.

3 Harvest from a distant site may be separately reportable. Where the tendon is obtained from the contralateral leg or another distant site through a separate incision, the appropriate graft harvesting code such as 20924 may apply, with a distinct procedural service modifier. Document the separate incision and the donor site explicitly.

4 Meniscal procedures are separately reportable with 29888. Per AAOS global service data, meniscectomy (29880, 29881) and meniscal repair (29882, 29883) may be reported in addition to 29888. Where meniscectomy and meniscal repair are performed on opposite menisci, both may be reported with an appropriate modifier and clear compartment documentation.

5 29874 and 29877 are bundled into 29888 under National Correct Coding Initiative edits with a modifier indicator of 0. Loose body removal and chondroplasty are not separately reportable with ACL reconstruction in the same compartment. Where chondroplasty is performed in a different compartment, Medicare directs the use of G0289 subject to the separate compartment criterion.

6 Arthroscopic and open work on the same ligament cannot both be reported. Do not report 29888 with 27428 for the ACL. Arthroscopic ACL reconstruction with open collateral ligament work - 29888 with 27427 - is reportable, as is 29888 with open PCL work on a different ligament with an appropriate modifier.

7 Revision has no distinct code. Report 29888 with modifier 22 accompanied by a comparative narrative quantifying the additional work, or unlisted code 29999, according to payer preference. Confirm the preference before submission rather than after denial.

Documentation that supports code selection

• Whether the procedure was a reconstruction, augmentation, or repair, stated explicitly.
• Graft type and source, and whether harvest was from the operative knee, a distant site, or allograft tissue.
• Where harvest was from a distant site, the separate incision and donor location.
• Every compartment entered and every service performed in each.
• For meniscal work, whether repair or resection, and which meniscus.
• Fixation method and devices used.
• In the revision setting, the prior construct, tunnel findings, staging decisions, bone grafting, and hardware removal, with a comparative statement of additional work.
• Laterality in the header and again in the procedure description.

Common coding and billing pitfalls

Pitfall	Consequence	Prevention
Reporting a separate graft harvest code for same-knee harvest	Denial and unbundling exposure	Hard edit; harvest is included in 29888 for patellar, hamstring, and quadriceps grafts taken from the operative knee
Reporting 29877 or 29874 with 29888 in the same compartment	Denial under a modifier-0 National Correct Coding Initiative edit	Coder edit; use G0289 for Medicare only where a genuine separate compartment criterion is met
Reporting 29888 with 27428 for the same ligament	Denial; arthroscopic and open reconstruction of the same ligament	Coder edit at the ligament level, not the code level
Reporting revision as a standard 29888 with no narrative	Underpayment for materially greater work	Confirm payer preference for 29888 with modifier 22 versus 29999, and prepare the comparative narrative in advance
Billing 0737T for a bridge-enhanced ACL implant	Incorrect code selection; 0737T is xenograft implantation into the articular surface for osteochondral regeneration, not an ACL product	Do not crosswalk cartilage codes to ACL devices. Confirm the reporting pathway with the manufacturer and the payer in writing before the case
Omitting laterality modifier	Front-end rejection	Require RT or LT on every ACL line
Reporting fluoroscopy for tunnel placement	Denial; integral to the arthroscopic procedure	Coder edit
Operative note describes repair where reconstruction was authorized	Post-service denial where the payer excludes repair	Pre-bill reconciliation comparing the note language to the authorized procedure

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Procedure Guide

Applicable CPT Codes

Descriptors are abbreviated for readability. Verify against the current CPT code set. CPT is a registered trademark of the American Medical Association.

Primary and directly related codes

Code	Descriptor (abbreviated)	Operational Note
29888	Arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction	The primary ACL code. Covers repair, augmentation, and reconstruction in a single descriptor. Includes graft harvest from the operative knee and intraoperative fluoroscopy. Revision is reported with modifier 22 or unlisted 29999 per payer preference
29889	Arthroscopically aided posterior cruciate ligament repair/augmentation or reconstruction	Addressed in the GoHealthcare PCL Reconstruction guide. May be reported with 29888 in multi-ligamentous injury
29870	Arthroscopy, knee, diagnostic, with or without synovial biopsy (separate procedure)	Separate procedure designation; not reportable with 29888
29880 / 29881	Arthroscopy, knee, surgical; with meniscectomy medial AND lateral / medial OR lateral, including chondroplasty when performed	Separately reportable with 29888 per AAOS global service data. Chondroplasty is inclusive to both descriptors
29882 / 29883	Arthroscopy, knee, surgical; with meniscus repair medial OR lateral / medial AND lateral	Separately reportable with 29888. Concurrent repairable meniscal tear is an explicit conservative-care exception at eviCore
29874	Arthroscopy, knee, surgical; for removal of loose body or foreign body	Bundled into 29888 with a modifier indicator of 0
29877	Arthroscopy, knee, surgical; debridement/shaving of articular cartilage (chondroplasty)	Bundled into 29888 with a modifier indicator of 0. For Medicare, separate-compartment chondroplasty is reported with G0289
29879	Arthroscopy, knee, surgical; abrasion arthroplasty or multiple drilling or microfracture	May be reported with 29888 per AAOS global service data where independently indicated
29866 / 29867 / 29868	Arthroscopy, knee, surgical; osteochondral autograft / osteochondral allograft / meniscal transplantation	Independent criteria sets apply; frequently require separate named authorization
29884	Arthroscopy, knee, surgical; with lysis of adhesions (separate procedure)	Separate procedure designation; not reportable with another ipsilateral arthroscopic procedure

Open and adjunct codes appearing on knee ligament policy lists

Code	Descriptor (abbreviated)	Operational Note
27405	Repair, primary, torn ligament and/or capsule, knee; collateral	Open collateral repair
27407	Repair, primary, torn ligament and/or capsule, knee; cruciate	Open cruciate repair
27409	Repair, primary, torn ligament and/or capsule, knee; collateral and cruciate	Open combined repair
27427	Ligamentous reconstruction (augmentation), knee; extra-articular	The code most commonly associated with lateral extra-articular tenodesis and anterolateral ligament reconstruction. Reportable with 29888 where both are performed. Confirm payer position, since standalone performance is excluded by eviCore
27428	Ligamentous reconstruction (augmentation), knee; intra-articular (open)	Do not report with 29888 for the same ligament. Included in the AAOS global service data package for intra-articular ligament reconstruction
27429	Ligamentous reconstruction (augmentation), knee; intra-articular (open) and extra-articular	Combined open reconstruction
20924	Tendon graft, from a distance (e.g., palmaris, toe extensor, plantaris)	Separately reportable only where the graft is harvested from a distant site through a separate incision, not from the operative knee
29850 / 29851	Arthroscopically aided treatment of intercondylar spine and/or tuberosity fracture(s), without / with fixation	The correct pathway for tibial eminence avulsion, which is a fracture rather than a ligament reconstruction
29999	Unlisted procedure, arthroscopy	One accepted pathway for revision ACL reconstruction where the payer prefers unlisted reporting over modifier 22

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Procedure Guide

HCPCS Level II Codes

Code	Descriptor (abbreviated)	Operational Note
G0289	Arthroscopy, knee, surgical, for removal of loose body, foreign body, debridement/shaving of articular cartilage at the time of other surgical knee arthroscopy in a different compartment of the same knee	Medicare-specific. The pathway for reporting chondroplasty performed in a compartment other than the one addressed by the ACL reconstruction, where no other surgical service was performed in that compartment
Tissue and graft HCPCS codes	Allograft tendon tissue codes vary by product and payer recognition	Allograft tissue frequently requires its own verification and may be separately billable by the facility rather than the professional. Confirm the reporting pathway and coverage in writing before the case
S2112	Arthroscopy, knee, surgical for harvesting of cartilage (chondrocyte cells)	Temporary national code recognized by some commercial payers; not payable by Medicare. Relevant only where concurrent cartilage restoration is performed
J7330	Autologous cultured chondrocytes, implant	Relevant only where concurrent autologous chondrocyte implantation is performed. Independent criteria apply
G0428	Collagen meniscus implant procedure for filling meniscal defects	Appears on commercial knee policy code lists. Coverage is inconsistent; verify before scheduling

GoHealthcare Coding Alert | 0737T is not an ACL code

CPT 0737T, xenograft implantation into the articular surface, is a Category III code established for placement of a xenograft scaffold for osteochondral regeneration and is reported once per joint. It is associated with cartilage repair implants and is expressly excluded from reporting with 27415 and 27416. It appears on several commercial knee surgery policy code lists, and its presence there has produced recurring confusion about whether it applies to bridge-enhanced ACL implants. It does not. Practices reporting bridge-enhanced ACL restoration generally report the surgical procedure under 29888 and address the implant separately; there is no established dedicated code for the implant itself. Confirm the reporting pathway with the manufacturer and obtain written payer guidance before the case rather than after the denial.

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Procedure Guide

Common ICD-10-CM Diagnosis Codes

Coder verification required. Several parent codes in this family are non-billable and require additional characters for laterality and, for acute injury codes, a seventh character for encounter. Codes below reflect the fiscal year 2026 ICD-10-CM update effective October 1, 2025. Confirm full specificity against the current code set before submission.

