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ACG
​
h.o.l.M.E.S.

Automated Clinical Guidelines

Knee

Indicates Non-covered Service

Allograft Transplantation of the Knee
Arthroscopic anterior cruciate ligament surgery in the skeletally immature
Articular Cartilage Restoration  Repair of the Knee
Functional Status Assessment for Total Knee Replacement (CMS66v10)
High Tibial Osteotomy
Knee Arthroscopy
Aetna
UHC
FloridaBlue
Cigna
Anthem
Humana
Humana
UHC
Point32Health
Knee Surgery
Autologous Chondrocyte Implantation (ACI)
Knee injury & Osteoarthritis Outcome Score (KOOS)
FloridaBlue
Knee Arthroplasty
Osteoarthritis of the Knee: Selected Treatments
Treatment of Osteochondral Defects
Outpatient Total Knee & Total Hip Arthroplasty
Patellofemoral or Unicondylar Knee Replacement
Aetna
Aetna
Anthem
Cigna
Humana
UHC
FloridaBlue
Medicare
Humana
UHC

Indicates Non-covered Service

Autologous Chondrocyte Implantation
Computer-Assisted Navigation for Orthopedic Procedures
Continuous Passive Motion (CPM) & Mechanical Stretching Devices
Cooling & Heating Devices Used in the Outpatient Settings
Extracorporeal Shock Wave Therapy for Musculoskeletal Conditions
Knee Ligament Arthrometer Testing
Menaflex Device
Cigna
Aetna
FloridaBlue
Cigna
FloridaBlue
Aetna
Humana
Orthopedic Applications of Stem-Cell Therapy
Osteochondral Allograft Transplantatio
Osteochondral Autograft Transplantation

Unicondylar Interpositional Spacer

Devices

Visco-

supplements

FloridaBlue
Cigna
Cigna
FloridaBlue
FloridaBlue
Humana
UHC

27437, 27438, 27440, 27441, 27442, 27443, 27445, 27446, 27447, 27486, 27487, 29870, 29871, 29873, 29874, 29875, 29876, 29877, 29880, 29881, 29882, 29883, 29884, 29885, 29886, 29887, 29888, 29889

Anthem
MA
kneeopenscope.jpg
Arthroscopic Lavage & Arthroscopic Debridement for the Osteoarthritic Knee (NCD 150.9)
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