Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 42-year-old female with a large osteochondral defect in the right ankle. Her physician recommended autologous chondrocyte transplantation for the patient. The patient underwent this procedure on 10/22/04. The Health Plan has denied reimbursement for autologous chondrocyte transplantation indicating the safety and efficacy of this procedure has not been established.Autologous chondrocyte transplantation will give the patient the best chance of avoiding further damage to her ankle. She has a large defect, which is amenable to the type of coverage the procedure provides. There does not appear to have been any other options for the patient at this time. Autologous chondrocyte transplantation is clearly better than any available standard therapy and is likely to provide the patient with the best chance for recovery. Therefore, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Physician 2: The patient is a 42-year-old female who underwent previous arthroscopy surgery and did not respond well. She has requested reimbursement for autologous chondrocyte transplantation for talus large osteochondral defect, which she underwent in October 2005. Her Health Plan has denied coverage for this procedure on the basis it is investigational.Autologous chondrocyte transplantation is not the standard of care for treatment of patients such as this patient. The results so far have been no better than those of abrasive chondroplasty. There is not enough data with long-term follow-up to support the use of the procedure at issue. Additional controlled, peer-reviewed data is necessary before the efficacy of autologous chondrocyte transplantation can be established. Therefore, I have determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.Physician 3: The patient is a 42-year-old woman who has an osteochondral lesion of the talus. The first procedure performed failed. She subsequently consulted another provider who recommended autologous chondrocyte transplantation (ACT). The patient underwent an ACT procedure on 10/22/04. The Health Plan has denied reimbursement for the ACT procedure on the basis its safety and efficacy has not been established.Review of the relevant scientific literature demonstrates the efficacy of autologous chondrocyte implantation for treatment of patients such as this patient has been established. The submitted clinical evidence indicates this patient was an appropriate candidate for autologous chondrocyte transplantation. Considering the size of the lesion, it is not likely the patient would have experienced improvement with standard therapies. The procedure at issue was the most appropriate treatment option for this patient. Therefore, I have determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.