Kotlier Jacob L, Fathi Amir, Ong Meng-Yung, Feingold Cailan L, Lin Eric H, Freshman Ryan D, Bolia Ioanna K, Petrigliano Frank A, Liu Joseph N
Department of Orthopaedic Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, CA, USA.
Orthopaedic Surgery, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
Cartilage. 2025 Mar 28:19476035251329223. doi: 10.1177/19476035251329223.
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by current evidence on MAT.ConclusionThis study demonstrates that insurance coverage policies for MAT frequently use outdated references or cite references inappropriately.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.
目的
探讨半月板同种异体移植（MAT）的保险覆盖标准在政策文件中是否有充分依据，以及这些标准是否代表了该手术适应症的当前研究和专家共识。
设计
确定了美国11家主要的全国性商业医疗保险支付方对MAT的支付情况。通过谷歌搜索来确定支付方的覆盖政策。政策文件中引用的参考文献按参考文献类型进行分类，并对证据水平（LOE）进行审查。然后提取每个支付方的具体覆盖标准并进行比较，以评估商业支付方之间的相似性。最后，检查所有引用的参考文献，以确定它们是否支持每个特定支付方政策中规定的覆盖标准。
结果
11家支付方中有7家有可获取的覆盖政策。本研究发现，大多数引用的参考文献是初级期刊文章（20篇，占57.1%），并且绝大多数引用的参考文献（27篇，占77.1%）是IV级证据。在这7家支付方中，只有两家（信诺保险 = 8篇，HCSC = 19篇）引用的文献超过6篇。支付方之间的覆盖标准具有高度同质性。引用的文献并未始终支持特定支付方的覆盖标准。支付方的标准也往往是随意的，且缺乏关于MAT的当前证据的充分支持。
结论
本研究表明，MAT的保险覆盖政策经常使用过时的参考文献或不恰当地引用参考文献。此外，这些政策未能反映该手术适应症的当前研究和共识。