Acute cruciate ligament injury

Code Family	Description	Specificity Requirement
S83.51-	Sprain of anterior cruciate ligament of knee	S83.511 (right), S83.512 (left), S83.519 (unspecified), each requiring a seventh character: A (initial encounter), D (subsequent), S (sequela). Example: S83.511A for an acute right ACL injury at initial encounter
S83.52-	Sprain of posterior cruciate ligament of knee	Same laterality and seventh-character structure
S83.41- / S83.42-	Sprain of medial / lateral collateral ligament of knee	Same structure. Relevant to multi-ligamentous documentation
S83.2-	Tear of meniscus, current injury	Encodes tear type, meniscus, and laterality plus a seventh character. Frequently reported alongside acute ACL injury
S83.3-	Tear of articular cartilage of current knee injury	Laterality plus seventh character
S83.10- through S83.19-	Subluxation and dislocation of knee	Relevant to multi-ligamentous and knee dislocation presentations

Chronic instability and old injury

Code	Description	Operational Note
M23.61-	Other spontaneous disruption of anterior cruciate ligament of knee	M23.611 (right), M23.612 (left), M23.619 (unspecified). The primary code for chronic ACL insufficiency where the injury is not an acute current encounter
M23.62-	Other spontaneous disruption of posterior cruciate ligament of knee	Same laterality structure
M23.5-	Chronic instability of knee	M23.5 alone is not billable. M23.50 (unspecified), M23.51 (right), M23.52 (left). Strongly supportive of the instability criterion
M23.8X-	Other internal derangements of knee	Requires the X placeholder plus laterality: M23.8X1, M23.8X2, M23.8X9
M23.2-	Derangement of meniscus due to old tear or injury	M23.2 alone is not billable. Six characters required encoding meniscus and laterality
M24.26-	Disorder of ligament, knee	M24.261 (right), M24.262 (left). Supportive rather than primary
M25.36-	Other instability, knee	M25.361 (right), M25.362 (left), M25.369 (unspecified). Supportive of the instability criterion
M25.46- / M25.56-	Effusion of knee / Pain in knee	Supportive only. Do not report knee pain as the primary diagnosis on an ACL reconstruction claim; instability, not pain, is the operative indication

Complications, revision, and aftercare

Code Family	Description	Operational Note
T84.4-	Mechanical complication of other internal orthopedic devices, implants and grafts	Seventh character required. Relevant to graft or fixation failure in the revision setting
T84.5- / T84.6-	Infection and inflammatory reaction due to internal joint prosthesis / internal fixation device	Seventh character required
M96.6-	Fracture of bone following insertion of orthopedic implant, joint prosthesis, or bone plate	Relevant to tunnel-related complications
Z98.890	Other specified postprocedural states	Supportive in the revision narrative where prior surgery must be established
Z96.65-	Presence of artificial knee joint	Not applicable to ACL reconstruction; listed to avoid miscoding

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Procedure Guide

Applicable Modifiers

Modifier	Application	Operational Note
RT / LT	Right / left	Required on every ACL line. Omission is a leading front-end rejection
22	Increased procedural services	The principal revision ACL pathway where the payer prefers modifier 22 over unlisted reporting. Requires a comparative narrative quantifying additional operative time, hardware removal, tunnel management, bone grafting, and complexity, plus a cover letter
59	Distinct procedural service	Historically used to identify meniscectomy and meniscal repair performed on opposite menisci, and to distinguish work on a different ligament. Confirm payer preference regarding which line carries the modifier
XS	Separate structure	The more specific alternative where the distinction rests on a different meniscus, compartment, or ligament. Preferred by payers that have adopted the X-series
XU	Unusual non-overlapping service	Where the second service does not overlap the usual components of the primary service
51	Multiple procedures	Applied by payer edit in many cases. Confirm whether the payer expects it appended or applies it automatically
50	Bilateral procedure	Rare for ACL. Confirm whether the payer expects a single line with modifier 50 or separate RT and LT lines
58	Staged or related procedure during the postoperative period	For planned staged revision, such as bone grafting of tunnels followed by reconstruction
78	Unplanned return to the operating room for a related procedure	For example, arthroscopic lysis of adhesions for arthrofibrosis, or lavage for infection
79	Unrelated procedure during the postoperative period	Commonly contralateral knee surgery within the global period
62	Two surgeons	Occasionally applicable in complex multi-ligamentous reconstruction. Both surgeons must document their distinct operative work
80 / 82 / AS	Assistant at surgery	Verify payer assistant-at-surgery eligibility for 29888 before the case
73 / 74	Discontinued outpatient or ASC procedure before / after anesthesia	Facility claim modifiers
GA / GY / GZ	Advance Beneficiary Notice issued / statutorily excluded / expected denial with no notice on file	GZ results in provider liability. Issue the notice and use GA where a Medicare denial is anticipated

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Procedure Guide

Place of Service and Ambulatory Surgery Center Considerations

Setting	Code	Operational Considerations
Ambulatory surgery center	POS 24	The predominant setting for isolated primary ACL reconstruction. CPT 29888 is on the Medicare ASC covered procedures list; confirm current-year status and commercial payer ASC lists. Facility and professional claims are billed separately
Hospital outpatient department	POS 22 (type of bill 13X)	Appropriate for multi-ligamentous reconstruction, complex revision, significant comorbidity, anesthesia risk, or pediatric cases requiring specialized support. Several payers apply separate site-of-service review; document the clinical rationale contemporaneously rather than after a denial
Inpatient hospital	POS 21	Uncommon for isolated ACL reconstruction. Generally limited to knee dislocation, multi-ligamentous reconstruction with vascular concern, polytrauma, or complex staged revision
Office	POS 11	Not applicable to ACL reconstruction

Ambulatory surgery center operational checklist

• Confirm the authorization covers the facility as well as the professional service.
• Confirm allograft tissue coverage and the billing pathway separately. Allograft cost on an ACL case can exceed the professional fee, and facility and professional responsibility for the tissue charge varies by contract.
• Confirm fixation implant coverage where the payer applies implant review.
• Confirm the ASC is in network and the surgeon's privileges are current.
• Where a hospital outpatient department is selected, document comorbidity, complexity, or revision status before booking.
• Reconcile the anesthesia authorization requirement, which some plans manage separately.
• Confirm postoperative bracing and continuous passive motion coverage in advance; several payers designate continuous passive motion not medically necessary after knee arthroscopy.

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Procedure Guide

Clinical Documentation Checklist

Consolidated pre-submission and pre-billing checklist. Reproducible as a standalone quality assurance instrument.

Before submitting the authorization request

• Procedure named explicitly as reconstruction rather than repair, with laterality
• Graft selection stated with rationale, particularly where allograft is chosen in a young active patient
• Adjunct procedures identified, including meniscal repair and any planned augmentation
• Anticipated intraoperative contingency codes identified
• MRI or CT arthrogram confirming tear, disruption, or significant laxity of the ACL
• At least one positive instability test documented, ideally graded
• Subjective instability documented in the patient's own words, with dates
• Functional limitation stated against activities of daily living, occupational demands, or return-to-sport requirements
• Either a dated conservative care ledger with reevaluation showing persistent instability, or an affirmatively named acute exception with the qualifying condition
• Where an exception is invoked, the clinical rationale for not delaying is stated
• Concurrent meniscal repairability documented where applicable
• Preoperative intra-articular injection window verified against the governing policy
• Explicit medical necessity statement linking all elements
• Correct reviewing entity and governing guideline version confirmed
• Allograft tissue and implant coverage verified separately and in writing

Before releasing the claim

• Operative note states reconstruction where reconstruction was authorized
• Graft type and harvest site documented; same-knee harvest not separately reported
• Where harvest was from a distant site, separate incision and donor location documented
• Every compartment entered and every service performed documented
• Meniscal work documented as repair or resection, with the meniscus named
• No chondroplasty or loose body code reported with 29888 in the same compartment
• 29888 not reported with 27428 for the same ligament
• Fluoroscopy not separately reported
• Laterality modifier present on every line
• Revision cases carry the comparative narrative supporting modifier 22, or use the payer-preferred unlisted pathway
• Diagnosis codes at full specificity, including seventh characters on acute injury codes
• Primary diagnosis reflects instability or ligament disruption rather than knee pain
• Procedure performed reconciled against the authorized code set

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Procedure Guide

Procedure Comparison

Reconstruction versus repair versus bridge-enhanced restoration

Dimension	Reconstruction	Primary Repair	Bridge-Enhanced Restoration
Principle	Torn ligament replaced with graft through bone tunnels	Native ligament reattached or sutured	Resorbable collagen scaffold plus autologous blood enables native ligament healing
Evidence posture	AAOS 2022 strong-strength recommendation favoring reconstruction over repair based on lower revision rates	Historic technique with high failure rates; modern revival is technique-dependent with limited comparative evidence	Randomized data reported non-inferiority to autograft reconstruction at two years; FDA cleared expanded labeling January 14, 2026 including reduced post-traumatic osteoarthritis risk at six years versus hamstring autograft
Payer posture	Approvable under criteria at every major payer	Designated not medically necessary by eviCore CMM-312; varies elsewhere	Live coverage dispute. Frequently caught by repair exclusions or investigational designations. Requires written plan-specific confirmation
Candidacy constraint	Broad	Tear pattern dependent	Labeled requirements include an ACL stump attached to the tibia and a defined timing window from injury; pediatric candidacy requires sufficient epiphyseal bone
Coding	29888	29888 - same code, different operation	Procedure generally reported under 29888; no established dedicated implant code. 0737T is not applicable

Graft selection

Graft	Considerations	Authorization Relevance
Bone-patellar tendon-bone autograft	AAOS moderate recommendation in skeletally mature patients to reduce graft failure and infection risk. Bone-to-bone healing. Anterior knee and kneeling pain is the principal donor-site morbidity	Rarely questioned. Harvest included in 29888
Hamstring autograft	AAOS moderate recommendation to reduce anterior and kneeling pain. Soft-tissue healing in the tunnel	Rarely questioned. Harvest included in 29888
Quadriceps tendon autograft	Increasingly used; large cross-sectional area, versatile in revision	Rarely questioned. Harvest included in 29888
Allograft	AAOS strong recommendation favoring autograft over allograft to improve outcomes and reduce graft failure, particularly in young and active patients. Advantages include no donor-site morbidity, shorter operative time, and availability for revision and multi-ligamentous cases	Requires separate tissue verification. Where selected in a young active patient, state the reason. Aetna addresses knee ligament allograft under Clinical Policy Bulletin 0364, including primary reconstruction of combined ligament injuries where an adequate autologous graft is unavailable
Biologic augmentation	Bone marrow aspirate concentrate and platelet-rich plasma augmentation of the graft	Designated not covered or investigational by multiple payers, including expressly by Aetna for bone marrow aspirate concentrate. Do not include without written confirmation

Reconstruction alone versus reconstruction with lateral augmentation

The STABILITY randomized trial reported that adding lateral extra-articular tenodesis to hamstring autograft reconstruction reduced graft failure at two years, while functional outcome scores did not differ. AAOS 2022 carries a moderate-strength recommendation that anterolateral ligament reconstruction or lateral extra-articular tenodesis may be considered in selected patients. Payer criteria track this: augmentation is approvable when it accompanies a qualifying ACL reconstruction and the rationale is documented, and is excluded when performed standalone. Document the specific indication - high-grade pivot shift, revision setting, generalized ligamentous laxity, young pivoting athlete, or hyperextension - rather than describing it as routine.

