Clover Health Knee Meniscectomy prior authorization requirements (2026)
What Clover Health generally requires to approve Knee Meniscectomy (CPT 29880, 29881, 29882, 29883), for medicare_advantage plans. Yes. Clover Health generally requires prior authorization for Knee Meniscectomy (CPT 29880, 29881, 29882, 29883).
Medical-necessity criteria Clover Health generally applies
Prior authorization required via eviCore (same CMM-312 knee criteria). As a Medicare Advantage plan, CMS NCD 150.9 also binds: arthroscopic lavage alone and arthroscopic debridement for OA knee pain (Outerbridge III-IV) are non-covered; there is no NCD governing meniscectomy itself, so eviCore CMM-312 controls.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Knee Meniscectomy. Confirm the covered diagnosis list against the current Clover Health policy.
How to submit
- Method: eviCore portal
- Portal: eviCore (by Evernorth)
Sources & verification
- BindingSource — eviCore CMM-312 Knee Surgery (CMS NCD 150.9 floor for OA debridement) (CMM-312) · effective 2025-07-01.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 2026-06-26.
Frequently asked questions
Does Clover Health require prior authorization for Knee Meniscectomy?
Yes. Clover Health generally requires prior authorization for Knee Meniscectomy (CPT 29880, 29881, 29882, 29883).
What does Clover Health require to approve Knee Meniscectomy?
Prior authorization required via eviCore (same CMM-312 knee criteria). As a Medicare Advantage plan, CMS NCD 150.9 also binds: arthroscopic lavage alone and arthroscopic debridement for OA knee pain (Outerbridge III-IV) are non-covered; there is no NCD governing meniscectomy itself, so eviCore CMM-312 controls. Always confirm against the current Clover Health policy.
How long does a Clover Health prior authorization take?
Turnaround varies by plan and submission method. Check the Clover Health portal for current timeframes.
Submitting Knee Meniscectomy to Clover Health?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.