Appeal type: Experimental
Decision: Insurer Denial Upheld

Summary Reviewer 2 
 
A 46-year-old female enrollee has requested authorization and coverage for bone marrow 
aspiration (38220). The Health Insurer has denied this request and reported that the requested 
services are investigational for the treatment of the enrollees medical condition. The physician 
reviewer found that Lin and colleagues performed a study comparing bone marrow aspirate 
concentrate with cancellous allograft to iliac crest bone graft in the treatment of long bone 
nonunions. The authors concluded, We found no significant difference in union rate for long 
bone nonunions treated with iliac crest bone graft or bone marrow aspirate concentrate with 
allograft. Bone marrow aspirate concentrate and allograft led to 75% successful healing in this 
series. Given the heterogeneity of the control group and loss to follow-up, further prospective 
investigation should be conducted to more rigorously compare bone marrow aspirate concentrate 
to iliac crest bone graft for nonunion treatment. Blanton and colleagues noted, The stem cells 
collected are multipotent and regenerative in nature. In addition to stem cells, other biological  components collected augment the mitogen of local cells, proliferation, and angiogenesis, and 
inhibit proinflammatory cytokine and bacteria to optimize an environment to heal. The most 
common site for harvest is the iliac crest. Techniques for harvesting bone marrow aspirate are 
simple to perform, financially modest, and associated with low morbidity. Additional research is 
needed to evolve and standardize the technology; however, bone marrow aspirate is proven to be 
advantageous for tissue repair. Modest and colleagues noted, Femoral neck nonunion in young 
patients is a challenging problem with treatment strategies aimed at improving the biological and 
biomechanical fracture environment. While the use of both vascularized and nonvascularized 
bone grafting has shown promising results, they have high complication rates and substantial 
donor site morbidity. Bone marrow aspirate concentrate has demonstrated multiple uses 
throughout orthopedic surgery and may result in an improved fracture healing environment with 
minimal patient morbidity. Schottel and colleagues noted, Bone marrow aspirate grafting 
entails mesenchymal stem cell-containing bone marrow harvesting and injection into a fracture 
site to promote bone formation. Although the use of bone marrow aspirate in orthopedic trauma 
is not widespread, an increasing number of studies are reporting clinical success. Advantages of 
using bone marrow aspirate are that it is readily obtainable, has low harvest morbidity, and can 
be easily and quickly injected. However, no universally accepted role for its use exists. Future 
studies directly comparing bone marrow aspirate with conventional techniques are needed to 
define its role in the treatment of orthopedic trauma patients. This patient was being treated for 
a proximal tibial fracture. She presented status post a left knee tibial tubercle osteotomy 
performed in April 2021. She had a complication from the procedure, namely a tibial shaft 
fracture. She was not immobilized during this time. It is unclear whether the fracture appeared in 
the summer of last year or later. The lack of immobilization has resulted