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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a matrix autologous chondrocyte implantation to the right knee. Findings:  The physician reviewer found that  Na and colleagues report, Currently, the best-available evidence suggests that some clinical outcomes of articular cartilage lesions of the knee treated with modified versions of autologous chondrocyte implantation (ACI) (ACI with a modified collagen membrane or matrix-applied chondrocyte implantation) can significantly improve patient outcomes at the mid-term follow-up of five years compared with those obtained using microfracture. Gou and colleagues note, Pooled analysis found no significant difference in the improvement in International Knee Documentation Committee or Lysholm scores or overall Knee Injury and Osteoarthritis Outcome Score measures between patients in the ACI and microfracture (MF) groups at one to five years of follow-up. Patients treated with ACI may have a significant benefit in activities of daily living, quality of life, and pain relief compared with patients treated with MF, although clinical relevance may not be achieved. Andriolo and colleagues conclude, The use of cartilage regenerative surgical procedures, such as matrix-assisted autologous chondrocyte transplantation (MACT), as salvage procedures for young, active patients affected by chondral and osteochondral lesions in osteoarthritic knees led to a limited improvement, with the majority of patients experiencing failure at long-term follow-up. Although a minor subpopulation experienced favorable and stable improvement, the use of MACT for such a challenging indication remains questionable until responding patients can be profiled. In this case, the patient has right knee pain and was status post right knee arthroscopic chondroplasty with arthroscopic partial medial and lateral meniscectomy. She was noted to be improving postoperatively and at full weight-bearing status. She was not on pain medications. An examination of the right knee reported antalgic gait, with mild swelling and effusion. There was atrophy of the gluteus medius/maximus, tenderness to the medial joint line, and McMurrays meniscal tests were guarded medially and laterally. Range of motion was noted as painful with active extension at 3 degrees and flexion at 120 degrees. The provider noted that the patient was being treated for treated for right knee pain due to a grade 4 chondral defect on the weight-bearing medial femoral condyle and a grade 4 chondral lesion of the trochlear groove. However, given the limited nature of current medical literature and lack of data on long-term safety and efficacy of the requested service for the noted pathology, the requested service is not medically indicated. Therefore, a matrix autologous chondrocyte implantation to the right knee is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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.