DESCRIPTION
Osteochondral allografting is one of several types of cartilage transplant procedures used in the treatment of individuals with symptomatic, disabling cartilage injury or disease. The literature indicates that osteochondral allografting can provide significant relief of pain and improved joint function for individuals with focal articular cartilage defects due to trauma or osteochondritis dissecans. The procedure involves the transplantation of a piece of articular cartilage and attached subchondral bone to a damaged region of the articular surface of a joint. The goal is to provide viable chondrocytes and supporting bone that will be sufficient to maintain the cartilage matrix and thereby relieve pain and reduce further damage to the articular surface of the joint. Alternatives to osteochondral allografting include abrasion chondroplasty, osteotomy and total knee replacement, arthrodesis (fusion) or prosthetic arthroplasty of the ankle.
POLICY
Osteochondral allografting for the treatment of chondral defects of the knee is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Osteochondral allografting for the treatment of all other joints including the patellar and talar joints is considered investigational.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
Policies with similar titles:
MEDICAL APPROPRIATENESS
Osteochondral allografts for the treatment of an individual with chondral defects of the knee are considered medically appropriate if ALL of the following criteria are met:
The individual has a large (10cm2) full thickness chondral defect determined by radiographs, magnetic resonance imaging (MRI), and arthroscopy
ABSENCE of ALL of the following:
Severe obesity with a BMI greater than 35 kg/m2
Unrepaired instability or misalignment of the joint
ADDITIONAL INFORMATION
The literature does not include enough randomized control studies to demonstrate the benefit of using osteochondral allografting for treating any other joint problems except those of the knees. The physician specialty societies and academic medical centers consider allografts reasonable for individuals with full-thickness chondral defects who meet specific criteria. There is some evidence showing the short term efficacy of allografting but there is not enough data to determine the long term results.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (11:2008). Osteochondral autografts and allografts in the treatment of focal articular cartilage lesions (7.01.78). Retrieved February 18, 2009 from BlueWeb. (25 articles and/or guidelines reviewed)
Bugbee, W. D., & Convery, F. R. (1999). Osteochondral allograft transplantation. Clinical Sports Medicine, 18 (1), 67 - 75. (Level 5 Evidence)
Caldwell, P. E., 3rd, & Shelton, W. R. (2005). Indications for allografts. Orthopedic Clinics of North America, 36 (4), 459 - 467. (Level 5 Evidence)
Chu, C. R., Convery, F. R., Akeson, W. H., Meyers, M, & Amiel, D. (1999). Articular cartilage transplantation. Clinical results in the knee. Clinical Orthopedics and Related Research, (360), 159 - 168. (Level 4 Evidence)
Colangeli, M., Donati, D., Benedetti, M., Catani,F., Gozzi, E., Montanari,E., et al. (2007). Total knee replacement versus osteochondral allograft in proximal tibia bone tumours. International Orthopaedics, 31 (6), 823 - 829. (Level 4 Evidence)
EMedicine. (2005, March). Osteochondral ghrafting of articular cartilage injuries. Retrieved February 24, 2009 from http://www.emedicine.com/orthoped/topic595.htm.
Ghazavi, M. T., Pritzker, K. P., Davis, A. M., & Gross, A. E. (1997). Fresh osteochondral allografts for post-traumatic osteochondral defects of the knee. Journal of Bone and Joint Surgery. British Volume, 79 (6), 1008 - 1013. (Level 4 Evidence)
Gross, A., Kim, W., Las Heras, F., Backstein, D., Safir, O., & Pritzker,K. (2008). Fresh osteochondral allografts for posttraumatic knee defects: long-term followup. Clinical Orthopedic Related Research, 466 (8), 1863 - 1870. (Level 4 Evidence)
Hayes. Medical Technology Directory. (2004, April). Meniscal Allograft. Retrieved January 21, 2009 from www.Hayesinc.com/subscribers. (40 articles and/ or guidelines reviewed)
Jeng, C., Kadakia, A., White, K., Myerson, M. (2008). Fresh osteochondral total ankle allograft transplantation for the treatment of ankle arthritis. Foot Ankle International, 29 (6), 554 - 560. (Level 4 Evidence)
Mologne, T. S., Friedman, M. J. (2000). Graft options for ACL reconstruction. The American Journal of Orthopedics, 29 (11), 845 - 853. (Level 5 Evidence)
National Institute for Health and Clinical Excellence. (3, 2006). Mosaicplasty for knee cartilage defects. (162). Retrieved January 29, 2009 from http://www.nice.org.uk/guidance/index.jsp. (6 articles and/ or guidelines reviewed)
National Institute for Health and Clinical Excellence. (4, 2005). Interventional procedure overview of mosaicplasty for knee cartilage defects. Retrieved January 29, 2009 from http://www.nice.org.uk/ip283overview. (6 articles and/ or guidelines reviewed)
Sasha, N., Krywulak, S., Backstein, D., Pressman, A., & Gross, A. E. (2003). Long-term follow-up of fresh tibial osteochondral allografts for failed tibial plateau fractures. Journal of Bone and Joint Surgery American 85 - A Supplement, 2, 33 - 39. (Level 4 Evidence)
University of California at San Diego (UCSD). (2000). Fresh Osteochondral Allografting General Information. Retrieved February 24, 2009 from http://medicine.ucsd.edu/ortho/procedures/allografting.shtml. (Level 5 Evidence)
U.S. Food and Drug Administration. (2005, February). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K043421. Retrieved February 24, 2009 from http://www.fda.gov/cdrh/pdf4/K043421.pdf.
ORIGINAL EFFECTIVE DATE: 5/1/2001
MOST RECENT REVIEW DATE: 7/11/2009
ID_BT
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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