Osteochondral Autografts (Mosaicplasty, OATS) — CPB 0637 | AETNA Coverage Update

TL;DR: Aetna, a CVS Health company, modified CPB 0637 governing osteochondral autograft (OATS/mosaicplasty) coverage, effective January 18, 2026. Here's what billing teams need to act on now.

This update to the Aetna osteochondral autograft coverage policy tightens the criteria matrix for CPT 29866 and 27416 — the two primary covered codes for knee OATS procedures. The policy also expands the experimental/investigational exclusion list, adding several emerging techniques that your surgeons may already be performing. If your practice handles orthopedic sports medicine or reconstructive knee surgery and bills Aetna, this is a policy you need in your queue before January 18, 2026.

Quick-Reference Table

Aetna Osteochondral Autograft Coverage Criteria and Medical Necessity Requirements 2026

The Aetna osteochondral autograft coverage policy covers OATS and mosaicplasty for the knee only — and only when the member clears all nine criteria simultaneously. Miss one, and the claim denies. That's the structure of this policy and it hasn't changed, but the specificity of each criterion has been sharpened in this update.

Here's the full medical necessity checklist as written in CPB 0637:

Criterion nine deserves special attention. Aetna doesn't just want the surgeon to note nicotine cessation in an op note or clinic summary. For any member with nicotine use within the past year, documentation must include a lab report — not a surgeon summary — showing blood or urine nicotine levels ≤ 10 ng/ml or urinary cotinine ≤ 10 ng/ml, drawn within six weeks before surgery. If your pre-auth packet doesn't include that lab report, expect a denial.

This is the kind of criterion that slips through intake and only surfaces at claim review. Build the lab requirement into your prior authorization checklist now, before the effective date of January 18, 2026.

For prior authorization: Aetna generally requires prior auth on surgical procedures billed under CPT 29866 and 27416. Confirm PA requirements with the specific plan benefit design, since employer-sponsored plans can vary. The medical necessity criteria above are what your PA clinical reviewer will evaluate — document all nine in the prior auth submission, not just the ones that are easy.

Aetna Osteochondral Autograft Exclusions and Non-Covered Indications

Aetna classifies 12 specific procedures as experimental, investigational, or unproven under this coverage policy. This list is long and it directly affects reimbursement — or rather, the absence of it. Several of these are techniques your surgeons may consider standard adjuncts.

The full experimental/investigational list under CPB 0637:

The biologic augmentation exclusion is the one most likely to generate claim denials. PRP is widely used perioperatively. If your surgeon adds PRP to a covered OATS procedure and you bill 0232T or P9020 alongside 29866 or 27416, Aetna will not reimburse the PRP component. Don't bill it as bundled. Don't bill it separately. It's not covered.

The combination ACI/OATS exclusion also matters. If your surgeon performs both an autologous chondrocyte implantation (CPT 27412, HCPCS J7330 or S2112) and an OATS procedure in the same session, the combination is experimental under this policy. The individual procedures may be covered in isolation under their own criteria — but together, they're not.

Coverage Indications at a Glance

Aetna Osteochondral Autograft Billing Guidelines and Action Items 2026

CPT, HCPCS, and ICD-10 Codes for Osteochondral Autografts Under CPB 0637

Covered CPT Codes (When Selection Criteria Are Met)

Covered HCPCS Codes (When Selection Criteria Are Met)

Not Covered / Experimental Codes

Key ICD-10-CM Diagnosis Codes

CPB 0637 references 293 ICD-10-CM codes in total. The M23.x series (articular cartilage defect, internal derangement of knee) is your primary diagnosis code family for covered knee OATS claims. Full code list available at app.payerpolicy.org/p/aetna/0637.