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

Physician 1:  The patient is a 39-year-old male with focal arthritis and loss of lateral meniscus. A request has been made for meniscal allograft and osteochondral allograft resurfacing. The Health Plan has denied this request on the basis that the procedures are considered experimental/investigational.Meniscal allograft reconstruction and osteochondral allograft resurfacing are appropriate for this patient. He is very young, and the proposed surgical intervention may allow him to avoid knee replacement in the future. There are no viable alternatives for the patient at this time. The requested procedures are medically appropriate and necessary to alleviate pain and prevent further arthritic changes. Therefore, I have determined that the requested procedures are 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 39-year-old male. In October 2004 he had a partial lateral meniscectomy of the right knee and was found to have a chondral defect of the right lateral femoral condyle. He did well initially but subsequently his condition deteriorated and his knee became painful. Arthroscopy was repeated in February 2006. Further debridement of the unstable lateral meniscal edge and the lateral femoral condyle articular cartilage was necessary. The orthopedic surgeon recommends fresh osteochondral allograft for the lateral femoral condyle and a lateral meniscus allograft for the right knee, which was denied by the Health Plan on the basis that there is insufficient evidence in the peer-reviewed literature to conclude the treatment is effective and comparable to alternative accepted therapy.Review of the relevant scientific literature including the articles submitted by the patients provider demonstrates there is sufficient evidence of efficacy to support the proposed meniscal allograft reconstruction and osteochondral allograft resurfacing in the case of this patient.  The patient is an appropriate candidate for the procedures and is likely to experience a superior clinical outcome than is available from standard treatment. Accordingly, I have determined that the requested procedures are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.Phisician 3:  The patient is a 39-year-old male who is requesting authorization for meniscal allograft reconstruction and osteochondral allograft resurfacing. Standard treatment has not been effective. In light of his age, he wishes to avoid a knee replacement. His provider believes the proposed surgery is the most appropriate option for the patient at this time. The Health Plan considers the requested procedures experimental.The proposed surgery, meniscal allograft reconstruction and osteochondral allograft resurfacing, remains an unproven treatment. There is insufficient mid and long-term data to support the use of these procedures in this clinical setting. Although this patient is young, further data is needed before the procedures can be recommended. Therefore, I have determined that the requested procedures are 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.