Frequently asked questions
Frequently given answers.
When should I contact Vericel about a patient?
How do I initiate the prior-authorization process?
What should I include in the arthroscopic operative report to ensure proper reimbursement for the biopsy procedure?
What should I include in the operative report to ensure proper reimbursement for the implant procedure?
When is the implant scheduled?
What is the cancellation policy?
As soon as you identify a patient as a clinically appropriate candidate for Carticel, it may be beneficial to discuss the patient with your Carticel Cell Therapy Specialist.
The patient’s Carticel Care Coordinator (CCC) will submit the prior-authorization request to the insurance provider. The CCC's experience with Carticel will increase the likelihood of obtaining a prior-authorization and expedite the processing time.
Since authorization is often dependent upon documentation and since insurance company case managers rely on measurable objective data, it is important to provide very detailed information in the patient’s arthroscopic operative report.
The following information must be highlighted:
- Prior surgical procedures, particularly cartilage treatment procedures (e.g., debridement, microfracture, drilling/abrasion arthroplasty, or osteochondral allograft/autograft)
- Current symptoms and physical/functional limitations (unless these are noted in H&P)
- Number of defects
- Location(s) of defects
- Size of defect(s) (estimated after debridement)
- Grade of defect(s) (Using Outerbridge or ICRS scales, specify)
- Health and stability of rest of the knee (health of other articular cartilage in the knee, meniscal status, joint alignment and ligamentous stability)
- Absence of osteoarthritis (Carticel is not indicated for use in patients with OA)
- Clearly state the medical necessity for and intent to treat with Carticel.
- Clearly state lack of other surgical options for the patient given their condition.
- Clearly state that the patient was counseled about their condition and Carticel as a treatment option and that the patient has made an informed decision about their care.
Physicians’ offices should attach a copy of the operative report, or a narrative note, with each claim. Greater detail in the documentation of the implantation procedure increases the probability of appropriate reimbursement.
Please include the following information in the operative report:
- Preparation/debridement of defect site(s)
- Harvesting of periosteal patch
- Microsuturing technique
- Testing for water tightness
- Fibrin glue application
- Implantation of chondrocytes
- NOTE: Use the word "implant" not "transplant"
Physician office reimbursement will depend upon the unique contract established by the provider and the patient’s health plan. The physician office may want to consult with its contracting representative to determine specific reimbursement rates for implant procedures.
Surgical dates may be discussed during the prior-authorization process. Your Carticel Care Coordinator will confirm the surgical date upon receipt of insurance approval of the Carticel implantation.
Carticel is a customized product that requires careful calculations of the cell culturing time for each individual patient.
The final culturing phase begins at the Manufacturing Date. At this time, the cells are taken from their cryopreserved state and put into a nonreversible, final cell culturing process to meet the implantation date requested.
If a Carticel order is canceled for any reason on or after the Manufacturing Date, the patient may be responsible for the cost of the cells.
Please contact your Carticel Cell Therapy Specialist or Carticel Care for detailed individualized information.