Autologous Chondrocyte Implantation — CPB 0247 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0247 covering autologous chondrocyte implantation (ACI) for knee cartilage defects, effective January 18, 2026. Here's what billing teams need to do.

This update to the Aetna autologous chondrocyte implantation coverage policy tightens the medical necessity criteria your team needs to document before billing CPT 27412 or submitting HCPCS J7330 for MACI implants. The policy governs a procedure with high per-claim dollar exposure — MACI (Vericel) isn't cheap, and a claim denial on a missing documentation element is a painful write-off. Know the 13 required criteria before the claim leaves your practice.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Autologous Chondrocyte Implantation — CPB 0247
Policy Code	CPB 0247
Change Type	Modified
Effective Date	January 18, 2026
Impact Level	High
Specialties Affected	Orthopedic Surgery, Sports Medicine, Orthopedic Billing
Key Action	Audit all ACI prior authorization requests against the full 13-criteria checklist before submitting to Aetna

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Aetna Autologous Chondrocyte Implantation Coverage Criteria and Medical Necessity Requirements 2026

The Aetna autologous chondrocyte implantation coverage policy under CPB 0247 Aetna system sets a high bar. Every single one of 13 criteria must be met for Aetna to consider the procedure medically necessary. Miss one, and the claim gets denied — or the prior authorization never clears.

Here are the 13 required criteria for CPT 27412 and HCPCS J7330 to be covered:

The nicotine criterion is the one that trips up the most authorizations. A surgeon's note saying the patient "reports not smoking" doesn't satisfy this requirement. Aetna wants a lab value, from a qualified lab, drawn within the six-week window. Build that into your pre-auth workflow now.

Aetna treats FDA-approved matrix-induced chondrocyte implantation — specifically MACI (Vericel), billed under HCPCS J7330 — as an equally acceptable alternative to the original autologous cultured chondrocytes (Carticel). Carticel was pulled from the U.S. market in 2017 and replaced by MACI, so if you still have Carticel in your charge master, remove it. MACI and HCPCS J7330 are your billing path here.

Prior authorization is effectively required given the clinical complexity and cost of ACI. Confirm your Aetna contract's PA requirements, but don't submit without every documentation element above.

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Aetna Autologous Chondrocyte Implantation Exclusions and Non-Covered Indications

This is where autologous chondrocyte implantation billing gets complicated. Aetna considers several related procedures experimental, investigational, or unproven — and that designation means no reimbursement.

ACI is not covered for:

Separate procedures also considered experimental:

#	Excluded Procedure Copy
1	Autologous matrix-induced chondrogenesis (AMIC) for articular cartilage defects of the talus, patellofemoral lesions, or other osteochondral defects
2	Autologous platelet-rich plasma and fibrin-augmented minced cartilage implantation for chondral defects

The exclusion on first-line surgical therapy connects directly to the conservative care criterion above. If your patient hasn't completed at least six weeks of physical therapy in the past year, Aetna will deny this as non-medically necessary — not just inappropriate sequencing. Document that PT failure explicitly in the authorization request.

The total meniscectomy exclusion is worth flagging at scheduling. If a patient has had a prior total meniscectomy, don't put them through the PA process. This is a hard stop under the current coverage policy.

CPT codes 20900, 20902 (bone grafts), and 29868 (meniscal transplantation) are not covered for the indications listed in CPB 0247. Don't bundle these onto an ACI claim expecting coverage.

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Coverage Indications at a Glance

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Aetna Autologous Chondrocyte Implantation Billing Guidelines and Action Items 2026

This policy was modified January 18, 2026. If your team hasn't updated your ACI authorization workflow since then, do it now.

Copy Action Items

If your practice has complex cases — patients near the age cutoffs, borderline BMI, or prior surgical history — loop in your compliance officer before the effective date for those cases. The denial exposure on a single ACI case is significant.

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CPT, HCPCS, and ICD-10 Codes for Autologous Chondrocyte Implantation Under CPB 0247

Covered CPT and HCPCS Codes (When Selection Criteria Are Met)

Not Covered CPT Codes for CPB 0247 Indications

Code	Type	Description	Reason Copy
20900	CPT	Bone graft, any donor area; minor or small (e.g., dowel or button)	Not covered for indications listed in CPB 0247
20902	CPT	Bone graft, any donor area; major or large	Not covered for indications listed in CPB 0247
29868	CPT	Arthroscopy, knee, surgical; meniscal transplantation (includes arthrotomy for meniscal insertion)	Not covered for indications listed in CPB 0247

Key ICD-10-CM Diagnosis Codes

The full ICD-10 list under CPB 0247 includes 254 codes. Review the complete code set at the official Aetna CPB 0247 source before coding.

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