P192 - Inconsistent Reporting of Preauthorization Medical Criteria for Osteochondral Allograft Transplantation Surgery
- D. Crawford (Portland, US)
- D. Crawford (Portland, US)
- S. Tabbaa (Flagstaff, US)
- M. Provencher (Vail, CO, US)
- J. Farr (Greenwood, US)
- W. Bugbee (La Jolla, US)
Abstract
Purpose
Although osteochondral allograft (OCA) transplantations have been a standard care for patients with osteochondral lesions, there is a disagreement in commercial payers’ medical criteria to define medical suitability and eventual authorization for OCA transplantation. The purpose of the current study is to 1) investigate the preauthorization medical criteria between commercial payers and 2) assess the level of agreement between an expert panel of cartilage surgeons with criteria from insurance payer policies.
Methods and Materials
A literature review was conducted to identify supporting evidence for consensus statements based on private payer medical criteria. The MOCA committee, 30 experienced surgeons and subject-matter experts in OCAs, used a Likert-scale 1 (strongly disagree) to 5 (strongly agree) to rank each statement. The extent of agreement and disagreement between participants was measured for each statement. Consensus was defined as agreement or disagreement that was greater than 75%.
Results
57 statements that spanned relevant medical criteria for OCA transplantation were included in the survey (Level II, Level III, and/or Level IV clinical studies). All 30 MOCA members completed the survey (100% response rate). Over half of the statements (54.4%) did not reach consensus (Table 1). Inconsistent voting was observed for statements related to osteoarthritis, inflammation, and degenerative changes to the joint. Strong disagreement between MOCA and payer medical criteria was observed for statements describing use of OCA for patella and other joint locations (Figure 1).
Conclusion
Commercial payers are not consistent in the medical criteria that are used to define patient care and eventual authorization for OCA transplantation. In contrast, “cartilage expert surgeon” consensus identified a clear consistency for specific OCA indications. This study demonstrates the need to standardize medical criteria for cartilage restorations based on the most current and contemporary literature, as well as in conjunction with experienced cartilage restoration experts in the field.