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Review
. 2022 Oct 29;4(6):e2107-e2113.
doi: 10.1016/j.asmr.2022.09.005. eCollection 2022 Dec.

Variability in Private Payer Medical Policies for Osteochondral Allograft Transplantation Demonstrates the Absence of Standardization in Medical Criteria Between Payers

Suzanne M Tabbaa  1 , Dennis C Crawford  2 , Matthew Provencher  3 , Jack Farr  4 , Willliam D Bugbee  5
Affiliations
Review

Variability in Private Payer Medical Policies for Osteochondral Allograft Transplantation Demonstrates the Absence of Standardization in Medical Criteria Between Payers

Suzanne M Tabbaa et al. Arthrosc Sports Med Rehabil. .

Abstract

Purpose: To define the criteria for coverage for a cartilage restoration procedure and osteochondral allograft (OCA) transplantation and to investigate coverage for OCA procedures among private payer medical policies.

Methods: A systematic search of private payer websites was conducted to identify publicly available 2018 OCA medical policies. Medical criteria related to patient demographics, defect characteristics, and previous treatment were analyzed. Trends in coverage for treatment of talus and patella and the extent of restrictiveness of medical policies were evaluated from 2016 to 2018. The extent of restrictiveness of a policy was defined by number of medical criteria established by payer policies. Policies with >5, 3-5, and <3 specified criteria for OCAs were considered strongly, moderately, and weakly restrictive, respectively.

Results: In total, 49 private payer medical policies for OCA transplantation were identified. Extracted criteria varied greatly between medical policies. Ten different defect size ranges were reported across payer policies. Criteria for patient body mass index was specified in 63% of policies. Criteria for failed arthroscopic or traditional surgical procedure were identified in 20% of the policies. More than one half of policies (51%) specified knee defect location to load-bearing surfaces. Analysis of trends in positive coverage statements and restrictiveness showed an increase from 4.7% in 2016 to 39.5% for talus, 4.7% to 7.0% for patella, and a slight shift (4.7% of payers) toward weakly restrictive medical policies.

Conclusions: This study demonstrates wide variability and inconsistencies in published criteria among OCA medical policies.

Clinical relevance: This study informs clinicians of the current state of coverage for OCA transplantation, providing insights into the variability of payer policies and potential impact.

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Figures

Fig 1
Fig 1
Reported defect size range by payers for osteochondral allograft treatment of chondral defects of the knee. (NR, not reported.)
Fig 2
Fig 2
Criteria defined for patient prior treatment. Left, Percent of payers with various criteria describing conservative care. Right, Percent of payers with various criteria defining previous or other surgical procedures that should be considered.
Fig 3
Fig 3
Change in medical criteria for coverage of talus and patella over 2016-2018 medical policies.
Fig 4
Fig 4
Percentage of payers with strongly (>5 criteria), moderately (3-5 criteria), or weakly (<3 criteria) restrictive medical policies for osteochondral allograft transplantation.
Appendix Fig 1
Appendix Fig 1
Flow chart of search strategy methods and included private payer companies. (BCBS, Blue Cross Blue Shield; OCA, osteochondral allograft.)
See this image and copyright information in PMC

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