Horizon BCBS NJ Autologous Chondrocyte Implantation prior authorization requirements (2026)
What Horizon BCBS NJ generally requires to approve Autologous Chondrocyte Implantation (CPT 27412, J7330, S2112), for PPO plans. Yes. Horizon BCBS NJ generally requires prior authorization for Autologous Chondrocyte Implantation (CPT 27412, J7330, S2112).
Medical-necessity criteria Horizon BCBS NJ generally applies
Prior authorization required; managed by TurningPoint Healthcare Solutions (Horizon Surgical & Implantable Device Management Program, orthopedic). Binding TurningPoint OR criteria are portal-only [SPOT-CHECK]. Autologous chondrocyte implantation (ACI/MACI) is generally covered for disabling full-thickness articular cartilage defects of the KNEE (weight-bearing femoral condyle or trochlea); ACI of other joints and most other indications is investigational. Public BCBS-family proxy criteria (verify against TurningPoint): focal defect at least 1.5 cm2; skeletally mature with closed growth plates and too young for total knee arthroplasty (e.g., under 55); minimal-to-absent degenerative change in surrounding cartilage (Outerbridge grade II or less); normal knee alignment and stability (achieved concurrently if needed); failed prior conservative or marrow-stimulation treatment. All numeric thresholds are from a BCBS-family proxy policy, NOT Horizon-binding [NEEDS VERIFICATION].
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Autologous Chondrocyte Implantation. Confirm the covered diagnosis list against the current Horizon BCBS NJ policy.
Related procedure codes
Codes often billed alongside Autologous Chondrocyte Implantation: 27412, J7330, S2112. Verify the correct codes for your documentation.
Commonly required documentation
- Imaging (MRI/arthroscopy) documenting a full-thickness cartilage defect with location and size (cm2)
- Outerbridge/ICRS grade of surrounding cartilage
- skeletal maturity/age
- documentation of failed prior conservative or cartilage procedure
- knee alignment and ligamentous stability
- operative plan. Exact TurningPoint checklist is portal-only [SPOT-CHECK].
Situations to verify before submitting
Horizon BCBS NJ may not cover Autologous Chondrocyte Implantation in these situations. Verify against the current policy rather than assuming a denial:
- ACI for joints other than the knee (incl. talar) - investigational
- ACI for indications other than full-thickness knee femoral condyle/trochlea defects - investigational
- Advanced osteoarthritis / generalized degenerative joint disease
- Patellar lesions excluded under some plans [NEEDS VERIFICATION for Horizon]
How to submit
- Method: portal
- Portal: TurningPoint Healthcare Solutions Web Portal
Sources & verification
- Portal-onlyTurningPoint — Horizon Surgical & Implantable Device Management Program (TurningPoint), orthopedic.View
- ProxyPayer medical policy — BCBS-family ACI medical policy (public proxy; e.g. South Carolina Blue / Aetna CPB 0247) (CPB 0247).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 2026-06-20.
Frequently asked questions
Does Horizon BCBS NJ require prior authorization for Autologous Chondrocyte Implantation?
Yes. Horizon BCBS NJ generally requires prior authorization for Autologous Chondrocyte Implantation (CPT 27412, J7330, S2112).
What does Horizon BCBS NJ require to approve Autologous Chondrocyte Implantation?
Prior authorization required; managed by TurningPoint Healthcare Solutions (Horizon Surgical & Implantable Device Management Program, orthopedic). Binding TurningPoint OR criteria are portal-only [SPOT-CHECK]. Autologous chondrocyte implantation (ACI/MACI) is generally covered for disabling full-thickness articular cartilage defects of the KNEE (weight-bearing femoral condyle or trochlea); ACI of … 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 Autologous Chondrocyte Implantation 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.