Medicare AdvantageCoverageMedium impact
Osteochondral and Subchondral Defects Surgery - Medicare Advantage (Revised)
Humana·Orthopedics, Sports Medicine·Medicare Advantage
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicare Advantage updated its coverage policy for osteochondral and subchondral defects surgery effective 07/01/2026. The policy establishes medical necessity criteria for multiple cartilage repair procedures including ACT/ACI, osteochondral allografts/autografts, and subchondroplasty, with specific requirements for BMI, defect size, conservative treatment failure, and other clinical factors. Billing teams must verify patient eligibility against these criteria before submitting claims.
Action Required
Before July 1, 2026: Billing team and prior authorization staff must implement the updated medical necessity criteria for osteochondral and subchondral defect surgeries in the Humana Medicare Advantage prior authorization system. Specifically: (1) Update authorization templates to verify BMI ≤ 35; (2) Require documentation of focal chondral defect size ≥ 2-10 cm² with radiological interpretation (MRI or arthroscopy); (3) Require evidence of failed conservative treatment; (4) Verify absence of contraindications per policy; (5) Train prior authorization staff on the different procedure types (ACT/ACI, osteochondral allografts, autografts, subchondroplasty) and their specific coverage requirements. Obtain from providers complete clinical documentation per criteria before claim submission. Update encounter forms and billing software rules to reflect new requirements. Without proper prior authorization based on these criteria, claims for CPT 27412 and J7330 will be denied by Humana Medicare Advantage plans.