Blue Cross NC ACL Reconstruction prior authorization requirements (2026)

Medical-necessity criteria Blue Cross NC generally applies

Anterior cruciate ligament reconstruction - "is considered medically necessary when ALL the following criteria are met: There is not advanced knee arthritis (Kellgren-Lawrence grade 4); A diagnosis of ACL tear as established by EITHER of the following: Exam findings of a positive anterior drawer sign, pivot shift test or Lachman test; Report of CT or MRI which demonstrates an ACL tear; EITHER of the following scenarios apply: ACL tear occurring in conjunction with a meniscal tear or ligamentous injury (i.e., medial or posterior collateral ligament, posterior cruciate ligament, or posterolateral corner ligamentous injury); Failure of at least 2 weeks of conservative treatment." Anterolateral ligament reconstruction or extra articular tenodesis "may be required if ANY of the following criteria are met: Skeletal immaturity that makes ACL ligament reconstruction not feasible; A revision ACL reconstruction is planned; Positive pivot shift or other evidence of rotational instability; Ligamentous laxity as confirmed by use of Beighton score greater than 5." [NEEDS CLINICAL SPOT-CHECK]

Diagnoses that commonly support medical necessity

ICD-10-CM diagnoses frequently associated with medical necessity for ACL Reconstruction. Confirm the covered diagnosis list against the current Blue Cross NC policy.

Commonly required documentation

• Exam documenting anterior drawer / pivot shift / Lachman, or CT/MRI report showing the ACL tear
• radiographic OA grade
• either the concomitant meniscal/ligamentous injury or a dated record of at least 2 weeks of conservative treatment. Documentation supporting medical necessity and a clearly stated plan of care should be submitted at the time of the request and must include the following components: Clinical notes describing symptom duration and severity, specific functional limitations related to symptoms, and type and duration of all therapeutic measures provided. If conservative management is not appropriate, the reason must be clearly documented. Conservative management must include a combination of strategies to reduce inflammation, alleviate pain, and correct underlying dysfunction, including physical therapy AND at least ONE complementary conservative treatment strategy (physical therapy rendered by a qualified provider, or a supervised home treatment program with initial active instruction by MD/DO/PT and documented compliance
• complementary = anti-inflammatory medications and analgesics, adjunctive medications, intra-articular corticosteroid injection(s), or activity modification / trial period of rest). Failure of conservative management requires ALL the following: Patient has completed a full course of conservative management (as defined above) for the current episode of care
• Worsening of or no significant improvement in signs and/or symptoms upon clinical reevaluation
• More invasive forms of therapy are being considered. Reporting symptom severity - significant pain and functional impairment refer to pain rated at least 3 out of 10 in intensity and associated with inability to perform ADLs and/or IADLs. Imaging reports obtained within the past 12 months describing the degree of cartilage damage: X-ray report or provider interpretation of x-rays that utilizes or can be correlated with the Kellgren-Lawrence grading system of osteoarthritis, and/or MRI report from a radiologist that utilizes or can be correlated with the modified Outerbridge or similar classification system. General Recommendations (strongly recommended, not required): tobacco/nicotine abstinence for at least 6 weeks prior to surgery
• hemoglobin A1C of 8% or less prior to any joint replacement surgery
• BMI equal to or greater than 40 attempt weight reduction prior to surgery.

How to submit

• Method: Prior authorization is delegated to Carelon Medical Benefits Management for spine surgery, joint surgery, interventional pain management, and small joint surgery (Commercial Fully Insured since 2023-10-01; ASO groups only if the group elected the program, effective 2025-01-01 - verify by member ID on the Carelon portal or via the number on the member ID card). Submit through the Carelon Provider Portal via Blue e (24/7, real-time against Carelon clinical guidelines) or by phone at 866-455-8414, Monday-Friday 8 a.m.-6 p.m. ET. Applies in both outpatient and inpatient admission settings. Since 2025-07-01 (Fully Insured only; excludes Medicare Advantage, DSNP, EGWP, FEP and ASO), a request for a hospital-based OUTPATIENT setting for interventional pain or joint-arthroscopy/small-joint procedures gets an additional site-of-care review.
• Portal: Carelon Provider Portal (via Blue e)
• Typical turnaround: about 3 days

Sources & verification

• BindingSource - Carelon Clinical Appropriateness Guidelines: Joint Surgery (Joint Surgery 2025-11-15) · effective 2025-11-15.View
• BindingSource - Blue Cross NC Musculoskeletal Program and Interventional Pain Management effective October 1, 2023 (Carelon delegation) (Provider news 2023-10-01) · effective 2023-10-01.View

Binding = the payer's own policy. Proxy = a public, evidence-based clinical guideline the payer mirrors. Portal-only = the binding criteria are confirmed in the administrator's portal. Always confirm against the payer for the member's specific plan. Last verified 2026-09-20.

Frequently asked questions

Other Blue Cross NC prior authorization requirements

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