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

Physician 1This patient is a 46-year-old female with articular cartilage disease who has failed arthroscopy and microfracture treatment. The patients provider has recommended osteochondral allografting. The Health Plan has denied authorization for osteochondral allografting on the basis that it is considered experimental.Osteochondral allografting has adequate short-term and intermediate-term results. Though long-term results of osteochondral allografting are not yet known it is a reasonable option in this case given the lack of other available treatment options. The requested procedure is likely to provide the best chance at a positive outcome 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.Physician 2The patient is a 46-year-old female who is relatively active. In January 2003, she underwent an arthroscopy, chondroplasty, and microfracture treatment of condylar defects of the trochlea, medial tibial plates, and lateral tibial plateau, as well as partial medial meniscectomy of the left knee. She has continued pain in the left knee. Later in 2003, the patient underwent a mosaicplasty on the right side with good results. The patients orthopedic surgeon has requested approval for a fresh osteochondral allografting procedure for the symptomatic left knee. The Health Plan has denied authorization for the requested procedure on the basis that it is considered experimental in nature. Though osteochondral allografting is a promising technique, the long-term results of the procedure are not yet known. The submitted records demonstrate the patient had a good response to mosaicplasty of the right knee. Given this response the patient appears to be an appropriate candidate for mosaicplasty of the left knee. She should undergo an arthroscopy to determine her suitability for mosaicplasty. If the results of the arthroscopy reveal the patient is not an appropriate candidate for mosaicplasty, fresh osteochondral allografting is the next best alternative and should be authorized.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 at this time. The Health Plans denial should be upheld at this time. However, if it is determined that the patient is not an appropriate candidate for mosaicplasty the requested procedure should be authorized.Physician 3The patient is a 46-year-old woman with long-standing knee pain. She had documented lesions in several areas of her knee, secondary to cartilage loss. A request has been made for osteochondral allografting. The Health Plan has denied the request indicating osteochondral allografting is considered investigational.Osteochondral allografting is an accepted procedure, which is performed specifically in cases such as this. The patient is not a candidate for knee replacement. Continuation of standard modalities is not likely to improve the patients condition. Osteochondral allografting is the only procedure available to the patient that is likely to be of benefit. 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.