Kotlier Jacob L, Lin Eric H, Fathi Amir, Iyer Avinash S, Telang Sahil S, Bolia Ioanna K, Ahmad Aamir, Petrigliano Frank A, Liu Joseph N
Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Cartilage. 2024 Sep 30:19476035241276930. doi: 10.1177/19476035241276930.
The aim of this study is to both quantify and qualify the way insurance companies justify their coverage policies for autologous chondrocyte implantation (ACI) and determine whether these policies align with recent research on the subject.
The top 11 national commercial health insurance payers for ACI were identified. Coverage policy documents were recovered for 8 payers. These documents were examined, and the type of reference and the level of evidence (LOE) were recorded for each applicable reference. Specific coverage criteria for each individual payer were then extracted and assessed for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria.
This study found that the majority of cited references were primary journal articles (86, 58.1%) and that only 30 (20.2%) references were level I or level II evidence. This study also found significant homogeneity among payer coverage criteria. Cited sources inconsistently mentioned specific payer coverage criteria. In addition, payer criteria tended to be poorly supported by current evidence on ACI.
This study demonstrates that commercial insurance payers' coverage policies for ACI poorly cite references, cite a majority of references with low LOE, and cite references which infrequently mention their specific coverage criteria. In addition, payer coverage policies have a high degree of homogeneity and many of their specific criteria are poorly supported by current research on ACI.
本研究旨在量化并定性保险公司为自体软骨细胞植入术（ACI）制定保险覆盖政策的方式，并确定这些政策是否与该主题的最新研究一致。
确定了11家为ACI提供保险的全国性商业健康保险公司。获取了其中8家保险公司的保险覆盖政策文件。对这些文件进行审查，并记录每个适用参考文献的参考文献类型和证据水平（LOE）。然后提取每个保险公司的具体保险覆盖标准，并评估商业保险公司之间的相似性。最后，审查每个保险公司引用的所有参考文献，以确定它们是否提及了具体的保险公司标准。
本研究发现，大多数引用的参考文献是初级期刊文章（86篇，58.1%），只有30篇（20.2%）参考文献为I级或II级证据。本研究还发现保险公司的保险覆盖标准之间存在显著的同质性。引用的资料来源不一致地提及具体的保险公司保险覆盖标准。此外，目前关于ACI的证据对保险公司标准的支持往往不足。
本研究表明，商业保险公司对ACI的保险覆盖政策参考文献引用不佳，大多数引用的参考文献证据水平较低，且引用的参考文献很少提及它们的具体保险覆盖标准。此外，保险公司的保险覆盖政策具有高度同质性，其许多具体标准在目前关于ACI的研究中支持不足。
