Fathi Amir, Kotlier Jacob L, Telang Sahil S, Patel Vishal S, Bolia Ioanna K, Biedermann Brett M, Cruz Christian A, Lin Eric H, Petrigliano Frank A, Liu Joseph N
Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
Cartilage. 2024 Aug 30:19476035241276859. doi: 10.1177/19476035241276859.
The purpose of this study is to analyze how the largest insurance companies support their medical necessity policies regarding osteochondral allograft transplantation (OCA) and to determine whether the literature they cite in their policies is of a high level of evidence (LOE).
The 10 largest national health insurance companies were identified. Each payer was contacted via phone or email to obtain their coverage policy regarding OCA. For each policy, the medical necessity criteria were recorded, and all cited references were screened. For all references applicable to OCA, the LOE was recorded, and each reference was screened to determine whether they mentioned the specific criteria reported in the policies.
The medical policies for 6 of the 10 national health insurance companies were identified. These 6 policies cited a collective total of 102 applicable references. Most of these studies were an LOE of IV ( = 58, 56.9%) and an LOE of V ( = 18, 17.6%). There were similarities amongst the medical necessity criteria between different commercial payers; however, most criteria were poorly supported by the cited literature.
Our results demonstrate that commercial insurance companies utilize studies that are of a low LOE when justifying their medical necessity criteria. Moreover, these cited studies infrequently support or mention the commercial payers' criteria. Future studies should continue to explore how well-supported insurance policies are with the goal of potentially increasing access and authorization for well-supported treatment modalities.
本研究旨在分析最大的几家保险公司如何支持其关于同种异体骨软骨移植（OCA）的医疗必要性政策，并确定其政策中引用的文献是否具有高水平的证据等级（LOE）。
确定了全国最大的10家健康保险公司。通过电话或电子邮件联系每个付款方，以获取其关于OCA的保险政策。对于每项政策，记录医疗必要性标准，并筛选所有引用的参考文献。对于所有适用于OCA的参考文献，记录其证据等级，并对每个参考文献进行筛选，以确定它们是否提及了政策中报告的具体标准。
确定了10家全国健康保险公司中6家的医疗政策。这6项政策共引用了102篇适用的参考文献。这些研究大多证据等级为IV（=58，56.9%）和证据等级为V（=18，17.6%）。不同商业付款方之间的医疗必要性标准存在相似之处；然而，大多数标准在引用文献中缺乏有力支持。
我们的结果表明，商业保险公司在证明其医疗必要性标准时使用的是证据等级较低的研究。此外，这些引用的研究很少支持或提及商业付款方的标准。未来的研究应继续探索保险政策得到充分支持的程度，目标是潜在地增加对有充分支持的治疗方式的获取和批准。
