QualCare Knee Arthroscopy prior authorization requirements (2026)
What QualCare generally requires to approve Knee Arthroscopy (CPT 29875, 29876, 29877, 29879), for commercial plans. Yes. QualCare generally requires prior authorization for Knee Arthroscopy (CPT 29875, 29876, 29877, 29879).
Medical-necessity criteria QualCare generally applies
Prior authorization via eviCore (Cigna MSK program). Meniscectomy/meniscal repair medically necessary when MRI/CT-arthrogram shows a meniscal tear extending to the articular surface that correlates with symptoms, with at least two positive exam findings (e.g., joint-line tenderness, positive McMurray/Thessaly/Apley) and function-limiting pain, in the absence of Kellgren-Lawrence Grade II or worse OA (exception: locked knee). Governed by eviCore CMM-312.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Knee Arthroscopy. Confirm the covered diagnosis list against the current QualCare policy.
How to submit
- Method: eviCore portal
- Portal: eviCore by Evernorth (Cigna MSK/Spine)
Sources & verification
- BindingSource — Cigna CMM-312 Knee Surgery — Arthroscopic and Open Procedures (CMM-312) · effective 2026-03-07.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 QualCare require prior authorization for Knee Arthroscopy?
Yes. QualCare generally requires prior authorization for Knee Arthroscopy (CPT 29875, 29876, 29877, 29879).
What does QualCare require to approve Knee Arthroscopy?
Prior authorization via eviCore (Cigna MSK program). Meniscectomy/meniscal repair medically necessary when MRI/CT-arthrogram shows a meniscal tear extending to the articular surface that correlates with symptoms, with at least two positive exam findings (e.g., joint-line tenderness, positive McMurray/Thessaly/Apley) and function-limiting pain, in the absence of Kellgren-Lawrence Grade II or worse … Always confirm against the current QualCare policy.
How long does a QualCare prior authorization take?
Turnaround varies by plan and submission method. Check the QualCare portal for current timeframes.
Submitting Knee Arthroscopy to QualCare?
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.