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

Physician #1:  The patient is a 61-year-old male with left knee chondromalacia. He is requesting reimbursement for an articular cartilage paste grafting procedure that was performed in November 2005. The Health Plan has denied coverage for the procedure at issue citing a lack of peer-reviewed literature supporting its use.There is no class I data to support the use of this procedure for knee osteochondral defects. The procedure remains experimental at this time. There is insufficient evidence that articular cartilage paste grafting is efficacious in this clinical setting. Furthermore, there were alternative standard procedures available for this patients condition. Therefore, I have determined that the procedure at issue was 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 61-year-old male requesting reimbursement for left knee articular cartilage paste grafting of a trochlear lesion performed arthroscopically in November 2005. He had a history of increasing pain and swelling of the left knee. He also had partial medial and lateral meniscectomy and extensive debridement of the left knee. The Health Plan has denied coverage for the procedure on the basis that it is considered investigational for treatment of the patients medical condition.The body of the operative report describes the details of the procedure. The paste is prepared by harvesting articular cartilage and cancellous bone from the medial condylar notch with an 8mm trephine. The graft is then smashed into a paste of cartilage and bone, which is impacted into the debridement defect following microfracture of the base of the defect with a pick.The paste graft is similar to an OATS procedure in that both involve use of an osteochondral graft. The difference is that with the paste graft the donor material is ground up and in the OATS procedure the donor material is transplanted as an intact plug.Although additional studies are needed, there is adequate evidence at this time to conclude that the use of articular cartilage paste grafting was medically reasonable in the case of this patient. Therefore, I have determined that the procedure at issue was 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 61-year-old man who has degenerative arthrosis of his knee with bilateral meniscus tears, a Bakers cyst and an osteochondral defect in the trochlea. He received an osteochondral paste grafting. He is requesting reimbursement for the procedure at issue. The Health Plan has denied this request on the basis that the efficacy of osteochondral paste grafting remains unproven.Osteochondral autograft procedures are performed for osteochondral defects. Single and multiple grafts can be utilized. The graft in essence is a plug shaped graft including articular cartilage and subchondral bone. Plugs are used in the size between 6 and 10mm. The depth of the plugs is between 15 and 20mm. The articular cartilage is still viable since it remains attached to the depth of subchondral bone.Osteochondral paste grafting, however, remains unproven. The graft is harvested including subchondral bone and cartilage and then according to the surgeons report smashed up and impacted into the trochlear defect. There are several questions to be answered with this procedure that are not documented in the literature and are extremely controversial. First, it is not known what holds or contains the graft impacted into the trochlea. Second, when articular cartilage and bone are smashed up as the surgeons report indicates, there is no evidence that purely articular cartilage is regenerated. The collagen structure may very well be inappropriate. The paste graft produces a combination of Type I and Type II collagen. Since there is much more bone smashed with a plug graft, primarily Type I collagen is produced. Articular cartilage is made up primarily of Type II collagen. Thus, the mixture of a paste graft containing predominately Type I collagen would seem to be inappropriate since Type II collagen is needed for articular cartilage grafting.In summary, the efficacy of the procedure at issue remains unproven and it was 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.