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Review
. 2022 Oct 19;104(20):1841-1853.
doi: 10.2106/JBJS.21.01191. Epub 2022 Aug 18.

Inconsistent Reporting of Preauthorization Medical Criteria for Osteochondral Allograft Transplantation Surgery

Suzanne M Tabbaa  1 , William D Bugbee  2 , Matthew Provencher  3 , Jack Farr  4 , Dennis C Crawford  5 ; on behalf of the Metrics of Osteochondral Allografts (MOCA) Committee
Collaborators, Affiliations
Review

Inconsistent Reporting of Preauthorization Medical Criteria for Osteochondral Allograft Transplantation Surgery

Suzanne M Tabbaa et al. J Bone Joint Surg Am. .

Abstract

Background: Although osteochondral allograft (OCA) transplantation has been a standard treatment for patients with osteochondral lesions, there is a disagreement in commercial payers' medical criteria regarding the definition of medical suitability and thus authorization for OCA transplantation. The primary goal of this study was to understand where consensus between a committee of experienced cartilage restoration surgeon scientists and payer policies existed and where there was significant disagreement.

Methods: U.S. private payers were identified by reviewing health insurance market research literature. Medical criteria were then obtained from publicly available payer medical polices. A literature review was conducted to identify supporting evidence for consensus statements based on private payer medical criteria. The MOCA (Metrics of Osteochondral Allograft) Committee, 30 experienced surgeons and subject-matter experts in OCA transplantation, used a Likert scale of 1 (strongly disagree) to 5 (strongly agree) to rank each statement. The extent of agreement and disagreement among participants was measured for each statement. Consensus was defined as agreement or disagreement of >75%.

Results: Fifty-seven statements regarding relevant medical criteria for OCA transplantation were included in the survey. All 30 MOCA Committee members completed the survey (100% response rate). Over half of the statements (52.6%) did not reach consensus. Of the remaining 27 statements that reached consensus, respondents agreed or strongly agreed with 16 statements, and disagreed or strongly disagreed with 11 statements. Inconsistent voting was observed for statements related to osteoarthritis, inflammation, and degenerative changes.

Conclusions: Commercial payers are not consistent in the medical criteria used to define patient eligibility for authorization of OCA transplantation. In contrast, an expert panel of cartilage surgeons reached a consensus that OCA transplantation was clearly suitable for a variety of specific indications. This study demonstrates the need to standardize medical criteria for cartilage restoration based on the most current literature, as well as in conjunction with experienced cartilage restoration experts.

Level of evidence: Therapeutic Level V . See Instructions for Authors for a complete description of levels of evidence.

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Conflict of interest statement

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H181 ).

References

    1. Abolghasemian M, León S, Lee PTH, Safir O, Backstein D, Gross AE, Kuzyk PRT. Long-Term Results of Treating Large Posttraumatic Tibial Plateau Lesions with Fresh Osteochondral Allograft Transplantation. J Bone Joint Surg Am. 2019 Jun 19;101(12):1102-8.
    1. Assenmacher AT, Pareek A, Reardon PJ, Macalena JA, Stuart MJ, Krych AJ. Long-term Outcomes After Osteochondral Allograft: A Systematic Review at Long-term Follow-up of 12.3 Years. Arthroscopy. 2016 Oct;32(10):2160-8.
    1. Beaver RJ, Mahomed M, Backstein D, Davis A, Zukor DJ, Gross AE. Fresh osteochondral allografts for post-traumatic defects in the knee. A survivorship analysis. J Bone Joint Surg Br. 1992 Jan;74(1):105-10.
    1. Chahal J, Gross AE, Gross C, Mall N, Dwyer T, Chahal A, Whelan DB, Cole BJ. Outcomes of osteochondral allograft transplantation in the knee. Arthroscopy. 2013 Mar;29(3):575-88.
    1. Familiari F, Cinque ME, Chahla J, Godin JA, Olesen ML, Moatshe G, LaPrade RF. Clinical Outcomes and Failure Rates of Osteochondral Allograft Transplantation in the Knee: A Systematic Review. Am J Sports Med. 2018 Dec;46(14):3541-9.

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