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

Physician 1:  The patient is a 24-year-old male that injured his left knee in October 2004 while playing soccer.  Radiographic studies demonstrated a complete tear of the anterior cruciate ligament (ACL) and a bucket handle tear of the medial meniscus. The patient underwent left knee ACL reconstruction in October 2005. The operative report noted the medial meniscus was too damaged for repair and it was debrided with a near complete medial meniscectomy. There was also a posterior horn lateral meniscus tear that was debrided. As of May 2006 X-ray  identified mild degenerative changes within the medial compartment however, the patient had no instability. The orthopedist noted the patient was currently asymptomatic. In September 2006 the provider noted the patient continued to do well with relatively no pain or instability, but he had occasional mild pain with descending stairs. The patients range of motion was normal with no crepitus. X-rays again showed mild degenerative changes within the medial compartment of the left knee. The provider recommended meniscal transplantation in light of the patients near complete medial meniscectomy to prevent progression of the degenerative changes. The Health Plan denied the request for authorization based upon a determination that meniscal allograft transplantation is investigational in this clinical setting. A review of the current literature indicates that miniscal allograft transplantation is not a  mainstream orthopedic treatment at this time. This is particularly true with regard to a patient that is essentially symptom free. In the absence of well controlled long-term follow up, this procedure remains investigational. Although short-term results are favorable for symptomatic patients, further studies and results are needed to establish a clear benefit for a patient such as this one. Meniscal transplantation cannot be recommended at this time. Therefore, I have determined 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 24-year-old male who sustained an injury to his left knee while playing soccer in October 2004. He underwent an anterior cruciate ligament (ACL) reconstruction and  was found to have a medial meniscus bucket handle tear that required near complete medial meniscectomy and a radial tear of the lateral meniscus that was debrided. The patient was evaluated by his orthopedist in May 2006 who noted occasional mild anterior knee pain while descending stairs or hills. The patient had no pain or instability. Examination demonstrated mild valgus and X-rays showed well placed tunnels with evidence of an ACL reconstruction graft. The graft and hardware were in excellent position and there were mild degenerative changes within the medial compartment. The patients provider indicated the patient had grade 3A chondromalacia changes of the posterior aspect of the medial tibial plateau and recommended a meniscus transplant. A subsequent progress note from August 2006 noted that the patients job was physically demanding and again proposed meniscus transplant to prevent progressive deterioration. In September 2006 the patients provider documented occasional mild pain with descending stairs but no instability. Physical examination revealed normal range of motion without crepitus. The patient is now requesting authorization for meniscal allograft transplantation. The health plan has classified this procedure as investigational and denied the request for authorization and coverage. While the long-term effect of subtotal meniscectomy is well documented in orthopedic literature, the protective benefits of meniscal transplant in conjunction with its inherent risks are not well documented in long-term follow up studies. As such, there is no assurance of benefit for an individual who appears to be relatively asymptomatic and has returned to his routine activities. At present, the ideal indications for meniscal transplantation are (1) age less than 50 years; (2) evidence of articular cartilage deterioration but no demonstrable instability; and (3) significant symptomatology. For this asymptomatic patient, the risks outweigh the potential benefits. For these reasons, I have determined the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Accordingly, the Health Plans denial should be upheld.Physician 3:  The patient is a 23-year-old male who injured his left knee while playing soccer in October of 2004. His diagnoses included a complete anterior cruciate ligament tear (ACL), a bucket handle medial meniscus tear and a lateral meniscus tear. In October 2005, the patient underwent left knee surgery with ACL reconstruction and functionally complete medial meniscectomy. Post-operatively, he did well with essentially no pain and no instability. The patient had occasional anterior knee pain when descending stairs or hills. The treating physician recommended a meniscal allograft transplant given the near complete medial meniscectomy and grade 3A chondromalacia changes involving the posterior aspect of the medial tibial plateau. The Health Plan denied authorization for the procedure citing the experimental nature of meniscus allograft transplantation.The patient has evidence of a large osteochondral defect. Although meniscal allograft transplantation may be a reasonable option for some patients, it is only appropriate for patients who have an otherwise normal knee. This patient does not satisfy the inclusion criteria for the requested procedure. There is no data supporting the efficacy of meniscal allograft under these circumstances and the condition of the patients knee would preclude the use of the meniscal allograft.Based upon the information set forth above, 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.