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Author Topic: Insurance Approval for Allograft  (Read 2614 times)

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Offline BezProblemów

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Insurance Approval for Allograft
« on: March 07, 2017, 04:15:20 AM »
For those who dabble in the art of the allo...

I'm looking at an osteochondral allograft on my patella in the future.  I found out that my insurance company (Blue Cross Blue Shield of Illinois) lists "inadequate response to prior surgery" as one of the prerequisites for authorization of an allograft.  It's crazy to me that my insurance requires me to have a scope procedure done that won't really help me just to authorize the actual procedure I need. 

Has anyone had an allograft authorized with no prior knee surgeries?  My OS says that he has never had someone get approval for an allograft without first having a staging scope done.

Also, how long did it take for you to get approval for an allograft?

Did your insurance refuse to authorize an allograft?  Did you doctor appeal and do a peer-to-peer review?  Great success?


Offline BezProblemów

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Re: Insurance Approval for Allograft
« Reply #1 on: March 16, 2017, 01:07:47 AM »
Well I have agreed to a staging scope that will pave the way to get the osteochondral allograft approved.  However, I was browsing BCBS of IL's medical policy manual this evening, because that's what I call fun, and found this zinger:

"Osteochondral autografting or allografting for joints other than the knee is considered experimental, investigational and/or unproven, including but not limited to the patellar (knee cap) and talar (ankle)."

So now I don't know what to think.  My scope is on the 21st.  Now it looks like the allograft might not be authorized since it's on my patella.

The maddening part is that the top of the page says:
"Osteochondral allografting may be considered medically necessary as a technique to repair full-thickness chondral defects of the knee caused by acute or repetitive trauma when other cartilage repair techniques (e.g., microfracture, osteochondral autografting or autologous chondrocyte implantation) would be inadequate due to the size, location, or depth of the lesion."

And then it goes on to quote a bunch of studies that show good results on the patella...but they still consider the patellar procedure experimental.   :-\

Offline dal_knee

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Re: Insurance Approval for Allograft
« Reply #2 on: March 16, 2017, 01:36:16 AM »
It's nutty isn't it.

I believe you'll be ok for approval, as long as you've tried non-surgical options like physical therapy, anti-inflammatories, bracing etc.  Or had a prior surgery to treat the OCD, that hasn't worked well. 
2007 - partial medial meniscectomy
2010 - full thickness chondral defect & adjacent subchondral edema MFC.   Direct result of stupid partial mensicectomy from 2007.
2014 - Subchondroplasty, chondroplasty, unauthorized 2nd partial medial meniscectomy.
2015 - partial failure of subchondroplasty.

Offline willrunagain

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Re: Insurance Approval for Allograft
« Reply #3 on: March 16, 2017, 02:17:18 PM »
Bez-

I wouldn't stress too much.  Dr. Farr is really good at getting insurance companies to pony up.  He has written many articles on how to get approval for patella defects.  It only took him two weeks to get my insurance on board.

Offline BezProblemów

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Re: Insurance Approval for Allograft
« Reply #4 on: March 19, 2017, 02:45:29 AM »
Thanks.  I wrote Dr. Farr's office; they wrote me back and said that the language I posted above is very typical of insurance companies.  It may require a few back and forths, but they were fairly confident that OCA for the patella could be authorized after my staging scope.

Offline BezProblemów

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Re: Insurance Approval for Allograft
« Reply #5 on: September 17, 2017, 01:20:32 AM »
Just to close out this thread - I was able to get pre-authorization for the allograft after my scope.















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