DESCRIPTION
Osteochondral lesions can occur in any joint but are most common in the knee and ankle. Such lesions are a tear or fracture in the cartilage covering one of the bones in a joint. The cartilage can be torn, crushed or damaged and, in rare cases, a cyst can form in the cartilage. Damaged articular cartilage can be associated with pain, loss of function, disability, and can lead to debilitating osteoarthrosis over time. These manifestations can severely impair an individual’s activities of daily living and quality of life. Most osteochondral lesions occur in the knee with the ankle and elbow being the next most frequent sites. The most common location of lesions is the medial femoral condyle (69%), followed by the weight-bearing portion of the lateral femoral condyle (15%), the patella (5%) and trochlear fossa. Talar lesions of the ankle are reported to be about 4% of osteochondral lesions.
Allogeneic grafts of osteochondral or chondral tissue have been proposed as treatment alternatives for individuals with clinically significant, symptomatic, focal defects of the articular cartilage. It is hypothesized that the implanted graft’s chondrocytes retain features of hyaline cartilage that is similar in composition and property to the original articulating surface of the joint. Osteochondral fresh allografting may be appropriate for large lesions of the knee or talus after failed marrow stimulation.
POLICY
Osteochondral fresh allografting of focal articular cartilage lesions is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Osteochondral allografting for the treatment of chondral defects in all other joints is considered investigational.
Osteochondral allografting for the treatment of focal articular cartilage lesions using the following techniques is considered investigational:
Allogeneic minced cartilage
Decellularized osteochondral allograft plugs (e.g., Chondrofix)
Reduced allograft discs (e.g., ProChondrix, Cartiform)
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Osteochondral fresh allografting is considered medically appropriate if ALL of the following criteria are met:
Indicated for ANY ONE of the following:
Symptomatic full thickness chondral defects of the knee if ALL of the following are met:
Defect is caused by acute or repetitive trauma
Other cartilage repair technique (such as micro-grafting, osteochondral autografting or autologous chondrocyte implantation) would be inadequate due to size, location or depth of lesion
Confirmation of defects by radiographs, magnetic resonance imaging (MRI) and arthroscopy
Osteochondral lesions of the talus if ALL of the following are met:
Treatment is indicated for ONE of the following:
Lesion greater than 1.5 cm2
Cystic lesion with volume greater than 3.0 cm
Osteochondral autografting would be inadequate due to size, location or depth of lesion
IMPORTANT REMINDERS
Any specific products referenced in this policy are just examples and are intended for illustrative purposes only. It is not intended to be a recommendation of one product over another and is not intended to represent a complete listing of all products available. These examples are contained in the parenthetical e.g. statement.
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits, or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan or government program (e.g., TennCare), the express terms of the health plan or government program will govern.
ADDITIONAL INFORMATION
Current evidence does not support the use of osteochondral allografting for joints other than the knee and ankle.
SOURCES
American Academy of Orthopaedic Surgeons. (2010). The diagnosis and treatment of osteochondritis dissecans. Guideline and evidence report. Retrieved November 29, 2016 http://www.aaos.org.
American Orthopaedic Foot and Ankle Society. Position Statement. (2022). The use of osteochondral transplantation for the treatment of osteochondral lesions of the talus. Retrieved September 12, 2024 from https://www.aofas.org/.
Assenmacher, A., Pareek, A., Reardon, P., Macalena, J., Stuart, M., & Krych, A. (2016). Long-term outcomes after osteochondral allograft: a systematic review at long-term follow-up of 12.3 years. Arthroscopy, 32 (10), 2160-2168. Abstract retrieved November 29, 2016 from PubMed database.
Balazs, George.C., Wang, D., Burge, A.J., Sinatro, A.L., Wong, A.C., & Williams, R.J. (2018). Return to play among elite basketball players after osteochondral allograft transplantation of full-thickness cartilage lesions. Orthopaedic Journal of Sports Medicine, 6 (7), doi: 2325967118786941. (Level 4 evidence)
BlueCross BlueShield Association. Evidence Positioning System. (5:2024). Autografts and allografts in the treatment of focal articular cartilage lesions (7.01.78). Retrieved September 12, 2024 from https://www.bcbsaoca.com/eps/. (86 articles and/or guidelines reviewed)
Chui, K., Jeys, L., & Snow, M. (2015). Knee salvage procedures: the indications, techniques and outcomes of large osteochondral allografts. World Journal of Orthopedics, 6 (3), 340-350. (Level 4 evidence)
Gross, C., Adams, S., Easley, M., & Nunley, J. (2016). Role of fresh osteochondral allografts for large talar osteochondral lesions. Journal of the American Academy of Orthopaedic Surgeons, 24, e9-e17. (Level 5 evidence)
Kunze, K. N., Ramkumar, P. N., Manzi, J. E., Wright-Chisem, J., Nwachukwu, B. U., et al. (2023). Risk factors for failure after osteochondral allograft transplantation of the knee: a systematic review and exploratory meta-analysis. The American Journal of Sports Medicine, 51 (5), 1356-1367. Abstract retrieved September 12, 2024 from PubMed database.
Pereira, G. F., Steele, J. R., Fletcher, A. N., Clement, R. D., Arasa, M. A., & Adams, S. B. (2021). Fresh osteochondral allograft transplantation for osteochondral lesions of the talus: a systematic review. The Journal of Foot and Ankle Surgery, 60 (3), 585-591. Abstract retrieved September 12, 2024 from PubMed database.
Sadr, K., Pulido, P., McCauley, J., & Bugbee, W. (2016). Osteochondral allograft transplantation in patients with osteochondritis dissecans of the knee. The American Journal of Sports Medicine, 44 (11), 2870-2875. Abstract retrieved November 29, 2016 from PubMed database.
Van Tienderen, R., Dunn, J., Kusnezov, N., & Orr, J. (2017). Osteochondral allograft transfer for treatment of osteochondral lesions of the talus: a systematic review. Arthroscopy, 33 (1), 217-222. Abstract retrieved June 27, 2017 from PubMed database.
ORIGINAL EFFECTIVE DATE: 5/1/2001
MOST RECENT REVIEW DATE: 10/10/2024
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Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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