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

Physician 1: The patient is a 44-year-old woman with long-standing knee pain and is status post multiple surgical procedures. Her most recent surgery was an osteochondral allograft procedure in 2003. Although the patient initially experienced relief following the procedure, her pain has now returned. The patients provider has requested authorization for a revisional osteochondral allograft procedure, which has been denied by the Health Plan as investigational in nature.Osteochondral allografting for the treatment of chondral lesions is neither experimental nor investigational. It is a procedure that is utilized in cases such as this to provide cartilaginous covering in patients of relatively young age who have lost cartilage. There are no viable treatment options for the patient other than replacement-type surgery, which is undesirable in younger patients. Despite the results of the first procedure, revisional osteochondral allografting remains the best available 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.Physician 2: The patient is a 44-year-old female who is requesting authorization for an osteochondral allograft for a knee osteochondral lesion. She is status post a previous osteochondral allograft, which did not result in long-term improvement. The Health Plan has denied authorization for the requested procedure on the basis it remains experimental/investigational at this time.Osteochondral allograft transplantation for the treatment of osteochondral defects is an unproven treatment. There is insufficient mid and long-term data to support the use of the procedure in this clinical setting. Furthermore, this patient has a documented previous failure with the procedure. For these reasons, the requested procedure cannot be recommended for the patient. 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 44-year-old female who seeks an osteochondral allograft revision for a significant defect of the medial femoral condyle. The initial osteochondral allograft was performed in July 2003. The Health Plan has denied authorization and coverage for the revisional procedure, citing the lack of peer-reviewed medical literature supporting its efficacy.Review of the submitted clinical evidence indicates reasonable, alternative treatments have been tried in this case without success. Unfortunately, the patient is not a good candidate for uni-compartmental replacement because of her young age. Osteochondral allograft is the only reasonable alternative at this time. The likelihood of success is diminished by the fact that this would represent a revisional procedure and because of the patients smoking status, which is a deterrent to bone healing. Nonetheless, osteochondral allograft is likely to be more effective than any standard surgical or non-surgical intervention for this condition given the clinical circumstances.As set forth above, 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.