Commercial Insurance Payer References Do Not Substantiate Coverage Denial of Stem Cell Therapy for Orthopedic Applications.

Background: Regenerative therapies are being studied for use in several orthopedic conditions, but as these approaches gain in popularity, insurance coverage denials have become a critical issue for patients, physicians, hospitals, and payers.

Purpose: We sought to analyze the references commercial payers use to support their policies denying coverage for orthopedic applications of mesenchymal stem cell (MSC) therapy.

Methods: We reviewed the policies regarding orthopedic applications of MSC therapy of the top 11 national commercial health insurance payers, 5 of which had publicly accessible policies. Supporting references were screened by title and/or abstract. Selected references were categorized by type of reference and reviewed for level of evidence (LOE), anatomic location under investigation, and type and source of MSC. Studies that were not LOE I or II were defined as low LOE. Finally, efficacy of the therapy was recorded in a binary fashion.

Results: To support denial of coverage for MSC use in orthopedics, the 5 insurance companies cited a majority of level IV evidence, despite available and pertinent level I and II studies on the subject. The knee was the most common anatomic location investigated and, along with the spine, the most likely to report favorable outcomes with MSC use. Primary journal articles and studies with higher LOE were more likely to report favorable outcomes than review articles or those with lower LOE.

Conclusion: This analysis of 5 commercial insurance payers' policies found that they substantiate their denial of coverage for MSC use in orthopedic applications primarily with low-level evidence. It also found that higher-level evidence, when cited, often points to the potential efficacy of MSCs.