Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of autologous chondrocyte implantation knee (CPT code 27412) and anterior tibial tubercleplasty (CPT code 27418) for treatment of the enrollees knee pain. Findings:  The physician reviewer found that There is sufficient support in the medical literature for the medical necessity of the requested services in this clinical setting. Direct visualization and inspection is the most reliable method of assessing the extent of the cartilage lesion. The issue of efficacy of autologous chondrocyte implantation has been under discussion for several years. While autologous chondrocyte implantation is one of several possible interventions, it has been studied in follow up with subsequent second look arthroscopies with an acceptable percentage of documentation of surviving graft. The need to re-align the quadriceps mechanism in patients who have a patellofemoral tracking abnormality has been a part of orthopedic practice for many years and the malalignment present must be addressed or the cartilage transplant procedure will fail. In this patients case, the planned surgical treatment of autograft cartilage reconstruction of the medial patellar facet combined with re-alignment of quadriceps mechanism is one of a range of methods of restoring cartilage surfacing including bone and cartilage allograft implantation, osteochondral bone plugs and osteoarticular transfer system procedures. While the presence of cartilage surfacing changes on the trochlear side of the patellar lesion is a negative finding prognostically, it is appropriate to proceed with the autologous cartilage transplant. The patient will have a realignment procedure which may improve the prognosis and the efficacy of the surgery. There is careful documentation of the extent of the cartilage lesion within the trochlear. There is no documentation of exogenous obesity or a systemic arthritic condition. The case specific aspects in this decision supporting the proposed procedure include the patients relatively young age. At this age, if the lesion is not addressed then there will be progressive deterioration of the patellofemoral joint. The medical evidence shows that patellofemoral or total knee arthroplasty introduces a number of specific problems and concerns, which are accentuated in the younger patient. These concerns include particulate wear debris and the autoimmune reaction associated with the individuals reaction to this debris. The extent of the reaction is dependent upon the patients own individual immune system but is also time dependent with increased likelihood of the need for revision over time if this patient comes to a patellofemoral or total knee arthroplasty. For that reason, the long term negative durability of a metal to methyl methacrylate implant provides an indication for the proposed procedure. The provider has considered and rejected patellofemoral partial total knee replacement for the above stated reasons. In summary, autologous chondrocyte implantation knee (CPT code 27412) and anterior tibial tubercleplasty (CPT code 27418) are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.