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

Physician 1: The patient is a 22-year-old woman with a history of severe ankle injury as the result of a motor vehicle accident. She has lost cartilage. An autologous chondrocyte implantation has been recommended. The Health Plan has denied this request indicating the requested procedure is considered investigational. Autologous chondrocyte implantation will give the patient the best chance of avoiding further damage to her ankle. There does not appear to be any other options for the patient at this time. Autologous chondrocyte implantation is clearly better than any available standard therapy and is likely to provide the patient with the best chance for recovery. 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 22-year-old female who was involved in a motor vehicle accident in December 2002 and injured her ankle. She is having pain while walking and driving. The patient has requested authorization and coverage for autologous chondrocyte implantation. The Health Plan has denied the request on the basis that the requested procedure is considered investigational for treatment of the patients medical condition. Autologous chondrocyte implantation is not the standard of care for treatment of patients such as this patient. The results so far have been no better than those of abrasive chondroplasty. There is not enough data with long-term follow-up to support the use of the requested procedure. Additional controlled, peer-reviewed data is necessary before the efficacy of autologous chondrocyte implantation can be established.  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 3: The patient is a 22-year-old female who was involved in a motor vehicle accident in December 2002, which resulted in a fracture of the right tibia/fibula. She is status post surgical repair of her ankle injury. The patient was non-weight bearing for several weeks and then underwent physical therapy. She continues to have pain when driving and walking. A request has been made for authorization for osteochondral chondrocyte implantation. The Health Plan has denied this request indicating the requested procedure is considered investigational. Review of the relevant scientific literature demonstrates the efficacy of autologous chondrocyte implantation for treatment of patients such as this patient has been established. The submitted clinical evidence indicates this patient is an excellent candidate for autologous chondrocyte implantation. It is not likely the patient will experience improvement with standard therapies. The requested procedure is the most appropriate treatment option for this patient. 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.