Surgical reconstruction versus structured rehabilitation

The ACL SNNAP randomized trial compared rehabilitation with surgical reconstruction for non-acute ACL injury and remains the principal citation payers use when questioning reconstruction in chronic, low-demand presentations. Its scope is important and frequently misapplied: it addresses non-acute injury, not the acute setting, and it does not contradict the AAOS position favoring early reconstruction for acute isolated tears. Where a reviewer cites

rehabilitation-first evidence against an acute case, the distinction between acute and non-acute presentation is the correct response, together with the documented instability and any repairable meniscal pathology at risk.

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Procedure Guide

Device Manufacturers and System Considerations

ACL reconstruction is implant-dependent, and implant and tissue costs frequently exceed the professional fee. Categories below are provided for operational awareness. Product availability, FDA clearance status, labeled indications, and coverage change frequently and must be verified for each case against the manufacturer's current instructions for use and the applicable payer policy.

Category	Representative Systems and Manufacturers	Operational Considerations
Femoral cortical suspensory fixation	Arthrex TightRope and ACL TightRope RT, Smith & Nephew ENDOBUTTON and ULTRABUTTON, Stryker VersiTomic and Citrelock, ConMed XO Button	Adjustable-loop and fixed-loop designs. Generally included in the facility payment. Document the device and fixation strategy in the operative note
Interference screw fixation	Arthrex BioComposite and Delta screws, Smith & Nephew BIOSURE, Stryker BIOSTEON, Zimmer Biomet	Bioabsorbable, biocomposite, and metallic options. Screw composition can matter in revision planning and for subsequent imaging
Tibial and supplementary fixation	Arthrex Bio-Interference and GraftBolt, Smith & Nephew BIOSURE, staples, screws and washers, ConMed Cross Pin	Backup fixation is common in soft-tissue graft constructs. Document supplementary fixation where used
Suture augmentation and internal bracing	Arthrex InternalBrace with FiberTape, Smith & Nephew ULTRABRAID constructs	Coverage is inconsistent. Some payers treat suture augmentation as integral to the reconstruction; others scrutinize it as an unproven adjunct, particularly when described as augmenting a repair rather than a reconstruction. Document precisely what was augmented and why
Bridge-enhanced ACL restoration	BEAR Implant, Miach Orthopaedics	The highest-attention item in this service line. FDA De Novo authorization December 2020; 510(k) clearance January 14, 2026 for updated labeling including reduced risk of radiographically confirmed post-traumatic osteoarthritis at six years compared with hamstring autograft reconstruction. Bovine-derived collagen implant saturated with autologous blood. Labeled indication covers adults, adolescents, and children with complete or partial ACL rupture confirmed by MRI; an ACL stump attached to the tibia is required, and children with open physes must have sufficient epiphyseal bone. A defined timing window from injury applies. Coverage remains inconsistent and may be caught by categorical repair exclusions. Obtain written plan-specific confirmation and complete a patient financial responsibility discussion before scheduling. No established dedicated implant code exists; 0737T is not applicable
Allograft tissue	MTF Biologics, JRF Ortho, LifeNet Health, Allosource, RTI Surgical, and other tissue banks	Bone-patellar tendon-bone, Achilles, tibialis anterior and posterior, and hamstring allografts. Requires separate coverage verification. Irradiation and processing method may affect outcome and occasionally payer position. Confirm whether the tissue charge is a facility or professional responsibility under the applicable contract
Graft preparation and tensioning systems	Arthrex Graft Prep station, Smith & Nephew, Stryker graft preparation systems	Capital and disposable equipment. Not separately reportable
Postoperative bracing and rehabilitation devices	Functional and range-of-motion knee braces from DJO, Breg, Ossur, Bledsoe; continuous passive motion devices	Durable medical equipment authorization is separate from surgical authorization. Several payers designate continuous passive motion not medically necessary following arthroscopic knee surgery. Verify before dispensing
Adjuncts designated investigational by multiple payers	Bone marrow aspirate concentrate and platelet-rich plasma augmentation of the ACL graft; synthetic ligament devices	Do not schedule without written plan-specific confirmation and a documented financial responsibility discussion

GoHealthcare Best Practice | Verify the tissue before you verify the room

On ACL cases, the most common uncompensated cost is not the professional fee - it is allograft tissue or an adjunct implant that was never separately verified. Practices routinely obtain surgical authorization, book the room, and discover at billing that the tissue was not covered, was covered under a different entity's contract, or required a separate authorization that nobody requested.

Build tissue and implant verification as a mandatory, separately signed-off step in the ACL scheduling pathway, ahead of room booking. For any device on an investigational list - and bridge-enhanced restoration currently sits in that category at multiple payers - require written plan confirmation in the chart before the case is scheduled, not a verbal representation from a benefits line.

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Procedure Guide

Common Prior Authorization Denials

Denial Reason	What It Usually Means	Prevention
No documented instability	The leading ACL denial. The record documents the tear and the pain but never records giving way, buckling, or subjective weakness	Capture instability in the patient's words at the first visit as a required template field
No positive instability test recorded	Examination documents effusion and tenderness but no Lachman, anterior drawer, or pivot shift	Full ligamentous examination as a standing template on every knee injury visit, with grading
Imaging does not confirm tear, disruption, or laxity	MRI report uses descriptive language such as increased signal or attenuation without confirming disruption	Radiology addendum where the images support it, or a documented surgeon interpretation
Conservative management neither completed nor excepted	The case proceeds to surgery with no conservative trial and no affirmative exception statement	Pathway determination at intake; two distinct templates
Exception invoked without a qualifying condition	The request asserts an acute injury but does not name the qualifying feature the criteria require	Name the specific qualifying condition: return-to-pivoting need, repairable meniscus tear, or concomitant ligament injury
Procedure described as repair	The request or note describes ACL repair where the payer excludes repair categorically	Specify reconstruction. Where repair or bridge-enhanced restoration is genuinely intended, obtain written confirmation in advance
Lateral augmentation denied	Anterolateral ligament reconstruction or lateral extra-articular tenodesis requested without documented rationale, or requested standalone	Document the specific augmentation indication and confirm the primary reconstruction qualifies
Allograft questioned in a young active patient	Graft choice conflicts with the AAOS autograft recommendation with no stated reason	State the reason: revision, multi-ligamentous injury, inadequate autograft, or patient-specific factor
Biologic augmentation denied	Bone marrow aspirate concentrate or platelet-rich plasma included in the request	Remove from the request unless written coverage confirmation exists
Bridge-enhanced implant denied	Caught by a categorical repair exclusion or an investigational designation	Written plan-specific confirmation before scheduling; financial responsibility discussion
Allograft tissue not authorized	Surgical authorization obtained; tissue never separately verified	Mandatory separate tissue verification step ahead of room booking
Site of service not supported	Hospital outpatient department requested without documented rationale	Document comorbidity, revision status, or multi-ligamentous complexity contemporaneously
Authorization expired	Surgical date outside the validity window	Record the window at determination; scheduling alert at 75 percent of the window

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Procedure Guide

Appeal Strategies

ACL denials are unusually reversible, because the underlying indication is rarely in genuine dispute. In most cases the reviewer applied the criteria correctly to a record that omitted instability. The appeal should close that specific gap rather than restate the clinical narrative.

1 Identify the exact criterion cited and request the specific criteria set in writing where the denial letter does not name it.

2 Answer the criterion directly, one paragraph per criterion, with page references into a paginated record.

3 Supply the instability documentation. This resolves the majority of ACL denials. Attach the original office note containing the giving-way history, highlighted, rather than a note written after the denial.

4 Name the exception and its qualifying condition where the acute pathway applies. Do not argue generally that surgery is urgent; state which enumerated condition is present.

5 Quantify the time-dependent risk in acute cases, specifically the risk to meniscal repairability and the risk of additional articular and meniscal injury with delay.

6 Address graft and adjunct questions separately from the core reconstruction. A denial of lateral augmentation is not a denial of reconstruction; do not let the adjunct dispute delay the primary procedure.

7 Cite selectively. The AAOS 2022 clinical practice guideline positions on reconstruction over repair, autograft over allograft, early reconstruction in acute tears, and lateral augmentation in selected patients are the highest-value citations. A bibliography is not.

