Osteochondral Allograft denials in California external review

What the reviewers wrote

Where the denial was overturned

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 McMurray’s, 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.

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 patient’s 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.

Where the denial was upheld

Physician 1: The patient is a 26-year-old female who is post anterior cruciate ligament (ACL) repair. She is experiencing pain and loss of motion and is unable to obtain relief with standard treatment modalities. Her provider has recommended she undergo an osteochondral allograft procedure. The Health Plan has denied this request on the basis that the requested procedure is considered investigational.There is no literature regarding the use of osteochondral allograft for focal defects of the knee after ACL reconstruction surgery. This patient now has established arthritis. Allografting the cartilage defects is not likely to be successful in this clinical setting. Given the lack of scientific data, the efficacy of the requested procedure remains unproven at this time and therefore, it cannot be recommended.

Nature of Statutory Criteria/ Case Summary: The enrollee is requesting authorization and coverage for an open osteochondral allograft of the left knee. The enrollee suffered a knee injury while playing basketball. He was unable to ambulate. The enrollee underwent arthroscopic medial meniscus repair and partial lateral meniscectomy, and medial and lateral femoral condyle chondroplasty. A post-surgical re-evaluation reported the enrollee will need a second surgery to the medial femoral condyle and a chondral allograft.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Osteochondral Allograft, then check the rights and deadlines that apply to your plan.