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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Article info
Publication history
Published online: October 29, 2022
Accepted:
September 13,
2022
Received:
September 29,
2021
Footnotes
The authors report the following potential conflicts of interest or sources of funding: S.M.T. and D.C. report personal fees from JRF Ortho, outside the submitted work. M.P. reports personal fees from Arthrex, JRF Ortho, SLACK, and Arthrosurface, outside the submitted work. In addition, M.P. has a patent, 922764, 20150164498, 20150150594, 20110040339 issued. J.F. reports personal fees from Aesculap, Arthrex, CartiHeal, Exactech, JRF Ortho, Moximed, Organogenesis, Samumed, TRX Orthopedics, Vericel, Zimmer Biomet, Zipline Medical, and ZKR Orthopedics; grants from Active Implants, Arthrex, Ceterix Orthopaedics; Fidia Pharma, Histogenics, Moximed, and Novartis; grants and personal fees from Organogenesis; grants from Vericel, Zimmer Biomet; personal fees from DePuy Synthes, Biopoly LLC; other from MedShape and OrthoRegenerative Technologies, outside the submitted work. W.D.B. reports personal fees from JRF Ortho and Arthrex, outside the submitted work. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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