REVIEW REQUEST FOR
Treatment of Osteochondral Defects
Provider Data Collection Tool Based on Medical Policy SURG.00093
Policy Last Review Date: 08/14/2014
Policy Effective Date:
10/14/2014
Provider Tool Effective Date:
Individual’s Name:
Date of Birth:
Insurance Identification Number:
Individual’s Phone Number:
Ordering Provider Name & Specialty:
Provider ID Number:
10/14/2014
Office Address:
Office Phone Number:
Office Fax Number:
Rendering Provider Name & Specialty:
Provider ID Number:
Office Address:
Office Phone Number:
Office Fax Number:
Facility Name:
Facility ID Number:
Facility Address:
Date/Date Range of Service:
Place of Service:
Service Requested (CPT if known):
Outpatient
Home
Inpatient
Other:
Diagnosis Code(s) (if known):
Please complete this General Criteria section before proceeding to the disease specific
criteria sections listed below:
Member height, weight and BMI fields must be provided for all requests:
Member Height:
in
cm Member Weight:
Member BMI:
lbs
kg
Skeletally mature adolescent with documented closure of growth plates or adult
Individual has persistent symptoms of disabling localized knee pain for at least 6 months, which have failed to respond to
conservative treatment
A normal joint space is present
No active infection present
No inflammation or osteoarthritis present in the joint
Stable knee with functionally intact menisci and ligaments and normal alignment. (Corrective procedures, for example,
ligament or tendon repair, osteotomy for realignment, meniscal allograft transplant or repair may be performed in
combination with or prior to transplantation)
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 35
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 (grades 0, 1, 2)
The individual has no “kissing lesions”
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REVIEW REQUEST FOR
Treatment of Osteochondral Defects
Provider Data Collection Tool Based on Medical Policy SURG.00093
Policy Last Review Date: 08/14/2014
Policy Effective Date:
10/14/2014
Provider Tool Effective Date:
10/14/2014
AUTOLOGOUS CHONDROCYTE TRANSPLANTATION (ACT) / AUTOLOGOUS
CHONDROCYTE IMPLANTATION (ACI)
Request is for Autologous chondrocyte transplantation (ACT), also known as autologous chondrocyte implantation (ACI)
(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 square cm (i.e. length x width)** 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 10 mm or less in depth and has failed prior
conservative treatment
Individual has lesions due to osteochondritis dissecans which is associated with a bony lesion of greater than 10 mm in
depth which has undergone corrective bone grafting
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 (trochlear groove of the femur) 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 or magnetic resonance imaging (MRI) examination results detail the size, location and type of osteochondral
defect
The size of the cartilage defect is greater than or equal to 2 squared cm (i.e. length x width)** 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 (trochlear groove of the femur) caused by acute or repetitive trauma
Other (Please list):
Page 2 of 3
REVIEW REQUEST FOR
Treatment of Osteochondral Defects
Provider Data Collection Tool Based on Medical Policy SURG.00093
Policy Last Review Date: 08/14/2014
Policy Effective Date:
10/14/2014
Provider Tool Effective Date:
10/14/2014
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 or magnetic resonance imaging (MRI) examination results detail the size, location and type of osteochondral
defect
The size of the cartilage defect is between 1.0 to 2.5 squared cm (i.e. length x width)** in total area
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 (trochlear groove of the femur) caused by acute or repetitive
trauma
Other (Please list):
OTHER
Request is for Non-autologous mosaicplasty using resorbable synthetic bone filler materials (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):
** Note: Square centimeters (square cm) is equal to the total surface area (length x width). Square cm can be
calculated by multiplying the length in cm by the width in cm.
This request is being submitted:
Pre-Claim
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 the health plan or its
designees 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
Anthem UM Services, Inc., a separate company, is the licensed utilization review agent that performs utilization
management services on behalf of your health benefit plan or the administrator of your health benefit plan.
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