8 Escalate deliberately through reconsideration, independent external review, and state department of insurance complaint where warranted. For workers' compensation, follow the jurisdiction's utilization review appeal process, which operates on separate timelines.

Documentation that most often reverses an ACL denial

• The original office note documenting instability episodes in the patient's words, with dates.
• A graded Lachman with endpoint quality, or a documented positive pivot shift.
• A radiology addendum confirming ACL disruption where the initial report was descriptive.
• An affirmative exception statement naming the qualifying condition.
• MRI documentation of a repairable meniscal tear at risk with delay.
• For multi-ligamentous cases, documentation of the additional ligament injuries requiring reconstruction for stability.
• For revision cases, the prior operative note, imaging of tunnel position, and the identified failure mechanism.
• For workers' compensation, a causation statement distinguishing acute traumatic rupture from pre-existing degenerative attenuation.

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Procedure Guide

GoHealthcare Clinical Insights

Documentation quality

• Make instability capture a required field in the knee injury template, phrased to elicit the patient's own description rather than a yes-or-no checkbox.
• Make the full ligamentous examination a standing template rather than a discretionary section. Lachman grade and endpoint, anterior drawer, and pivot shift on every acute knee.
• Record the pathway determination - acute exception versus conservative care - as an explicit note element, not an inference.
• State reconstruction rather than repair in both the plan of care and the operative note, and reserve the word repair for cases where repair is genuinely intended.
• Document graft rationale as a routine element, particularly for allograft in young active patients.

Workflow improvement

• Triage ACL referrals at intake into acute and chronic pathways. The two require different documentation, different timelines, and different urgency.
• Flag ACL plus repairable meniscal tear cases for expedited handling as a standing rule.
• Build tissue and implant verification as a separate, signed-off step ahead of room booking.
• Maintain a plan-level matrix capturing the reviewing entity, conservative care duration and exceptions, position on repair and bridge-enhanced restoration, position on lateral augmentation, and allograft verification requirements.
• Run quarterly guideline surveillance. eviCore moved to V2.0.2025 effective March 2026, Carelon has a September 2026 update announced, and UnitedHealthcare refreshed its knee policy effective June 2026.

Prior authorization success

• Submit a criteria-mapped cover page with page references on every request.
• Submit 29888 together with anticipated adjunct codes rather than the primary code alone.
• Where the acute exception applies, lead with it and name the qualifying condition.
• Separate the adjunct dispute from the primary procedure so a lateral augmentation question does not delay reconstruction.
• Track pends by cited criterion. For ACL, the pattern is dominated by instability documentation.

Denial prevention and communication

• Give surgeons a one-page ACL criteria card emphasizing the three instability elements: imaging confirmation, positive test, and reported giving way.
• Report the top three cited criteria to the clinical team monthly.
• Escalate bridge-enhanced restoration, suture augmentation, and biologic adjunct questions to a written-confirmation track before booking.
• Where a request will predictably be denied, complete the financial responsibility conversation before surgery rather than after the explanation of benefits.

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Procedure Guide

GoHealthcare Leadership Perspective

A procedure where the risk sits in the adjuncts

ACL reconstruction is a rare service line in which the primary procedure is well accepted and the financial and administrative risk concentrates almost entirely in what surrounds it - allograft tissue, suture augmentation, lateral augmentation, bridge-enhanced devices, biologic adjuncts, and postoperative durable medical equipment. Organizations that manage ACL as a single authorization event will absorb recurring uncompensated cost. Organizations that manage it as a bundle of separately verified components will not.

Documentation excellence as the operative variable

The clinical decision to reconstruct an unstable ACL is rarely contested. What is contested is whether the record demonstrates instability. This is a documentation problem with a documentation solution, and it is measurable: the proportion of ACL charts containing a dated, patient-reported instability description is a leading indicator of first-pass approval rate, and it is a field that can be made mandatory in a template at negligible cost.

The timing tension is a clinical governance issue, not just an administrative one

Current guideline evidence favors early reconstruction in acute isolated tears because secondary cartilage and meniscal injury accrues within three months, while most payer criteria default to a three-month conservative trial. The exception pathways exist precisely to reconcile this. An organization that does not train its authorization staff to recognize and invoke those exceptions is, in effect, allowing an administrative default to override a clinical recommendation. Leadership should treat exception recognition as a competency to be trained and audited, not as tribal knowledge.

Revenue cycle implications

• Allograft tissue and implant exposure on a single ACL case can exceed the professional fee. Verification discipline is a margin issue.
• Revision ACL has no distinct code. Practices that default to a standard 29888 without a modifier 22 narrative or the payer-preferred unlisted pathway systematically underrecover on their most complex cases.
• The bundling structure means revenue leakage more often comes from failure to document compartments and separate incisions than from failure to bill a code.
• Workers' compensation is a significant share of ACL volume in many markets and operates on different criteria, different timelines, and different appeal mechanics. It warrants a dedicated workflow rather than being handled as an exception to the commercial process.

Emerging technology governance

Bridge-enhanced ACL restoration illustrates a recurring pattern: a technology obtains FDA authorization and expanded labeling before payer criteria are updated to address it, leaving it exposed to categorical exclusions written for a different technique. Organizations adopting such technologies should establish a standing process - written plan-specific confirmation before scheduling, documented patient financial responsibility discussion, tracking of determinations by payer, and periodic re-verification as criteria are updated. The clinical case for a technology and its coverage status are separate questions, and conflating them transfers financial risk to the patient or the practice.

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Procedure Guide

GoHealthcare Prior Authorization Insight

Operational expertise not readily found in payer policies or clinical guidelines.

Eight things experienced ACL authorization specialists know

1 The tear is not the case; the instability is. A complete ACL disruption on MRI does not satisfy any major criteria set on its own. Every vendor requires reported instability in addition to imaging and in addition to a positive test.

2 Three elements, three sources. Imaging supplies the structural confirmation, the examination supplies the objective instability, and the patient supplies the subjective instability. A packet missing any one of the three will pend.

3 The exception is the pathway for most acute cases, not a rarity. Learn the enumerated qualifying conditions well enough to recognize them at intake.

4 A repairable meniscal tear is a clock. It justifies the exception, supports an expedite request, and gives the peer-to-peer its strongest argument.

5 Never let the word repair appear where reconstruction is intended. One vendor excludes repair categorically, and the code does not distinguish. The word in the note decides the outcome.

6 Adjuncts are separate cases. Lateral augmentation, allograft tissue, suture augmentation, and biologic adjuncts each carry independent coverage risk. Submit them clearly and do not let a dispute over one delay the reconstruction.

7 Verify tissue before booking the room. The most common uncompensated ACL cost is allograft that nobody separately authorized.

8 Revision requires a decision before submission. Confirm whether the payer prefers 29888 with modifier 22 or unlisted 29999, and prepare the comparative narrative in advance. Discovering the preference after a denial costs months.

Internal quality assurance recommendations

• Audit ten consecutive ACL charts quarterly against the documentation checklist, reporting pass rate by element rather than in aggregate. Report the instability-documentation rate separately; it is the single most predictive element.
• Maintain a denial register recording payer, reviewing entity, guideline and section cited, outcome, and days to resolution.
• Audit the acute-versus-chronic pathway determination rate. A practice invoking the exception in almost no cases is likely missing qualifying presentations.
• Require pre-bill reconciliation of the operative note against the authorized code set on every multi-code ACL case, with specific attention to whether the note says reconstruction.
• Track allograft and implant verification completion as a discrete scheduling gate with its own compliance rate.

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Procedure Guide

GoHealthcare Case Study

Original educational scenario. No actual patient or organization is depicted.

Clinical scenario

A 19-year-old collegiate lacrosse player sustained a non-contact pivoting injury to the right knee during preseason training. She felt a pop, developed immediate swelling, and was unable to continue. She was evaluated at a student health center, placed in a brace, and referred to an orthopedic sports medicine practice eleven days later. At that visit she reported one episode of the knee giving way while turning in a hallway. Examination demonstrated a Grade 3 Lachman with a soft endpoint, a positive pivot shift, a moderate effusion, and flexion limited to 110 degrees. MRI obtained at an outside imaging center was reported as "disruption of the anterior cruciate ligament" with "abnormal signal within the posterior horn of the medial meniscus."

Documentation challenges

• The giving-way episode was recorded in the intake questionnaire but not carried into the physician's assessment, where the narrative read "persistent pain and swelling."
• The MRI report described medial meniscus signal abnormality without characterizing tear pattern, location, or repairability.
• No conservative care had been delivered, and the plan of care did not address the conservative care requirement in any form.
• The plan of care documented "ACL repair" as the planned procedure - the surgeon's shorthand for reconstruction, but the exact word the governing guideline excludes.

Prior authorization barriers

The initial request was submitted to the plan's delegated musculoskeletal vendor and denied within 72 hours on two grounds: the requested procedure as described was ACL repair, which the guideline designates not medically necessary, and there was no documentation of three months of provider-directed non-surgical management or of any qualifying exception. The denial letter cited the guideline and section.

Payer considerations

The governing criteria required imaging or arthroscopy showing tear, disruption, or significant laxity of the ACL; at least one positive instability test; both function-limiting loss of function and reported instability described as subjective weakness or buckling; and three months of non-surgical management, waivable in an acute injury setting where instability is documented together with a qualifying condition - including a confirmed ACL tear with a repairable meniscus tear. Three of the four elements were already satisfied in the record. The fourth was available but had not been established, because the meniscal tear had never been characterized.

Operational workflow and resolution strategy

1 The authorization specialist recognized that the denial rested on two curable defects rather than a clinical disagreement, and did not request a peer-to-peer.

