Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Osteochondral lesion of the distal tibial plafond

Treatment: Open osteochondral autograft

The insurer denied coverage for open osteochondral autograft.

The denial is upheld. 

This is a female with a history of Coronavirus disease 2019 (COVID-19), diabetes, colitis, Grave's Disease, hyperlipidemia, and migraines. She presented to the Orthopedic Surgeon's office for a follow up visit for left ankle pain. The patient has been treated with conservative measures and was doing fair. She felt like conservative treatment has been exhausted and she would like to pursue operative treatment. A computed tomography (CT) scan of the ankle revealed an osteochondral abnormality of the anterior margin of the tibial plafond with mild subchondral cystic change. The physician recommended an open osteochondral autograft to treat the patient's condition.  

The records show a complex and extensive clinical history. The patient has ongoing ankle and foot problems for years. The records show no defined pain generator. She was found to have fractures to her mid foot, hind foot, and a lesion in her talus. She had received several treatments and injections to multiple sites. 

Originally there was a lesion of the talus which had not progressed. This was an incidental finding which did change, documented by several magnetic resonance imaging (MRIs). She then underwent a procedure where a drilling was performed with articular cartilage allograft placement. This failed. She has now been diagnosed with a lesion to the distal tibia. There were imaging studies showing ongoing reactive changes to her talus. 

Indications for reconstructive articular cartilage procedures (ie [that is] osteochondral autograft to tibial plafond) would require a defined pain generator. There should be likelihood the operation will provide benefit. The facts are the patient has never improved despite multiple treatment for years. She has had pain throughout her ankle and foot. She is "extremely obese" and her weight would also have an effect on the result. 

The most significant finding however is the presence of involvement to the talus. She has a likely "kissing lesion". This is defined as pathology to both sides of the joint. In her case, there is talar pathology and corresponding distal tibia involvement. Articular cartilage procedures are contraindicated in the presence of "kissing lesions". 

There has been discussion about the possible need for a total ankle replacement in the future. This type of operation is performed for end stage osteoarthritis. 

A literature search was performed using PubMed, National Library Medicine with key word osteochondral lesion of the distal tibial plafond. A single reference was found. This was a Systematic Review. The conclusion was additional studies would be required. There was no long term follow ups and small numbers of patients evaluated.  

Open osteochondral autograft is not considered medically necessary for this patient.

The health plan acted reasonably, with sound medical judgment, and in the best interest of the patient.

The insurer's denial of coverage for open osteochondral autograft is upheld. Medical necessity is not substantiated.