REVIEW REQUEST FOR
Treatment of Osteochondral Defects of
The Knee and Ankle
Provider Data Collection Tool Based on Medical Policies 7.01.78 SURG.00093
Policy Last Review Date: 12/2011; 11/17/11
Policy Effective Date: 1/1/2012; 01/11/2012
Provider Tool Effective Date: 03/14/2012
.
Individual’s Name:
Date of Birth:
Insurance Identification Number/HCID:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Date/Date Range of Service:
Service Requested (CPT/HCPCS if known):
Office Fax Number:
Place of Service:
Home
Outpatient
Inpatient
Other:
Diagnosis (ICD-9) if known):
Please complete this General Criteria section before proceeding to the disease specific
criteria section listed below:
Member height, weight, and BMI fields must be provided for all requests:
Member Height ______ in
cm
Member Weight: __________
Member BMI: _______
lbs
kg
Individual is 15-50 years of age
Individual has persistent symptoms of disabling localized knee pain for at least 6 months, which have failed to respond to
conservative treatment
An intact meniscus is present
A normal joint space is present
No active infection present
No inflammation or osteoarthritis present in the joint
Stable knee with normal alignment
Individual is willing and able to comply with post-operative weight-bearing restrictions and rehabilitation
No history of cancer in the bones, cartilage, fat or muscle of the affected limb
Body Mass Index (BMI) is less than or equal to 30
The lesion is discrete, single, and unipolar (involving only one side of the joint)
The lesion is largely contained with near normal surrounding articular cartilage and articulating cartilage (grade 0,1,2)
The individual has no “kissing lesions”
AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACT)/ AUTOLOGOUS
CHONDROCYTE IMPLANTATION (ACI)
Request is for autologous chondrocyte transplantation (ACT), also known as autologous chondrocyte implantation (ACI)
of: (check all that apply)
To treat cartilaginous defects of the knee
To treat cartilaginous defects of the ankle (talus)
Other (please list): _______________________
Individual has had an inadequate response to prior surgical therapy to correct the defect
The size of the cartilage defect is greater than or equal to 1.5 cm squared in total area
Individual has no known history of allergy to the antibiotic Gentamicin
Individual has no known sensitivities to bovine cultures
The defect involves only the cartilage and NOT the subchondral bone
Individual has osteochondritis dissecans which is associated with a bony defect of less than 7 mm in depth and has failed
prior conservative treatment
Individual has osteochondritis dissecans which is associated with a bony defect of less than 7 mm in depth which has
undergone corrective bone grafting and six months post op period to allow for healing of the cone underlying the defect
Individual’s condition involves a focal, full thickness, (grade III or IV) isolated defect involving the weight bearing surface
of the medial or lateral femoral condyles or trochlear region caused by acute or repetitive trauma
Other (please list): _______________________________________________________
OSTEOCHONDRAL ALLOGRAFT TRANSPLANTATION
Request is for osteochondral allograft transplantation: (Check all that apply)
To treat cartilaginous defects of the knee
To treat cartilaginous defects of the ankle (talus)
Other (please list): ______________________________________
Arthroscopic examination results detail the size, location, and type of the defect
The size of the cartilage defect is greater than or equal to 2 cm squared in total area
Individual’s condition involves a focal, full thickness, (grade III or IV) isolated defect of the weight bearing surface of the
medial or lateral femoral condyles or trochlear region cause by acute or repetitive trauma
Other (please list): ______________________________________________
OSTEOCHONDRAL AUTOGRAFT
TRANSPLANTATION(OATS)/AUTOLOGOUS MOSAICPLASTY
Request is for osteochondral autograft transplantation (OATS) or autologous Mosaicplasty: (check all that apply)
To treat cartilaginous defects of the knee
To treat cartilaginous defects of the ankle (talus)
Other (please list): ______________________________________
Arthroscopic examination results detail the size, location, and type of the defect
The size of the cartilage defect is between 1.0 to 2.5 cm squared in total area
Individual’s condition involves a focal, full thickness, (grade III or IV) isolated defect of the weight bearing surface of the
medial or lateral femoral condyles or trochlear region cause by acute or repetitive trauma
Other (please list): ______________________________________________
OTHER
Request is for Non-autologous mosaicplasty using resorbable synthetic bone filler material (including but not limited to
plugs and granules) to repair osteochondral defects of the knee or ankle
Request is to use minced articular cartilage (whether synthetic, allograft or autograft) to repair osteochondral defects of the
knee or ankle
Other (please list): ___________________________________________________
This request is being submitted:
Pre-Claim
Page 2 of 3
Post–Claim. If checked, please attach the claim or indicate the claim number
I attest the information provided is true and accurate to the best of my knowledge. I understand that Anthem may perform a
routine audit and request the medical documentation to verify the accuracy of the information reported on this form.
_____________________________________________________________
Name and Title of Provider or Provider Representative Completing Form and Attestation (Please Print)*
Date
*The attestation fields must be completed by a provider or provider representative in order for the tool to be accepted
Page 3 of 3