2 The plan of care was corrected at a same-week visit to state arthroscopically aided anterior cruciate ligament reconstruction with bone-patellar tendon-bone autograft, with the operative intent documented explicitly as reconstruction rather than repair.

3 The outside MRI was re-reviewed by the practice's musculoskeletal radiologist, who issued an addendum characterizing a peripheral vertical longitudinal tear of the posterior horn of the medial meniscus in the red-red zone, with features amenable to repair.

4 The physician documented the giving-way episode in the assessment in the patient's own words, obtained at the follow-up visit rather than by retrospective addendum, together with her requirement to return to a cutting and pivoting sport.

5 The resubmission led with the acute exception, naming two qualifying conditions - confirmed ACL tear with a repairable meniscus tear, and need to return to activities requiring cutting and pivoting - and stated the time-dependent risk to meniscal repairability specifically.

6 The request was submitted with 29888 and contingent 29882, with expedited handling requested on the basis of the repairable meniscal tear.

7 Allograft was not required, but the specialist separately confirmed fixation implant coverage and postoperative brace authorization before the case was booked.

Outcome

The resubmission was approved within 48 hours under expedited review, without a peer-to-peer. Surgery was performed at the practice's ambulatory surgery center twenty-two days after the initial injury. Arthroscopic findings confirmed a complete ACL disruption and a repairable peripheral medial meniscal tear, which was repaired. The operative note documented reconstruction with bone-patellar tendon-bone autograft harvested from the operative knee, the compartment in which the meniscal repair was performed, and the fixation constructs used. The claim was submitted with 29888 and 29882 with laterality modifiers and paid on first submission. No separate graft harvest code was reported.

Lessons learned

• A single word - repair rather than reconstruction - converted an approvable case into a categorical denial. Vocabulary discipline in the plan of care is not pedantry.
• The exception was available from the first day and was missed because nobody characterized the meniscal tear. The qualifying condition existed; the documentation did not.
• The giving-way history was in the chart, in the intake questionnaire, and was invisible to the reviewer because it never reached the physician's assessment. Information in the record is not the same as information in the packet.
• A radiology addendum characterizing tear pattern and repairability changed both the clinical plan and the authorization pathway.
• Declining the peer-to-peer and curing the defects was faster than arguing the denial.
• The eleven-day referral delay plus the denial cycle consumed three weeks of a window in which meniscal repairability was at stake. In a case with a more marginal tear, that delay would have changed the operation.

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Procedure Guide

GoHealthcare Best Practices

Domain	Practice
Template design	Mandatory fields for instability description in the patient's words, Lachman grade and endpoint, pivot shift, functional demand, and pathway determination
Intake triage	Acute versus chronic pathway determined at first contact; ACL plus repairable meniscal tear flagged for expedited handling as a standing rule
Vocabulary discipline	The word reconstruction used in the plan of care, the authorization request, and the operative note; repair reserved for cases where repair is genuinely intended and pre-confirmed
Imaging partnership	Agreed reporting language with the reading group: tear, disruption, or significant laxity for the ACL; tear pattern, zone, and repairability features for the meniscus
Two authorization templates	Acute exception template and completed conservative care template, selected at intake
Graft rationale	Documented as a routine element, with a stated reason wherever allograft is selected in a young active patient
Tissue and implant verification	Mandatory separately signed-off step ahead of room booking, with written plan confirmation for anything on an investigational list
Emerging technology governance	Standing process for bridge-enhanced restoration and similar technologies: written confirmation, financial responsibility discussion, determination tracking, periodic re-verification
Revision preparation	Payer preference for modifier 22 versus unlisted confirmed in advance; comparative narrative drafted before submission
Operative note standard	Reconstruction stated explicitly; graft type and harvest site; every compartment entered; meniscal work characterized; fixation documented
Pre-bill reconciliation	Every multi-code ACL case reconciled against the authorized set before claim release
Workers' compensation workflow	Dedicated pathway with causation documentation and jurisdiction-specific utilization review timelines
Guideline surveillance	Quarterly review of eviCore, Carelon, Evolent, UnitedHealthcare, Aetna, and AAOS publications, plus FDA labeling changes for adopted devices

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Procedure Guide

Common Mistakes

Clinical documentation

• Documenting the tear and omitting the instability.
• Recording effusion and tenderness without any ligamentous stability testing.
• Leaving the giving-way history in an intake questionnaire where it never reaches the assessment.
• Accepting an MRI report that describes signal abnormality rather than disruption.
• Failing to characterize a meniscal tear's pattern, zone, and repairability.
• Writing repair when reconstruction is intended.
• Neither completing conservative care nor documenting an exception.
• Selecting allograft in a young athlete without stating a reason.

Authorization

• Submitting a standard three-month conservative care request for an acute case that qualifies for an exception.
• Invoking an exception without naming the qualifying condition.
• Submitting 29888 alone with no adjunct or contingency codes.
• Allowing a lateral augmentation dispute to delay the primary reconstruction.
• Failing to verify allograft tissue and implants separately from the surgical authorization.
• Requesting biologic augmentation without written coverage confirmation.
• Scheduling a bridge-enhanced restoration case on a verbal benefits representation.
• Building the packet against a superseded guideline version.

Coding and billing

• Reporting a separate graft harvest code for harvest from the operative knee.
• Reporting 29877 or 29874 with 29888 in the same compartment.
• Reporting 29888 with 27428 for the same ligament.
• Reporting fluoroscopy for tunnel placement.
• Billing 0737T for a bridge-enhanced ACL implant.
• Reporting revision as a standard 29888 with no modifier 22 narrative and no unlisted alternative.
• Omitting the laterality modifier.
• Using non-billable parent codes such as M23.5 or M23.2 without required additional characters.
• Omitting the seventh character on S83 acute injury codes.
• Reporting knee pain as the primary diagnosis on an ACL reconstruction claim.

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Procedure Guide

Pearls and Pitfalls

Pearls	Pitfalls
Capture instability in the patient's own words at the first visit and date it	Assuming a complete tear on MRI establishes instability
Grade the Lachman and record the endpoint quality	Documenting effusion and tenderness with no stability testing at all
Determine the acute versus chronic pathway at intake	Defaulting every case to a three-month conservative trial
Name the exception and its qualifying condition explicitly	Asserting that surgery is urgent without citing an enumerated condition
Characterize the meniscal tear pattern, zone, and repairability	Accepting "meniscal signal abnormality" and losing the exception
Say reconstruction everywhere reconstruction is meant	Letting the shorthand word repair into the plan of care
State the graft rationale, especially for allograft in a young athlete	Selecting allograft with no documented reason against a guideline favoring autograft
Verify tissue and implants before booking the room	Discovering at billing that allograft was never authorized
Submit adjunct codes with the primary request	Discovering at billing that the meniscal repair performed was never authorized
Confirm the revision reporting pathway before submission	Reporting a complex revision as a routine 29888
Separate the adjunct dispute from the reconstruction	Allowing a lateral augmentation question to hold the whole case
Obtain written confirmation for emerging technologies	Relying on a verbal benefits representation for a bridge-enhanced implant

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Procedure Guide

Frequently Asked Questions

Q1. Is there a Medicare National Coverage Determination for ACL reconstruction?

No. No NCD addresses ACL reconstruction. NCD 150.9 governs only arthroscopic lavage and debridement for the osteoarthritic knee and does not reach ligament reconstruction. Coverage is at Medicare Administrative Contractor discretion under the general reasonable and necessary standard.

Q2. Is ACL reconstruction subject to the CMS WISeR Model?

No. ACL reconstruction is not a WISeR selected service. From the knee code set, only NCD 150.9 arthroscopic lavage and debridement for the osteoarthritic knee falls within the model. The boundary matters when ACL reconstruction is performed with concurrent debridement in an Original Medicare beneficiary in a model state; verify code-level applicability using the MAC prior authorization look-up tool.

Q3. What is the single most common reason ACL requests are denied?

Absence of documented instability. The record confirms the tear and describes pain, but never records giving way, buckling, or subjective weakness. Every major criteria set requires reported instability in addition to imaging confirmation and in addition to a positive examination test.

Q4. Do payers really require three separate instability elements?

In practice, yes. Imaging or arthroscopy must confirm tear, disruption, or significant laxity; the examination must show at least one positive test among Lachman, anterior drawer, and pivot shift; and the patient must report instability. A packet missing any one of the three will typically pend.

Q5. How long must conservative care last before ACL reconstruction?

Typically three months of provider-directed non-surgical management, but the requirement is commonly waived in the acute setting. Under eviCore CMM-312 the waiver applies where joint instability is documented together with any of: a need to return to cutting, pivoting, or agility activity; a confirmed ACL tear with a repairable meniscus tear; or concomitant ligament injuries requiring reconstruction for stability.

Q6. Does the guideline evidence support waiting three months?

Not for acute isolated tears. The AAOS 2022 clinical practice guideline holds that when surgical treatment is indicated for an acute isolated ACL tear, early reconstruction is preferred because the risk of additional cartilage and meniscal injury begins to rise within three months. This is precisely why the exception pathways exist and why recognizing them at intake matters clinically, not just administratively.

Q7. Is ACL repair covered?

eviCore CMM-312 states categorically that ACL repair is not medically necessary. Other payers vary from silence to investigational designation to case-by-case review. Because CPT 29888 covers repair, augmentation, and reconstruction in a single descriptor, the code does not distinguish them; the operative note and the authorization narrative must.

Q8. What about the BEAR Implant and bridge-enhanced ACL restoration?

