P228 - Analysis of Private Payer Medical Policies for Osteochondral Allograft Transplantation
Abstract
Purpose
Reimbursement in the field of cartilage restoration can be challenging for health care providers (HCPs), as the payer process for reimbursement and rationale for criteria deemed medically necessary is elusive. The purpose of this study was to conduct a systematic review of private payer medical policies to determine the variability between medical coverage and trends for a cartilage restoration procedure – osteochondral allograft transplantation.
Methods and Materials
A total of 43 private payers were searched for medical policies describing criteria for medical necessity for osteochondral allograft transplantation. Each payer’s medical policy was identified by searching for key terms related to OCA transplantation. The criteria for medical necessity was extracted for each provider, including defect characteristics, patient demographics and history, and prior treatments. The variability and trends in coverage across payers were evaluated.
Results
Analysis of payer criteria for cartilage defects, patient indications/history, and location varied between payers and even within payer companies and licensees (Fig1 & Fig2). 52% of payers analyzed did not report a defect size range, while the remaining payers varied between ten different reported ranges (Fig1-A). Analysis of criteria describing patient characteristics and prior surgeries (Fig1-B) and other anatomic locations (Fig 2-A) varied widely. Blue Cross Blue Shield companies and licensees demonstrated a trend towards standardized criteria over the past three years. 17/33 companies defined similar criteria for OCA of the knee and talus (Fig 2-A). Inclusion of criteria for patella and talus by the 43 payers has increased from 0.0% in 2016 to 39.5% for talus and 9.3% for patella in 2018 (Fig 2-B).
Conclusion
The lack of standardization in criteria defined for medically necessary treatment of osteochondral allograft transplantation results in challenges for healthcare providers. This analysis demonstrates the current variability in criteria and trends towards some standardization and expansion of OCA criteria for other anatomic locations.
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