Acellular Dermal Matrix Grafts (formerly Arthrex Bovine Collagen)

Policy ID: S-264-004

Section: Surgery

Effective Date: September 07, 2020

Revised Date: October 18, 2021

Revision Effective Date: January 03, 2022

Last Reviewed: May 23, 2023

Applies To: Commercial and Medicaid Expansion

Description

Acellular dermal matrix grafts are used to reinforce or reconstruct areas where weakness exists. Acellular dermal matrix may be used as reinforcement of the rotator cuff in superior capsular reconstruction surgery.

Criteria

Acellular dermal matrix grafts may be considered medically necessary for superior capsular reconstruction when ALL of the following criteria are met;

Massive, irreparable rotator cuff tear; and
There is minimal or no evidence of arthritis; and
Pain unrelieved through non-surgical treatment; and
Decreased mobility; and
Planned procedure includes one of the following:
- Latissimus dorsi tendon transfer; or
- Lower trapezius tendon transfer.

Acellular dermal matrix grafts not meeting the criteria as indicated in this policy are considered experimental/investigational and therefore non-covered because the safety and effectiveness cannot be established by review of the available published peer-reviewed literature.

Procedure Codes

29827

29999

Q4125

Diagnosis Codes

Eligible diagnosis codes for covered procedure code 29827 when reported with Q4125

M75.121

M75.122

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 New Policy

Internal Medical Policy Committee 7-20-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-23-2021 Added Procedure Code Q4125; and two (2) Diagnosis codes M75.121 and M75.122; Title Changed (old title: Arthrex bovine collagen)

Internal Medical Policy Committee 5-24-2022 Annual Review-no changes in criteria.

Internal Medical Policy Committee 5-23-2023 Annual Review-no change in criteria.

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: S-264-003

Section: Surgery

Effective Date: September 07, 2020

Revised Date: October 18, 2021

Revision Effective Date: January 03, 2022

Last Reviewed: November 23, 2021

Archived Date: January 02, 2022

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Acellular dermal matrix grafts may be considered medically necessary for superior capsular reconstruction when ALL of the following criteria are met;

Massive, irreparable rotator cuff tear; and
There is minimal or no evidence of arthritis; and
Pain unrelieved through non-surgical treatment; and
Decreased mobility; and
Planned procedure includes one of the following:
- Latissimus dorsi tendon transfer; or
- Lower trapezius tendon transfer.

Procedure Codes

29827

29999

Q4125

Diagnosis Codes

Eligible diagnosis codes for covered procedure code 29827 when reported with Q4125

M75.121

M75.122

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 New Policy

Internal Medical Policy Committee 7-20-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-23-2021 Added Procedure Code Q4125; and two (2) Diagnosis codes M75.121 and M75.122; Title Changed (old title: Arthrex bovine collagen)

Links

References (PDF)

Disclaimer

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Medical Policies Quick Search

Acellular Dermal Matrix Grafts (formerly Arthrex Bovine Collagen)

Description

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Criteria

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer