Poster 286: The Literature that Commercial Payers Use to Substantiate Coverage Policy Are of Low Level of Evidence
Authors: Fathi Amir , Kotlier Jacob L. , Telang Sahil S. , Patel Vishal S. , Mayfield Cory K. , Petrigliano Frank A. , Bolia Ioanna K. , Liu Joseph N. 
Published: August 2024

Objectives:

Injury to hyaline cartilage is problematic for both patients and physicians due to a limited potential for cartilage to heal. In the case of large chondral lesions, osteochondral allograft transplantation (OCA) is a popular and effective treatment modality with well-reported outcomes. However, given the costs of surgical operations in the United States, most patients require reimbursements through private insurance payers. It has previously been reported that the literature that substantiates the private commercial payers’ policies regarding certain orthopaedic procedures is based on low level of evidence studies. However, to the best of our knowledge, this information is not available regarding policies on OCA. Therefore, the purpose of this study is to determine the level of evidence of the referenced cited in the policies regarding OCA for the leading commercial payers in the United States and to determine whether these references investigated the criteria that has been established by the payers.

Methods:

Ten national commercial private health insurance payers were identified. These payers included Centene Corporation, United Healthcare, Humana, Health Care Service Corporation, Cigna, Kaiser Permanente, WellCare Health Plans, The UPMC Health Plan, Anthem, and Aetna. Each payer was contacted either via phone or email to obtain their coverage policies regarding OCA. For each policy, all references related to OCA were collected for a standardized review completed by reviewers. The information collected included the criteria set by each policy, level of evidence of each reference, and whether the cited reference investigated the commercial payers’ eligibility criteria for OCA.

Results:

Six main private health insurance companies had publicly available and current medical policies on osteochondral allograft transplants, including Centene Corporation, United Healthcare, Humana, Health Care Service Corporation, Cigna, and Aetna. A total of 110 references were found amongst these six medical healthcare providers of which 65 (59%) are primary journal articles, 29 (26%) are reviews or expert opinion articles, 5 (4.5%) are government reports, 6 (5.5%) are society guidelines, 3 (2.7%) are websites, 1 (1%) are rated as miscellaneous and 1 (1%) could not be found/accessed. Of the 102 references that were accessible, 1 reference showed a level of evidence (LOE) I (1%), 12 with LOE II (12%), 7 with LOE III (7%), 57 with LOE IV(57%), and 18 with LOE V(18%). The remaining 6 references had either a variable LOE or where an LOE rating was deemed unapplicable. Of the six main private health insurance medical policies attained, five (excluding United Healthcare) had corresponding publicly accessible medical necessity guidelines outlining criteria for procedural approval. From these five private health insurance companies, 22 of the 91 references directly tested for any of the listed medical necessity criteria. Amongst references directly testing the medical necessity criteria, 19 (86%) had a LOE IV, 1 (4.5%) with LOE I, 1 (4.5%) with LOE II, and 1 (4.5%) with a variable LOE.

Conclusions:

Analyzing commercial payers’ policies highlights that the majority of cited references that substantiate these policies are of low level of evidence. Furthermore, less than a quarter (24.2%) of references directly investigate the policy’s medical necessity. This perhaps illustrates a combination of a lack of high-quality studies investigating OCA and selective reporting of literature by these commercial payers. Patients and surgeons will benefit from future studies aimed at increasing awareness of the quality of evidence that helps establish commercial payers’ policies.