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

Physician 1The patient is a 24-year-old active woman status post four lateral arthroscopic knee procedures following an initial bucket handle tear first treated with meniscal repair. She has documented early chondral changes, and continues to be symptomatic. There is no apparent injury to the anterior cruciate ligament (ACL), nor does there seem to be concern regarding any angular deformity. She has been deemed a candidate for meniscal allograft transplantation (MAT), with apparent concurrence from more than one physician. The Health Plan has denied authorization for the requested procedure on the basis that it is considered experimental. The patient has demonstrated repeated injury requiring surgery following her initial failed meniscal repair. She has early chondral changes now requiring microfracture/drilling for reconstruction. Options would sometimes include osteotomy and/or bracing, but there is no apparent angular deformity. Since the patient is effectively without a lateral meniscus, her prognosis is not good without intervention. Early to intermediate clinical results of MAT that include isolated lateral meniscal transplants with early osteoarthritic changes are available with Lysholm or Fulkerson scores. A Canadian study that specifically included patients with osteoarthritis showed 90% good or excellent results at average follow-up of 2.5 years in patients with arthritic changes that underwent isolated meniscal grafts. Another report with average follow-up of 2.9 years study showed great improvement in 22 patients, and some improvement in 8 out of a total of 31 utilizing the Lysholm scoring system and the SF-36. No difference was seen between medial and lateral grafts, degree of chondral changes, and/or if an ACL reconstruction was done.A paper from the Netherlands using Lysholm scores demonstrated a clinical survival rate (76%) of isolated lateral meniscal grafts with 70-month follow-up that included a range of successful survivors out to 11 years. Of note, in regard to this patient the isolated lateral allografts had the best outcomes. Another paper specifically looking at medial allografts combined with ACL tears showed survival of eight out of nine grafts with high IKDC scores and patient satisfaction with an average follow-up of 9.7 years; their only failure was an early infection.Given the results of these studies and the patients age, activity level, lateral meniscal deficiency, and ongoing symptoms, it appears that the patient would benefit more from MAT than from alternative standard interventions. Therefore, 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 2The patient is a 24-year-old woman who has requested meniscal allograft transplantation (MAT) to prevent arthritis from developing in her knee. She has undergone four previous surgeries without relief of her pain. The Health Plan has denied authorization for the requested procedure on the basis that the long-term efficacy of MAT has not been established.Little is known of the long-term effects of meniscal allografts since the procedure is relatively new and no long-term results have been published. Complications of the procedure are not known (e.g., re-tear of meniscus, wear rates, incorporation of the meniscus). To date, it has not been shown that MAT is effective on a long-term basis, has an acceptable complication rate, and is beneficial to a particular patient group. Therefore, 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 3The patient is a 24-year-old female with a history of documented articular femoral condyle damage and multiple surgical procedures. The patient has requested authorization for meniscal allograft transplantation. The Health Plan has denied this request on the basis that the requested procedure is considered experimental.This patient is a poor candidate for allograft transplantation due to her articular cartilage damage in the femoral condyle. In addition, the patient is overweight, which is a contraindication to the proposed procedure. Furthermore, meniscal allograft transplantation has unclear long-term results in the best of candidates. Therefore, 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.