Appeal type: Medical necessity
Decision: Overturned in Part

Diagnosis:  Osteochondral Defect.
Treatment:  Osteochondral allograft transplant and osteochondral autograft procedures.

The insurer denied the osteochondral allograft transplant and osteochondral autograft procedures.  The determination is partly overturned.

The patient has a complaint of left knee pain.  His initial injury was while playing high school football.  The patient was a high school athlete, who participated in football and wrestling.  He attempted rest and oral medications but continued to complain of left knee pain.  A magnetic resonance imaging (MRI) scan of the left knee confirmed a 2 centimeter (cm) x 2 cm unstable osteochondral defect on the weight bearing surface of the medial femoral condyle.  This was initially identified on plain radiographs of the patient's symptomatic left knee.  The patient did report mechanical symptoms in his left knee, including popping and clicking.  The patient is now multiple years post injury and is still experiencing pain in his left knee.  The provider proposed osteochondral allograft transplant surgery for this patient's left knee cartilage lesion.  The patient's health plan denied this request as not medically necessary.  At issue in this case is the medical necessity of the proposed osteochondral allograft transplant and osteochondral autograft procedures.

The services are medically necessary in part.

The requested health service/treatment of fresh osteochondral allograft transplant surgery, CPT code 27415, is medically necessary for this patient.  The current procedural terminology (CPT) code 27416, osteochondral autograft, is not medically necessary in this case based on the size of the osteochondritis dissecans lesion documented on the MRI scan.  This lesion is 2 centimeter (cm) x 2 cm for a total of 4 cm squared; osteochondral autograft transplant is not appropriate for a lesion of this size.  Thus, this procedure, CPT code, 27416, is not medically necessary.  

The provided records in this case document that the patient sustained an injury to his left knee while playing football.  He now wishes to participate in recreational sports.  The records document that he has pain in the affected left knee with occasional clicking and popping.  The symptoms did not respond to conservative treatment.  The patient is multiple years post-injury and has failed conservative treatment for his left knee.  Plain radiographs and an MRI scan confirmed an unstable osteochondral lesion on the weight bearing portion of his medial femoral condyle. 

In addition, the performance of fresh allograft transplantation surgery has been proven to be clinically effective for pain relief and it has been proven to restore a patent's ability to participate in sports after surgery.  This was documented in the peer-reviewed literature by Nielsen and colleagues in the American Journal of Sports Medicine.  A recent article published by Nielsen and colleagues in the American Journal of Sports Medicine concluded that "osteochondral allograft transplantation is a successful treatment option for athletes and highly active patients who sustain a cartilage injury to their knee.  The majority of patients returned to sport or recreational activity."  Therefore, the proposed osteochondral allograft transplant surgery in this case is clinically effective and medically necessary per the peer-reviewed literature.  Osteochondral autograft is not medically necessary.