Knee Problem/Pain
Surgical Services (All)

The patient is a college student who was evaluated for knee pain and found to have a large osteochondral lesion of his lateral femoral condyle. He underwent an initial arthroscopy for removal of a loose body, but continued to have pain and significant functional limitations. He underwent a second surgery which involved using an autograft (cadaver bone and cartilage) to replace the injured area of bone and cartilage. At issue is whether this procedure is medically necessary.

The health plan's determination is overturned. The Osteochondral Knee Allograft is medically necessary for this patient. Large areas of osteochondral injury such as this patient had (greater than 50% of the articular surface of the lateral condyle) are not effectively treated by lesser procedures such as marrow stimulation or allograft from the intercondylar notch area. While it is not clear that this procedure will allow return to activity at the highest level for the majority of patients, it is considered more likely to improve symptoms in the short term and to delay the progression to degenerative arthritis in the long term. It was medically necessary for this patient.