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

Physician 1: The patient is a 35-year-old woman status post multiple surgeries on her left knee.  She reinjured her knee in August 2005 and now has a large lesion in the cartilage of the left lateral condyle. The patients provider recommends autologous chondrocyte implantation to repair the defect. The patients request for authorization was denied by the Health Plan based on a determination that the procedure is experimental/investigational.Autologous chondrocyte implantation has been FDA approved for almost ten years.  The procedure has been utilized extensively in both Europe and the United States. This patient is young and active and chondrocyte implantation offers her the best outcome.  Successful implantation will cover the defect and prevent further deterioration thus avoiding traumatic arthritis and knee replacement.  No long-term safety issues have been identified.  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 2: The patient is a 35-year-old female with a history of previous arthroscopic procedures in 1997 and 2004.  She had done well following the surgeries until the Fall of 2005 when she injured her left knee while playing volleyball.  The patient consulted with an orthopedic surgeon in October 2005. Her provider recommended an arthroscopic procedure, which was performed in December 2005. The operation revealed a femoral condylar defect of 2.0cm by 2.5cm. During the procedure, a biopsy was taken to culture cells for autologous chondrocyte implantation. The patients provider requested authorization for the implantation procedure to repair the defect in the cartilage. The Health Plan denied authorization citing the investigational nature of autologous chondrocyte implantation in this clinical context.Symptomatic articular cartilage lesions are typically treated surgically with debridement (chondroplasty). The patient has had arthroscopic debridement and partial meniscectomy and appears to be on the way to developing a significant degree of arthrosis. This condylar cartilage defect is too large for a mosaicplasty or an OATS procedure.  The autologous chondrocyte implantation procedure is approved by the FDA and is often employed with larger lesions. This procedure is specifically indicated for femoral condylar lesions in young patients who are physically active and not overweight.  After a thorough review of this case, 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 35-year-old woman who recently underwent diagnostic arthroscopy of the left knee.  A 2.0cm by 2.5cm lateral femoral condyle cartilage defect was identified. She has had two other arthroscopic surgeries and her orthopedist now recommends autologous chondrocyte implantation.  The patient submitted a request for the procedure to her Health Plan.  The Health Plan considers autologous chondrocyte implantation an investigational procedure and has denied authorization.There is no long-term data to support the use of autologous chondrocyte implantation in this setting.  The procedure is still experimental for the treatment of cartilage defects in the knee and there is limited data on the long-term outcomes and durability of this procedure.  Based on current evidence, 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.