Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: This patient has a history of chronic right knee pain. Conservative treatment has included exercise, activity modification, corticosteroid injection, stem cell injection, physical therapy, ice, bracing, and acupuncture. An x-ray series documented moderate medial patellofemoral osteoarthritis. There was mild bilateral genu varus with approximately equal leg lengths. The patient reported he was unable to tolerate running. Right knee physical examination documented no effusion, negative Steinmann and McMurrays, negative Hoffa fat pad test, neutral patellar tilt, and no pain or tenderness to palpation over the medial or lateral joint lines, trochlea, tibial tubercle, patellar tendon, or pes anserine. He had some pain in the anteromedial aspect of his knee with step-down test and full weight bearing. Surgery was recommended to include right knee arthroscopy and synovectomy, high tibial tubercle osteotomy with medial opening wedge and fresh open osteochondral allograft. An orthopedic report stated that the patient had been authorized for high tibial osteotomy procedure but not for fresh osteochondral allograft procedure. The treatment plan included a medial off-loading brace while surgery was planned. At issue is whether the requested osteotomy and osteochondral allograft procedure of the right knee are medically necessary for treatment of the patients medical condition.Researchers concluded that combining high tibial osteotomy with osteochondral allograft (OCA) transplantation in properly selected patients was safe and effective and may delay the need for arthroplasty. A study concluded that large OCA transplant has become a valid alternative to restore articular surface in challenging articular lesions in young and active patients, either in primary or in revision procedures. Overall, OCA transplantation for the knee has demonstrated reliable mid- to long-term results in terms of graft survival and patient satisfaction. In this case, the patient is physically active and presents with a two-year history of progressively worsening right knee pain. Significant functional limitations are noted in activities of daily living and recreational activities, affecting his quality of life. Clinical examination findings are consistent with a large osteochondral lesion of his medial femoral condyle with associated bony edema in the context of his varus malalignment. There is no evidence of meniscal tear or ligamentous instability. He has failed to achieve improvement with comprehensive conservative treatment, including physical therapy, corticosteroid injection, stem cell therapy, exercise, activity modification, icing, medications, and bracing. Evidence-based medical guidelines and peer-reviewed literature support the use of OCA transplantation as a primary or salvage procedure for large chondral or osteochondral defects with concomitant realignment surgery in this clinical setting. Given this patients age, functional loss, failure of conservative treatment, and imaging findings, the requested procedures are considered medically appropriate and necessary. Therefore, the requested osteotomy and OCA procedure of the right knee are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.