Horizon BCBS NJ ACL Reconstruction prior authorization requirements (2026)
What Horizon BCBS NJ generally requires to approve ACL Reconstruction (CPT 29888, 29889), for PPO plans. Yes. Horizon BCBS NJ generally requires prior authorization for ACL Reconstruction (CPT 29888, 29889).
Medical-necessity criteria Horizon BCBS NJ generally applies
Prior authorization required; managed by TurningPoint Healthcare Solutions under policy OR-1013 (ACL Repair/Reconstruction). Medical necessity generally requires ALL of: no advanced knee arthritis (not Kellgren-Lawrence grade 4); a documented ACL tear established by exam (positive Lachman, anterior drawer, or pivot-shift) OR by MRI/CT; and EITHER an ACL tear occurring with a concurrent meniscal or ligamentous injury (MCL, PCL, or posterolateral corner) OR failure of at least 2 weeks of conservative treatment.
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 Horizon BCBS NJ policy.
Related procedure codes
Codes often billed alongside ACL Reconstruction: 27407, 27409. Verify the correct codes for your documentation.
Commonly required documentation
- MRI/CT report or documented instability exam (Lachman, anterior drawer, or pivot-shift)
- documentation of any concurrent meniscal/ligamentous injury or of a conservative trial of at least 2 weeks
Situations to verify before submitting
Horizon BCBS NJ may not cover ACL Reconstruction in these situations. Verify against the current policy rather than assuming a denial:
- Advanced knee osteoarthritis (Kellgren-Lawrence grade 4)
- Asymptomatic or incidental ACL findings without instability or functional deficit
How to submit
- Method: portal
- Portal: TurningPoint Healthcare Solutions Web Portal
Source
PA confirmed required and managed by TurningPoint (Horizon Surgical & Implantable Device Management Program). Code-to-policy mapping (29888 -> OR-1013) verified from TurningPoint MSK crosswalk: . Exact OR-1013 criteria via TurningPoint (1-833-436-4083); framework references public Carelon Joint Surgery MSK02-1125.1 ACL section. View the source policy. Last verified 2026-06-18.
Frequently asked questions
Does Horizon BCBS NJ require prior authorization for ACL Reconstruction?
Yes. Horizon BCBS NJ generally requires prior authorization for ACL Reconstruction (CPT 29888, 29889).
What does Horizon BCBS NJ require to approve ACL Reconstruction?
Prior authorization required; managed by TurningPoint Healthcare Solutions under policy OR-1013 (ACL Repair/Reconstruction). Medical necessity generally requires ALL of: no advanced knee arthritis (not Kellgren-Lawrence grade 4); a documented ACL tear established by exam (positive Lachman, anterior drawer, or pivot-shift) OR by MRI/CT; and EITHER an ACL tear occurring with a concurrent meniscal or… Always confirm against the current Horizon BCBS NJ policy.
How long does a Horizon BCBS NJ prior authorization take?
Turnaround varies by plan and submission method. Check the Horizon BCBS NJ portal for current timeframes.
Submitting ACL Reconstruction to Horizon BCBS NJ?
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.