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

Physician 1: The patient is a 26-year-old female who is post anterior cruciate ligament (ACL) repair. She is experiencing pain and loss of motion and is unable to obtain relief with standard treatment modalities. Her provider has recommended she undergo an osteochondral allograft procedure. The Health Plan has denied this request on the basis that the requested procedure is considered investigational.There is no literature regarding the use of osteochondral allograft for focal defects of the knee after ACL reconstruction surgery. This patient now has established arthritis. Allografting the cartilage defects is not likely to be successful in this clinical setting. Given the lack of scientific data, the efficacy of the requested procedure remains unproven at this time and therefore, it cannot be recommended. Accordingly, I have determined that the requested procedure is 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 2: The patient is a 26-year-old woman with focal arthritis in her knee. She has undergone ACL reconstruction twice. She has constant pain in the patellar femoral joint. Her surgeon states that an osteochondral allograft procedure is the most appropriate treatment option for her at this time. The Health Plan has denied coverage for the procedure on the basis that it has not been established as efficacious.There is sufficient data supporting the proposed procedure in this clinical context. There are limited options for covering bone with cartilage drilling, cartilage transfer or osteochondral allografts. The only other option is joint replacement. The patient is too young for joint replacement; she has a defect too large for cartilage transfer. She underwent a chondroplasty with no relief. At this time, the best option for the patient is an osteochondral allograft and therefore, the procedure should be authorized.Based upon the information set forth above, I have determined that the requested procedure is 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 3: The patient is a 26-year-old woman who had multiple knee procedures for ACL instability. She has patellofemoral crepitus and has difficulty with activities of daily living. She has not responded to a multiplicity of Supartz injections (viscosupplementation).An arthroscopic examination reveals that this patient has Grade IV trochlear cartilage lesions. The December 2004 arthroscopy/operative report reveals mild anterior instability (1B Lachman). There is Grade IV chondromalacia of the patellofemoral joint in the central area of the trochlea. The operative report states mild Grade I/II medial chondromalacia. Laterally, there was also minimal chondromalacia present.Because of persistent symptomatology, her surgeon recommended an osteochondral allograft of the femoral trochlea. The Health Plan denied the procedure as experimental and investigational.The most recent orthopedic examination dated November 2005 states the patient had primary complaints of continuous grinding and crepitation and pain in the knee. Her physical examination at the point of her most recent examination is not documented. The patients provider noted the patient has significant arthritic changes in the area of the femoral trochlea primarily.Treatment of patellofemoral arthritis/arthrosis includes modification of activities, anti-inflammatory, viscosupplementation, a possible trial of chondroitin and glucosamine and MSM, extensive physical therapy and bracing. Surgical considerations include repeated arthroscopic debridement. Small focal lesions up to 12-15 mm can be treated with an osteochondral autograft patellofemoral decompression by means of a tibial tubercle osteotomy (Maquet). Distal femoral trochlear allografting remains an unproven procedure with less than stellar results. Even though the portion of the trochlea is replaced, patellar deficiencies remain. Thus, there is insufficient data to warrant the use of requested procedure in this case.Accordingly, I have determined that the requested procedure is 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.