The BEAR Implant received FDA De Novo authorization in December 2020, and on January 14, 2026 the FDA granted 510(k) clearance for updated labeling to include a reduced risk of radiographically confirmed post-traumatic osteoarthritis at six years compared with hamstring autograft reconstruction. Coverage nonetheless remains inconsistent, and the technique is frequently caught by categorical repair exclusions written before it existed. Obtain written plan-specific confirmation before scheduling and complete a documented patient financial responsibility discussion.

Q9. Is CPT 0737T the right code for a bridge-enhanced ACL implant?

No. 0737T is a Category III code for xenograft implantation into the articular surface, established for placement of a xenograft scaffold for osteochondral regeneration and reported once per joint. It is a cartilage code, not an ACL code, and it appears on knee policy code lists for that reason. Confirm the reporting pathway with the manufacturer and the payer in writing before the case.

Q10. Is graft harvest separately billable?

Not when the graft is harvested from the operative knee. Harvest and insertion are included in 29888 whether the graft is bone-patellar tendon-bone, hamstring, or quadriceps tendon. Where the tendon is obtained from a distant site such as the contralateral leg through a separate incision, the appropriate harvesting code such as 20924 may be reported with a distinct procedural service modifier and clear documentation of the separate incision.

Q11. Can meniscal procedures be billed with ACL reconstruction?

Yes. Per AAOS global service data, meniscectomy (29880, 29881) and meniscal repair (29882, 29883) may be reported in addition to 29888. Where meniscectomy and meniscal repair are performed on opposite menisci, both may be reported with an appropriate modifier and clear compartment documentation.

Q12. Can chondroplasty or loose body removal be billed with ACL reconstruction?

Generally no. 29874 and 29877 are bundled into 29888 under National Correct Coding Initiative edits with a modifier indicator of 0. For Medicare, chondroplasty performed in a different compartment where no other surgical service was performed is reported with G0289 subject to the separate compartment criterion.

Q13. How is revision ACL reconstruction coded?

There is no distinct CPT code. Revision is reported either with 29888 appended with modifier 22 and a comparative narrative quantifying the additional work, or with unlisted code 29999, depending on payer preference. Confirm the preference before submission; discovering it after a denial costs months.

Q14. Is autograft or allograft preferred?

AAOS 2022 carries a strong-strength recommendation favoring autograft over allograft to improve outcomes and reduce graft failure, particularly in young and active patients. Allograft remains appropriate in revision, multi-ligamentous injury, and cases where an adequate autologous graft is unavailable. Where allograft is selected in a young athlete, document the reason.

Q15. Which autograft should be used?

AAOS 2022 carries a moderate recommendation that in skeletally mature patients undergoing reconstruction with autograft, surgeons may favor bone-patellar tendon-bone to reduce the risk of graft failure or infection, or hamstring to reduce anterior or kneeling pain. Both are supported; the choice is a documented clinical judgment.

Q16. Does allograft tissue require separate authorization?

Frequently yes, and this is the most common source of uncompensated cost on ACL cases. Verify tissue coverage and the billing pathway separately from the surgical authorization, and confirm whether the tissue charge falls to the facility or the professional under the applicable contract.

Q17. Is lateral extra-articular tenodesis covered?

Under eviCore CMM-312, anterolateral ligament reconstruction and lateral extra-articular tenodesis are approvable only when performed to augment an ACL reconstruction that itself meets criteria; standalone performance is designated not medically necessary. AAOS 2022 carries a moderate-strength recommendation that these may be considered in selected patients. Document the specific indication rather than describing it as routine.

Q18. Is biologic augmentation of the graft covered?

Generally no. Bone marrow aspirate concentrate and platelet-rich plasma augmentation of ACL graft reconstruction are designated not covered or investigational by multiple payers, including expressly by Aetna for bone marrow aspirate concentrate. Do not include them in a request without written confirmation.

Q19. How should skeletally immature patients be handled?

Skeletal maturity rather than chronological age drives technique selection. Document physeal status, the technique selected, and the rationale for physeal-sparing or physeal-respecting approaches where used. The AAOS 2022 guideline addresses both skeletally immature and skeletally mature patients.

Q20. Does the ACL SNNAP trial mean rehabilitation should be tried first in every case?

No, and this is the most common misapplication of that trial. ACL SNNAP compared rehabilitation with surgical reconstruction for non-acute ACL injury. It does not address the acute setting and does not contradict guidance favoring early reconstruction for acute isolated tears. Where a reviewer cites it against an acute case, the acute versus non-acute distinction is the correct response.

Q21. Should intraoperative fluoroscopy be reported?

No. Fluoroscopy used to confirm tunnel placement is integral to the arthroscopic procedure and is not separately reportable under National Correct Coding Initiative Chapter IV policy.

Q22. Is 29888 performed in an ambulatory surgery center?

Predominantly, yes. CPT 29888 is on the Medicare ASC covered procedures list; confirm current-year status and commercial ASC lists. Hospital outpatient department is appropriate for multi-ligamentous reconstruction, complex revision, significant comorbidity, or pediatric cases requiring specialized support, and the rationale should be documented contemporaneously.

Q23. Is a continuous passive motion machine covered after ACL reconstruction?

Frequently not. Several payers designate continuous passive motion not medically necessary following arthroscopic knee surgery, and the evidence base does not support routine use. Verify durable medical equipment coverage separately and before dispensing.

Q24. How should workers' compensation ACL cases be documented differently?

Causation carries weight equal to medical necessity. Document the mechanism of injury, the temporal relationship between injury and symptom onset, and an explicit distinction between acute traumatic rupture and pre-existing degenerative attenuation. Jurisdiction-specific treatment guidelines and utilization review timelines apply and differ from commercial rules.

Q25. Which ICD-10-CM code should be primary?

For an acute presentation, S83.511A or S83.512A for right or left ACL sprain at the initial encounter. For chronic insufficiency, M23.611 or M23.612 for spontaneous disruption of the anterior cruciate ligament, commonly supported by M23.51 or M23.52 for chronic instability. Do not report a knee pain code in the M25.56 family as the primary diagnosis; instability is the operative indication.

Q26. How long is an ACL authorization valid?

It varies by payer and is commonly 60 to 90 days. Record the window at determination and build a scheduling alert. In acute cases with a repairable meniscal tear, the clinical window may be shorter than the administrative one.

Q27. What is the fastest way to improve ACL first-pass approval rates?

Two changes. First, make patient-reported instability and a graded Lachman required fields in the knee injury template. Second, determine the acute-versus-chronic pathway at intake and maintain two distinct authorization templates. Together these address the substantial majority of ACL pends and denials.

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Procedure Guide

Key Takeaways

• Instability, not the tear, is the operative criterion. Imaging confirmation, a positive examination test, and patient-reported giving way are three separate requirements from three separate sources.
• No NCD governs ACL reconstruction, and it is not a WISeR selected service. The operative payer environment is commercial, Medicaid, and workers' compensation.
• The three-month conservative care rule is more often excepted than satisfied. Learn the enumerated qualifying conditions and invoke them at intake.
• Guideline evidence favors early reconstruction in acute isolated tears because secondary cartilage and meniscal injury accrues within three months. The exception pathways exist to reconcile this with payer criteria.
• Reconstruction and repair are not the same word. One major vendor excludes repair categorically, and CPT 29888 does not distinguish them.
• Bridge-enhanced restoration is a live coverage frontier, with FDA labeling expanded January 14, 2026 and payer criteria not yet uniformly updated. Written confirmation before scheduling.
• Graft harvest from the operative knee is included in 29888. Separate reporting applies only to distant-site harvest through a separate incision.
• Meniscal procedures are separately reportable with 29888; chondroplasty and loose body removal generally are not.
• Revision has no distinct code. Confirm the payer's preference for modifier 22 versus unlisted reporting before submission.
• Allograft tissue and implants are a separate authorization workstream with cost exposure that can exceed the professional fee.
• Adjuncts carry the risk. Lateral augmentation, allograft in young athletes, suture augmentation, and biologic adjuncts each require independent documentation and verification.
• 0737T is not an ACL code. It is a cartilage xenograft code and its presence on knee policy lists has caused recurring miscoding.

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Procedure Guide

Future Outlook

Ligament preservation and restoration

The most consequential near-term development in this service line is the maturation of bridge-enhanced restoration. The January 2026 label expansion to include a reduced post-traumatic osteoarthritis risk claim is the first of its kind in sports medicine and creates direct pressure on criteria sets that exclude ACL repair categorically. Expect payer criteria to differentiate bridge-enhanced restoration from historic primary repair rather than continuing to treat them as a single excluded category, though the timeline for that differentiation will vary considerably by payer.

Post-traumatic osteoarthritis as an outcome measure

Payer and regulatory attention is shifting from short-term functional scores toward long-term joint preservation. As post-traumatic osteoarthritis risk becomes a labeled and measurable endpoint, expect it to appear in coverage arguments on both sides - supporting earlier intervention to protect the meniscus and cartilage, and supporting technology selection on the basis of long-term joint outcome rather than two-year function.

Lateral augmentation moving toward the mainstream

Randomized evidence supporting reduced graft failure with lateral extra-articular tenodesis, combined with a moderate-strength guideline recommendation, is gradually normalizing augmentation in selected patients. Expect criteria to become more explicit about which patients qualify - likely revision, high-grade pivot shift, generalized laxity, and young pivoting athletes - rather than remaining a general permission.

Graft selection and registry evidence

National and regional ligament registries continue to generate comparative data on graft choice, revision rates, and contralateral injury. Expect payer criteria to increasingly reference graft selection, particularly allograft use in young active patients, and expect practices to be asked to justify graft choice more often than they are today.

Return-to-sport criteria and rehabilitation accountability

Guideline attention to functional testing before return to sport, and published rehabilitation clinical practice guidelines, are creating an expectation that postoperative care is structured and documented. Expect this to migrate into payer expectations for rehabilitation authorization and, in some markets, into bundled arrangements that include the rehabilitation episode.

