Allograft Transplants of the Extremities — CPB 0364 | AETNA Coverage Update

Aetna modified CPB 0364 covering allograft transplants of the extremities, effective January 18, 2026. Here's what billing teams need to do.

Aetna, a CVS Health company, updated this coverage policy to clarify and tighten medical necessity criteria across knee ligament allografts, osteochondral allografts, meniscal transplantation, and ankle instability repair. The primary CPT codes affected include 27415, 29867, 29868, 29888, and 29889, along with the allograft codes 20932, 20933, and 20934. If your practice bills any of these procedures for Aetna members, review your documentation protocols now — the criteria are detailed, and missing a single element will cost you on adjudication.

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Quick-Reference Table

Field	Detail Copy
Payer	Aetna, a CVS Health company
Policy	Allograft Transplants of the Extremities
Policy Code	CPB 0364 Aetna system
Change Type	Modified
Effective Date	January 18, 2026
Impact Level	High
Specialties Affected	Orthopedic surgery, sports medicine, podiatry, physical therapy, ambulatory surgery centers
Key Action	Audit pre-authorization documentation against the updated eight-part osteochondral criteria before billing CPT 27415 or 29867

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Aetna Allograft Transplant Coverage Criteria and Medical Necessity Requirements 2026

The Aetna allograft transplant coverage policy under CPB 0364 covers four distinct clinical scenarios. Each has its own medical necessity criteria. They are not interchangeable — what qualifies a member for meniscal transplantation does not automatically qualify them for osteochondral allograft. Your documentation has to match the specific indication you're billing.

Knee ligament allografts are the most straightforward. Aetna covers allografts of the ACL, PCL, MCL, LCL, and MPFL (CPT 27427, 27428, 27429, 29888, 29889) as an alternative to autografts for knee ligament reconstruction. No separate list of criteria beyond medical necessity for reconstruction itself. That's a clean win for billing — if the autograft is medically necessary, the allograft substitute is covered.

Osteochondral allografts are where this policy gets demanding. To support medical necessity for CPT 27415 or 29867, you need eight criteria — all of them — documented in the record. The member must have a focal, full-thickness (grade III or IV) unipolar lesion on the femoral condyle or trochlea only. The lesion must be 3 sq cm or larger on MRI or arthroscopy. It must be surrounded by healthy, non-arthritic cartilage. The member must have disabling knee pain unresponsive to conservative treatment, including at least six weeks of in-person physical therapy — not home or virtual PT. Knee alignment must be normal or surgically corrected at the time of the allograft. The joint must be stable with intact meniscus and normal joint space on X-ray. The opposing tibial surface must be Outerbridge 0 or 1. BMI must be 35 or under. And the member must be nicotine-free — including tobacco and nicotine replacement therapy — for at least six weeks before surgery.

That last point deserves its own sentence. If the member has used nicotine within the past year, you need a lab report — not a surgeon summary — showing blood or urine nicotine levels at or below 10 ng/ml, drawn within six weeks of surgery. Urinary cotinine at or below 10 ng/ml is also acceptable. This is the kind of documentation requirement that denials are built on. Make sure your pre-op intake captures this.

Meniscal transplantation (CPT 29868) requires six criteria. Degenerative changes must be absent or minimal — Outerbridge grade II or less. The knee must be stable before surgery or corrected at the time of the allograft. The member must be under 55 years old. Alignment must be normal or corrected. Pre-operative MRI or arthroscopy must show absence or near-absence of the meniscus. And the member must have significant knee pain unresponsive to conservative treatment. Age 55 is a hard cutoff — there's no exception language in this policy.

Semitendinosus allograft for chronic ankle instability (CPT 27695, 27696, 27698) requires six months of failed non-operative treatment. That treatment must include braces, in-person physical therapy (balance and strength exercises), medication, and taping. Again — in-person PT, not home or virtual. Aetna is drawing that line consistently across this policy.

The Fast-Fix Meniscal Repair System gets a standalone covered designation for repair of meniscal tears. No complex criteria list attached to it. Bill accordingly.

Whether Aetna requires prior authorization for these specific CPT codes depends on your contract and the member's plan. Check the plan-level benefits before scheduling. Prior auth requirements vary, and a missing auth on a case this expensive will create a significant reimbursement problem.

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Aetna Allograft Transplant Exclusions and Non-Covered Indications

The policy explicitly designates certain allograft procedures as experimental, investigational, or unproven. The summary was truncated in the source document, but two CPT codes land squarely in the "not covered" bucket: 20957 (bone graft with microvascular anastomosis, metatarsal) and 20962 (bone graft with microvascular anastomosis, other sites). Also not covered for the indications listed in this CPB: 28103 (excision or curettage of bone cyst or benign tumor, talus or calcaneus, with allograft) and 28107 (excision or curettage of bone cyst or benign tumor, tarsal or metatarsal).

If you've been billing any of these codes for Aetna members under an allograft indication, expect a claim denial. The policy is clear that these fall outside covered indications.

The full experimental/investigational list wasn't available in the truncated summary. If your practice treats complex lower extremity pathology, pull the full CPB 0364 document from Aetna directly to confirm no other procedures your team performs are on the exclusion list. Don't assume — confirm. If you're uncertain how the experimental designations affect your case mix, loop in your compliance officer before the January 18, 2026 effective date.

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Coverage Indications at a Glance

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Aetna Allograft Transplant Billing Guidelines and Action Items 2026

These are specific steps based on the actual CPB 0364 criteria. Run through this list before the effective date of January 18, 2026.

Copy Action Items

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CPT, HCPCS, and ICD-10 Codes for Allograft Transplants of the Extremities Under CPB 0364

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered CPT Codes

Other CPT Codes Related to CPB 0364

Key ICD-10-CM Diagnosis Codes

The full ICD-10-CM code list for CPB 0364 includes 143 codes. Pull the complete list from the Aetna CPB 0364 source document to build your charge capture and authorization templates.

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