Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty

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

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by current evidence on MAT.ConclusionThis study demonstrates that insurance coverage policies for MAT frequently use outdated references or cite references inappropriately.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.

Evaluating the References of Insurance Policies for Computer-Assisted Navigation in Total Knee Arthroplasty Compared With the American Academy of Orthopaedic Surgeons Clinical Practice Guideline

BACKGROUND

This study aimed to investigate the quality and quantity of sources cited by insurance payers for computer-assisted navigation (CAN) in total knee arthroplasty (TKA) and to compare these sources with those cited by the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guideline (CPG).

MATERIALS AND METHODS

References were included from insurance payer policies on CAN that discussed the use of CAN in TKA, while every reference from the AAOS CPG for surgical navigation in TKA was included.

RESULTS

Fifty-four unique articles from insurance payers met criteria, with 68.5% being primary journal articles and 18.5% being reviews. The quality of cited studies was relatively evenly distributed between level of evidence (LOE) I/II (42.6%) and LOE III and below (50.0%). The 14 references cited in the AAOS CPG were 100% primary articles and 100% LOE I/II. Only 16.3% of cited insurance references were AAOS CPG articles. Nine of the 14 AAOS CPG studies were not cited by any of the insurance payer policies.

CONCLUSION

Compared with the AAOS CPG, insurance policies cited older articles with lower LOE. We recommend continued updating of the AAOS CPG and insurance policies as more research into the use of CAN in TKA is published. [Orthopedics. 2025;48(1):8-11.].

Commercial Insurance Coverage Criteria for Autologous Chondrocyte Implantation Poorly Reflect Current Research

OBJECTIVE

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.

DESIGN

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.

RESULTS

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.

CONCLUSIONS

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.

Evidence Guiding Commercial Payer Coverage Criteria for Total Ankle Arthroplasty

Background

Total ankle arthroplasty (TAA), first developed as an alternative to ankle arthrodesis, has become an increasingly popular management option for end-stage ankle arthritis. Prior studies have shown commercial insurance payers base their coverage criteria on limited and low level of evidence research. This study aims to quantify and describe the evidence insurance companies use to support TAA coverage policies.

Methods

The top 11 national commercial health insurance payers for TAA were identified. A google search was performed to identify payer coverage policies. Policy documents were examined and cited references were classified by type of reference as well as reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted. Criteria were compared to assess for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria.

Results

Six of the 11 payers had accessible coverage policies. The majority of cited references were primary journal articles (145, 60.9%) and the majority of references cited (179, 75.2%) were level III or level IV evidence. We found significant homogeneity in coverage criteria among payers. In addition, cited sources inconsistently mentioned specific payer coverage criteria.

Conclusion

This study demonstrates that commercial insurance payers rely on the relatively low level of currently available scientific evidence when formulating coverage policies for TAA use and adopt criteria that have not been thoroughly analyzed in the literature. More high level of evidence research is needed to help clinicians and insurance companies further refine indications for TAA so that patients who might benefit from the procedure are adequately covered.

Level of Evidence

Level IV, review.