Site of service and bundling

Continued migration of ACL reconstruction to ambulatory surgery centers will proceed alongside expanded site-of-service review and growing interest in episode-based arrangements that encompass the implant, the tissue, and the rehabilitation course. Practices should ensure their cost accounting captures tissue and implant separately, since these dominate episode cost variability.

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Procedure Guide

References

CMS, Medicare, and federal sources

1 Centers for Medicare & Medicaid Services. Medicare Coverage Database. https://www.cms.gov/medicare-coverage-database

2 Centers for Medicare & Medicaid Services. National Coverage Determination (NCD) 150.9, Arthroscopic Lavage and Arthroscopic Debridement for the Osteoarthritic Knee (cited for scope boundary only). https://www.cms.gov/medicare-coverage-database

3 Centers for Medicare & Medicaid Services Innovation Center. Wasteful and Inappropriate Service Reduction (WISeR) Model. https://www.cms.gov/priorities/innovation/innovation-models/wiser

4 Centers for Medicare & Medicaid Services. National Correct Coding Initiative Policy Manual for Medicare Services, Chapter IV (Surgery: Musculoskeletal System). https://www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits

5 Centers for Medicare & Medicaid Services. Ambulatory Surgical Center Payment and Covered Procedures List. https://www.cms.gov/medicare/payment/prospective-payment-systems/ambulatory-surgical-center-asc

6 Centers for Medicare & Medicaid Services. Medicare Physician Fee Schedule. https://www.cms.gov/medicare/payment/fee-schedules/physician

7 U.S. Food and Drug Administration. De Novo Classification Request DEN200035, BEAR (Bridge-Enhanced ACL Repair) Implant, Miach Orthopaedics. https://www.accessdata.fda.gov/cdrh_docs/reviews/DEN200035.pdf

8 U.S. Food and Drug Administration. Device classification and 510(k) databases. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfm

Utilization management vendor guidelines

1 eviCore by Evernorth. CMM-312: Knee Surgery - Arthroscopic and Open Procedures, Comprehensive Musculoskeletal Management Guidelines V2.0.2025, effective March 7, 2026. https://www.evicore.com/provider/clinical-guidelines

2 Carelon Medical Benefits Management. Clinical Appropriateness Guidelines: Joint Surgery, Doc ID MSK02-1125.1, effective November 15, 2025. https://guidelines.carelonmedicalbenefitsmanagement.com/joint-surgery-2025-11-15/

3 Carelon Medical Benefits Management. Current Musculoskeletal Guidelines and upcoming guideline changes. https://guidelines.carelonmedicalbenefitsmanagement.com/current-musculoskeletal-guidelines/

4 Evolent Health / National Imaging Associates. Clinical Guideline: Knee Arthroscopy, NIA_CG_316. https://www.evolent.com/

5 Cohere Health. https://www.coherehealth.com/

6 TurningPoint Healthcare Solutions. https://www.turningpoint-healthcare.com/

Commercial payer policies

1 Aetna. Clinical Policy Bulletin 0364: Allograft Transplants of the Extremities. https://www.aetna.com/cpb/medical/data/300_399/0364.html

2 Aetna. Clinical Policy Bulletin 0673: Knee Arthroscopy / Osteoarthritis of the Knee: Selected Treatments. https://www.aetna.com/cpb/medical/data/600_699/0673.html

3 UnitedHealthcare. Surgery of the Knee - Commercial and Individual Exchange Medical Policy, effective June 1, 2026. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/surgery-knee.pdf

4 UnitedHealthcare. Joint Procedures - Medicare Advantage Medical Policy. https://www.uhcprovider.com/content/dam/provider/docs/public/policies/medadv-mp/joint-procedures.pdf

5 Cigna Healthcare. Medical Coverage Policies - Musculoskeletal. https://www.cigna.com/health-care-providers/coverage-and-claims/policies

6 Humana. Medical Coverage Policies. https://provider.humana.com/coverage-claims/medical-resources

7 Elevance Health / Anthem. Medical Policies and Clinical Utilization Management Guidelines. https://www.anthem.com/provider/policies/

Professional societies and clinical practice guidelines

1 American Academy of Orthopaedic Surgeons. Management of Anterior Cruciate Ligament Injuries: Evidence-Based Clinical Practice Guideline. Published August 22, 2022. https://www.aaos.org/aclcpg

2 American Academy of Orthopaedic Surgeons. Anterior Cruciate Ligament Injuries quality program page. https://www.aaos.org/quality/quality-programs/anterior-cruciate-ligament-injuries/

3 Brophy RH, Lowry KJ. American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary: Management of Anterior Cruciate Ligament Injuries. J Am Acad Orthop Surg. 2023. https://journals.lww.com/jaaos/

4 American Orthopaedic Society for Sports Medicine. https://www.sportsmed.org/

5 Arthroscopy Association of North America. https://www.aana.org/

6 Pediatric Orthopaedic Society of North America. https://posna.org/

7 American Medical Association. CPT Editorial Panel and CPT Assistant. https://www.ama-assn.org/practice-management/cpt

8 AAPC. Orthopedic coding guidance for knee arthroscopy and ACL reconstruction. https://www.aapc.com/

Peer-reviewed literature

1 Beard DJ, Davies L, Cook JA, et al. Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial. Lancet. 2022;400(10352):605-615. https://www.thelancet.com/

2 Getgood AMJ, Bryant DM, Litchfield R, et al. Lateral extra-articular tenodesis reduces failure of hamstring tendon autograft anterior cruciate ligament reconstruction: 2-year outcomes from the STABILITY study randomized clinical trial. Am J Sports Med. 2020;48(2):285-297. https://journals.sagepub.com/home/ajs

3 Getgood A, Hewison C, Bryant D, et al. No difference in functional outcomes when lateral extra-articular tenodesis is added to anterior cruciate ligament reconstruction in young active patients: the STABILITY study. Arthroscopy. 2020;36(6):1690-1701. https://www.arthroscopyjournal.org/

4 Murray MM, Fleming BC, Badger GJ, et al. Bridge-enhanced anterior cruciate ligament repair is not inferior to autograft anterior cruciate ligament reconstruction at 2 years: results of a prospective randomized clinical trial. Am J Sports Med. 2020;48(6):1305-1315. https://journals.sagepub.com/home/ajs

5 Gee MSM, Peterson CDR, Zhou ML, Bottoni CR. Anterior cruciate ligament repair: historical perspective, indications, techniques, and outcomes. J Am Acad Orthop Surg. 2020;28(23):963-971. https://journals.lww.com/jaaos/

6 Biau DJ, Tournoux C, Katsahian S, et al. Bone-patellar tendon-bone autografts versus hamstring autografts for reconstruction of anterior cruciate ligament: meta-analysis. BMJ. 2006;332(7548):995-1001. https://www.bmj.com/

7 DeFazio MW, Curry EJ, Gustin MJ, et al. Return to sport after ACL reconstruction with a BTB versus hamstring tendon autograft: a systematic review and meta-analysis. Orthop J Sports Med. 2020;8(12). https://journals.sagepub.com/home/ojs

8 Rahardja R, Zhu M, Love H, et al. Effect of graft choice on revision and contralateral anterior cruciate ligament reconstruction: results from the New Zealand ACL Registry. Am J Sports Med. 2020;48(1):63-69. https://journals.sagepub.com/home/ajs

9 Sonnery-Cottet B, Saithna A, Cavalier M, et al. Anterolateral ligament reconstruction is associated with significantly reduced ACL graft rupture rates at a minimum follow-up of 2 years: a prospective comparative study of 502 patients from the SANTI Study Group. Am J Sports Med. 2017;45(7):1547-1557. https://journals.sagepub.com/home/ajs

10 Onggo JR, Rasaratnam HK, Nambiar M, et al. Anterior cruciate ligament reconstruction alone versus with lateral extra-articular tenodesis with minimum 2-year follow-up: a meta-analysis and systematic review of randomized controlled trials. Am J Sports Med. 2022;50(4):1137-1145. https://journals.sagepub.com/home/ajs

11 Kvist J, Pettersson M. Knee-related quality of life compared between 20 and 35 years after an anterior cruciate ligament injury treated surgically with primary repair or reconstruction, or nonsurgically. Am J Sports Med. 2024;52(2):311-319. https://journals.sagepub.com/home/ajs

12 Spindler KP, Huston LJ, Zajichek A, et al; MOON Knee Group. Anterior cruciate ligament reconstruction in high school and college athletes: graft choice and outcomes. Am J Sports Med. https://journals.sagepub.com/home/ajs

13 Sanders TL, Maradit Kremers H, Bryan AJ, et al. Incidence of anterior cruciate ligament tears and reconstruction: a 21-year population-based study. Am J Sports Med. 2016;44(6):1502-1507. https://journals.sagepub.com/home/ajs

14 Kaux JF, Bleakley C, Delvaux F, et al. Aspetar clinical practice guideline on rehabilitation after anterior cruciate ligament reconstruction. Br J Sports Med. 2023;57(9):500-514. https://bjsm.bmj.com/

15 Guenther D, Irarrazaval S, Bell KM, et al. The role of extra-articular tenodesis in combined ACL and anterolateral capsular injury. J Bone Joint Surg Am. 2017;99(19):1654-1660. https://journals.lww.com/jbjsjournal/

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Procedure Guide

Reading Recommendations

• For surgeons and advanced practice providers: the AAOS 2022 Management of Anterior Cruciate Ligament Injuries clinical practice guideline and its JAAOS summary. Every major payer criteria element in this guide traces to a recommendation in that document.
• For prior authorization specialists: read the eviCore CMM-312 ACL sections end to end, including the non-indications and the criteria exceptions. The exception language is where most winnable cases are decided.
• For revenue cycle leaders: Chapter IV of the National Correct Coding Initiative Policy Manual, together with AAOS global service data guidance on what is included in the 29888 package.
• For sports medicine practices adopting new technology: the FDA De Novo summary for the BEAR Implant and the January 2026 labeling update, read alongside your top three payers' current positions on ACL repair.
• For rehabilitation leaders: the Aspetar clinical practice guideline on rehabilitation after ACL reconstruction.
• For workers' compensation teams: the applicable state treatment guideline for knee ligament injury, which frequently differs materially from commercial criteria.

