Commercial Insurance Payer Coverage Criteria for Meniscal Allograft Transplantation Poorly Reflect Modern Indications for the Procedure.

Abstract

ObjectiveTo investigate whether insurance coverage criteria for meniscal allograft transplantation (MAT) are sufficiently supported in the policy documentation and whether these criteria represent current research and expert consensus on indications for the procedure.DesignThe top 11 United States (US)-based national commercial health insurance payers for MAT were identified. A Google search was performed to identify payer coverage policies. Cited references within policy documents were classified by type of reference and reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted and compared to assess for similarities among commercial payers. Finally, all references cited were examined to determine whether they supported the coverage criteria stated by policies for each specific payer.ResultsSeven of the 11 payers had accessible coverage policies. This study found that the majority of cited references were primary journal articles (20, 57.1%) and that the vast majority of references cited (27, 77.1%) were level IV evidence. Of the seven payers, only two (Cigna = 8, HCSC = 19) cited more than six sources. There was a high degree of homogeneity in coverage criteria among payers. The sources cited did not consistently support specific payer coverage criteria. Payer criteria also tended to be arbitrary and poorly supported by current evidence on MAT.ConclusionThis study demonstrates that insurance coverage policies for MAT frequently use outdated references or cite references inappropriately. In addition, these policies fail to reflect current research and consensus on indications for the procedure.