OATS Aetna

PLAIDMAN

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I am not sure I should post this here....but....

I had Aetna deny OATS procedure stating that any osteochondral lesion larger than 1 cm is considered experimental. The lesion my doc repaired was about 3 cm.

I can find no information on this. Is a payor allowed to just deem something experimental? It has a CPT code, which has to be approved by the AMA, AHA, FDA, aunties, uncles, cats, dogs ect...............

Anyone had this problem?? How do I fight it?
 

nyyankees

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I am not sure I should post this here....but....

I had Aetna deny OATS procedure stating that any osteochondral lesion larger than 1 cm is considered experimental. The lesion my doc repaired was about 3 cm.

I can find no information on this. Is a payor allowed to just deem something experimental? It has a CPT code, which has to be approved by the AMA, AHA, FDA, aunties, uncles, cats, dogs ect...............

Anyone had this problem?? How do I fight it?
go on the aetna website. i believe there is a policy that explains when + when not this procedure can get paid. As far as experimental..YES..insurance co's can deny as experimental when they deem not enough clinical data is available to support the CPT code. Aetna is the best at this..
 

josephmglick

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from Aetna's website:

Clinical Policy Bulletin:
Osteochondral Autografts (Mosaicplasty, OATS)

Number: 0637

Policy

I.Aetna considers osteochondral autografts medically necessary for repair of small (less than or equal to 1 cm2) focal chondral defects of articulating cartilage of the leg (ankle, hip, knee) that are causing significant symptoms that have not been relieved by appropriate non-surgical therapies.

II.Aetna considers all of the following procedures experimental and investigational because their effectiveness has not been established:

A.Autologous osteochondral mosaicplasty in the treatment of articular cartilage defects/lesions;
B.Hybrid autologous chondrocyte implantation/osteochondral autograft transfer system (OATS) technique for the treatment of osteochondral defects;
C.OATS in the treatment of articular cartilage defects/lesions;
D.Osteochondral autograft transplantation to repair chondral defects of the elbow, shoulder, or other joints.

Note: Osteochondral autograft using a single small plug for a small lesion is eligible for coverage. On the other hand, mosaicplasty and the OATS procedure entail broad resurfacing of larger areas with multiple plugs of autogenous articular cartilage. These procedures are considered experimental and investigational, thus ineligible for coverage.
 
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Also, just FYI, CPTs 27412, 27415, and 27416 are not covered by Medicare. In Washington state we have to get preauthorization for these codes for Medicaid patients sa well.

Arthroscopic codes 29866, 29867 and 29868 are not covered by Medicare OR Medicaid.
 
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