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Procedure Guide

Related GoHealthcare Resources

Available through the GoHealthcare Practice Solutions Knowledge Center at https://www.gohealthcarellc.com.

Resource	Relationship to This Guide
Knee Arthroscopy Procedure Guide	Companion guide covering diagnostic arthroscopy, debridement, meniscectomy, synovectomy, NCD 150.9, and the WISeR Model in full
PCL Reconstruction Procedure Guide	CPT 29889, including stress radiograph thresholds and multi-ligamentous considerations
Meniscus Repair Procedure Guide	Repair versus resection, root tear pathways, all-inside fixation devices, and the concurrent ACL scenario
Knee Arthroscopy Coding and Bundling Reference	Consolidated compartment rules, chondroplasty logic, and the G0289 pathway
Partial and Total Knee Arthroplasty Procedure Guides	Criteria for the arthritic knee outside the ligament reconstruction pathway
GoHealthcare Revenue Cycle Knowledge Center	Fee schedules, payment methodologies, relative value units, medically unlikely edit values, implant and tissue cost analysis
GoHealthcare Prior Authorization Playbook	Cross-procedure workflow standards, criteria-mapped submission templates, exception recognition training, and denial analytics frameworks
GoHealthcare Workers' Compensation MSK Operations Guide	Causation documentation standards and jurisdiction-specific utilization review workflows
GoHealthcare Emerging Technology Coverage Framework	Standing process for FDA-authorized technologies awaiting payer criteria updates
GoHealthcare AI Governance Framework	Governance standards for AI-assisted documentation and authorization tooling, including payer content licensing considerations

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Procedure Guide

Recommended Downloads

Planned resource recommendations. Availability should be confirmed before publication or linked distribution.

• ACL Reconstruction Prior Authorization Checklist (one page, print-ready)
• Acute Exception Authorization Template with enumerated qualifying conditions
• Completed Conservative Care Authorization Template
• Knee Injury Documentation Template with mandatory instability and Lachman grade fields
• Criteria-Mapped Submission Cover Page Template
• ACL Payer Matrix Worksheet (plan-level, including position on repair, bridge-enhanced restoration, and lateral augmentation)
• Allograft Tissue and Implant Verification Worksheet
• Operative Note Standard for ACL Reconstruction
• Revision ACL Modifier 22 Comparative Narrative Template
• Graft Selection Rationale Documentation Aid
• Appeal Letter Framework for ACL Denials
• Emerging Technology Written Confirmation Request Template
• Pre-Bill Reconciliation Worksheet

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Procedure Guide

Educational Disclaimer, Terms of Use, and Limitations

Please read in full. This section governs the use of this document.

Purpose and scope

This document is published by GoHealthcare Practice Solutions as part of the GoHealthcare MSK Specialty Procedure Library and is intended solely for educational and operational reference purposes for healthcare professionals. It is designed to help clinical, administrative, prior authorization, utilization management, coding, and revenue cycle personnel understand the operational, documentation, payer policy, and reimbursement environment surrounding this procedure. It is not clinical advice, medical advice, legal advice, coding advice, billing advice, reimbursement advice, compliance advice, or financial advice, and it must not be used as a substitute for any of them.

Not a clinical or procedural training resource

This document is not a procedural technique manual, a surgical training resource, a physician training guide, or a substitute for specialty society procedural manuals, clinical textbooks, residency or fellowship training, or supervised clinical experience. It does not provide surgical or interventional technique instruction, instrument or portal placement guidance, imaging guidance instruction, medication or anesthetic dosing, or intraoperative decision support. It does not replace the independent clinical judgment of a qualified, licensed healthcare professional who has personally evaluated the individual patient. Treatment decisions must be made by the treating clinician based on the specific facts of the individual patient.

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Nothing in this document guarantees, promises, or predicts that any payer will approve a prior authorization request, determine a service to be medically necessary, cover a service, or pay a claim. Coverage and payment determinations are made exclusively by the applicable payer under the terms of the individual member benefit plan document, applicable federal and state law, and the payer's own policies and criteria in effect on the date of service. Benefit plan documents supersede clinical policies and utilization management guidelines. GoHealthcare Practice Solutions makes no representation or warranty regarding the outcome of any authorization request, claim, appeal, audit, or dispute.

Time sensitivity and the reader's independent verification obligation

Healthcare coverage policy is dynamic. National and Local Coverage Determinations, Local Coverage Articles, utilization management guideline versions and effective dates, commercial medical policies, CPT and HCPCS Level II code sets and descriptors, ICD-10-CM codes and specificity requirements, National Correct Coding Initiative edits, medically unlikely edit values, ambulatory surgery center covered procedures lists, delegated vendor arrangements, CMS demonstration and innovation models, and state and federal regulations all change frequently - often on short notice and sometimes retroactively. They also vary materially by payer, by plan, by product line, by state, by Medicare Administrative Contractor jurisdiction, and by date of service.

The reader bears sole responsibility for independently verifying every statement in this document against the governing payer policy version in effect for the specific member and date of service, the current official code sets, and current primary regulatory sources, before relying on it for any clinical, documentation, coding, billing, authorization, appeal, or business decision. Policies and codes change. Verify current primary sources before use.

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Code references and descriptors in this document are abbreviated, paraphrased, or summarized for readability and are not a substitute for the current, complete, official CPT, HCPCS Level II, or ICD-10-CM code sets and their accompanying guidelines, conventions, instructional notes, and parenthetical instructions. Code selection is a professional judgment that must be made by a qualified coding professional based on the complete documentation in the individual medical record.

This document was prepared without live access to proprietary, subscription coding databases or encoder software, and every code and descriptor appearing in it must be independently verified by the reader against the current official code sets before use. Nothing in this document authorizes or supports reporting any code for a service that was not actually performed, not medically necessary, or not supported by the documentation in the medical record. The provider and the submitting entity remain solely responsible for the accuracy, completeness, and truthfulness of every claim submitted, and for compliance with the False Claims Act, the Civil Monetary Penalties Law, the Anti-Kickback Statute, the Stark Law, and all other applicable federal and state laws and payer contract terms.

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Payer, health plan, and utilization management vendor criteria described in this document have been synthesized, summarized, and restated in GoHealthcare's own words for educational purposes. Proprietary payer guideline language has not been reproduced. Summaries are necessarily incomplete, may omit conditions, exceptions, definitions, and plan-specific variations, and may not reflect the version of the guideline in effect for a particular member or date of service. Readers must consult the payer's own current, complete policy document and, where a determination has been issued, must request the specific criteria set applied. Certain payers and vendors publish terms restricting the reproduction, distribution, or automated or artificial intelligence processing of their guideline content; readers who build internal tools incorporating such content should obtain legal review.

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This document was developed by GoHealthcare Practice Solutions, under the leadership of Pinky Maniri, Founder and Chief Executive Officer, using structured research of publicly available primary sources including CMS coverage documents, published payer and utilization management guidelines, professional society guidance, and peer-reviewed literature, together with GoHealthcare's operational experience supporting musculoskeletal specialty practices. Artificial intelligence tools were used to assist with research synthesis, drafting, and document production under human editorial direction and review. Artificial intelligence-assisted content is subject to error, omission, and outdated source material, and all such content remains subject to human editorial review and quality assurance. GoHealthcare Practice Solutions does not use artificial intelligence to make, and this document does not constitute, any coverage, medical necessity, or clinical determination for any individual patient.

External links

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Jurisdictional and program variation

Requirements differ materially across Original Medicare, Medicare Advantage, Medicaid fee-for-service, Medicaid managed care, commercial group and individual products, self-funded plans governed by ERISA, federal employee programs, TRICARE, Veterans Affairs Community Care, workers' compensation, and automobile and no-fault carriers. State law, state Medicaid policy, state workers' compensation treatment guidelines, state utilization review statutes, and state appeal and external review rights vary. This document does not address the requirements of any specific jurisdiction, program, or contract.

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(c) 2026 GoHealthcare Practice Solutions. All rights reserved. GoHealthcare MSK Specialty Procedure Library is a trademark of GoHealthcare Practice Solutions. This document may be viewed, downloaded, and shared internally within a healthcare organization for non-commercial educational purposes with attribution intact. It may not be sold, sublicensed, republished, incorporated into a commercial product or training program, or used to train or fine-tune any artificial intelligence or machine learning model without the prior written permission of GoHealthcare Practice Solutions.

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Developed by

Pinky Maniri

MSc, BSc, CRCR, CSAPM, CSPPM, CSBI, CSPR, CSAF, Certified in Healthcare A.I. Governance

Founder and Chief Executive Officer, GoHealthcare Practice Solutions

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Coverage, authorization, coding, modifiers, units, payment, site-of-service requirements, and clinical criteria vary by payer, plan, product, employer group, jurisdiction, delegated reviewer, provider, facility, and date of service. Nothing in this guide guarantees authorization, coverage, reimbursement, or a specific claim determination. CPT is a registered trademark of the American Medical Association.