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

TL;DR: Aetna, a CVS Health company, modified CPB 0364 governing allograft transplants of the extremities, effective January 18, 2026. Billing teams coding CPT 27415, 29867, 29868, 29888, and 29889 for knee and ankle allograft procedures need to review updated medical necessity criteria before submitting claims.

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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
Change Type	Modified
Effective Date	January 18, 2026
Impact Level	High
Specialties Affected	Orthopedic Surgery, Sports Medicine, Podiatry, Physical Medicine & Rehabilitation
Key Action	Audit prior authorization workflows and documentation requirements for knee osteochondral, meniscal, and ankle allograft procedures before submitting claims dated on or after January 18, 2026

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Aetna Allograft Transplant Coverage Criteria and Medical Necessity Requirements 2026

The Aetna allograft transplant coverage policy under CPB 0364 covers three distinct knee indications and one ankle indication — each with its own checklist of requirements. Getting one wrong means a claim denial. There's no single "allograft transplant" approval; the payer evaluates each indication separately.

Knee Ligament Allografts (ACL, PCL, MCL, LCL, MPFL)

This is the most straightforward part of the policy. Aetna considers allografts of the knee ligaments — including the anterior cruciate ligament (ACL), posterior cruciate ligament (PCL), medial collateral ligament (MCL), lateral collateral ligament (LCL), and medial patello-femoral ligament (MPFL) — medically necessary as an alternative to autografts. No extra hoops beyond standard reconstruction medical necessity criteria.

CPT codes 27427 (extra-articular ligamentous reconstruction), 27428 (intra-articular, open), 27429 (intra-articular and extra-articular), 29888 (arthroscopically aided ACL repair/reconstruction), and 29889 (arthroscopically aided PCL repair/reconstruction) all fall under covered codes when selection criteria are met.

Knee Osteochondral Allografts (Femoral Articulation Only)

This is where the policy gets demanding — and where your documentation needs to be airtight. Aetna covers osteochondral allograft transplantation under CPT 27415 (open) and 29867 (arthroscopic) only for femoral articulation. Tibial surface procedures are a different story — see the exclusions section.

The member must meet all eight of the following criteria:

The nicotine requirement deserves special attention. The member must be nicotine-free — including smoking, tobacco products, and nicotine replacement therapy — for at least six weeks before surgery. For anyone with nicotine use within the past year, documentation must include a lab report (not a surgeon's note) showing blood or urine nicotine levels ≤ 10 ng/ml, or urinary cotinine levels ≤ 10 ng/ml, drawn within six weeks before surgery.

That's a specific lab value with a specific draw window. If your pre-op documentation packet doesn't include that lab report, expect a claim denial.

Knee Meniscal Allografts

CPT 29868 covers meniscal transplantation. Aetna considers this medically necessary when all six criteria are met:

The age cutoff at 55 is a hard stop. Document the member's date of birth clearly in the record. Don't let a coverage denial come down to a missing demographic field.

Semitendinosus Allograft for Chronic Ankle Instability

Aetna covers semitendinosus allograft for chronic ankle instability — billed under CPT 27695, 27696, or 27698 — when the member has failed six months of non-operative treatment. That treatment must include braces, in-person physical therapy (balance and strength exercises), medication, and taping.

Home or virtual physical therapy does not count here, just as it doesn't for the osteochondral criteria. This is a clear and consistent pattern in CPB 0364. If your documentation shows only virtual PT, Aetna will not consider conservative treatment exhausted.

Fast-Fix Meniscal Repair System

Aetna considers the Fast-Fix meniscal repair system medically necessary for repair of meniscal tears. This is a covered indication without the multi-criteria checklist. Bill it under the appropriate meniscal repair CPT codes.

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Aetna Allograft Transplant Exclusions and Non-Covered Indications

The policy explicitly excludes several allograft indications as experimental, investigational, or unproven. These carry real claim denial risk if coded incorrectly.

CPT 20957 (bone graft with microvascular anastomosis, metatarsal) and CPT 20962 (bone graft with microvascular anastomosis, other than fibula, iliac crest, or metatarsal) are not covered for indications listed in CPB 0364.

CPT 28103 (excision or curettage of bone cyst or benign tumor, talus or calcaneus, with allograft) and CPT 28107 (excision or curettage of bone cyst or benign tumor, tarsal or metatarsal, except talus or calcaneus) are also not covered under this policy.

If your surgeons are performing any of these procedures and billing under allograft-related diagnosis codes, pull those claims now. The reimbursement risk on non-covered indications isn't worth the appeal cycle.

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Coverage Indications at a Glance

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Aetna Allograft Transplant Billing Guidelines and Action Items 2026

The effective date of January 18, 2026 is already here. If your team hasn't reviewed documentation workflows against these updated criteria, do it now.

Copy Action Items

If your case mix includes high volumes of osteochondral or meniscal allograft cases billed to Aetna, loop in your compliance officer before resubmitting any claims from dates of service on or after January 18, 2026.

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

Covered CPT Codes (When Selection Criteria Are Met)

Not Covered CPT Codes for Indications Listed in CPB 0364

Other CPT Codes Related to CPB 0364

Key ICD-10-CM Diagnosis Codes

The full ICD-10 list in CPB 0364 includes 143 codes. Verify your complete diagnosis code set against the full policy at the Aetna source document.

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