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

Physician 1The patient is a 48-year-old female who has a history of chronic right knee pain following an ACL repair eight years ago. She reports pain causing her knee to give way. Her provider reports x-rays reveal osteochondral defect in the right medial femoral condyle, which appears to have a subchondral cyst. She has attempted other treatments, which have not had any real success. She is requesting an OATS procedure at her providers recommendation.The procedure that has been recommended to the patient by her treating physician appears to be the best option for her. The procedure is routinely performed and has been available for more than 10 years. Other available options would not be considered appropriate for this patient. The OATS procedure has the potential of benefiting this patient and is medically reasonable and appropriate. Therefore, I have determined 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 48-year-old female who has osteochondral defect of the right knee. She has undergone a number of treatments without sustained benefit. She is experiencing pain and giving way. Her provider demonstrates she is not an appropriate candidate for debridement or an autologous OATS procedure and has recommended an allograft OATS procedure.The OATS procedure is the best treatment option for this patient. Other treatment options will not be effective for this patient. This patient is an appropriate candidate for an OATS procedure. Furthermore, there is scientific evidence supporting an OATS procedure in this patient. Because other treatment options are not indicated for this patient, I have determined the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Physician 3The patient is a 48-year-old female. She saw her orthopedic surgeon on 11/21/03 in consultation at the request of her primary care physician for ongoing medial right knee pain after an ACL reconstruction seven years ago. The knee feels unstable and the pain causes giving way. She has pain after bicycling. There was medial joint line tenderness. Imaging studies show what appears to be an osteochondral defect in the right medial femoral condyle with a subchondral cyst. The orthopedic surgeon said the lesion is too large to respond well to debridement alone and/or an autologous OATS procedure. He recommended an allograft OATS procedure, which was denied by the Health Plan as being investigational.I have reviewed the references regarding osteochondral autografts (OATS mosaicplasty) in the treatment of articular cartilage lesions, which are included in the file. Based upon this information and the patients condition, it is apparent that the patients provider is correct in recommending an allograft OATS procedure. The recommended procedure has the best potential for benefiting 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.