MCG Criteria
I’m 32 years old and suffered a knee injury that damaged cartilage tissue. After an MRI and being referred a few times I got a doctor who said the best option was a Matrix Autologous Chondrocyte Implantation. It’s a two step procedure with an arthroscope to clean up the knee, remove floating bodies, and harvest tissue to grow in a lab. First part was done in February and what off without a hitch. They had already set up my next surgery where they implant the grown tissue onto the missing chondrocyte lesion. As the date got closer it got weird and insurance during preauthorization denied the procedure. Doctor went to set up a peer to peer and without even 30 seconds on phone the external doctor said nope the plan won’t cover this it’s experimental, click. The plan is self funded and the Third Part administrator is owned by the health care system I work at. I now have tissue from my body chilling in a lab which is ready to be grown and a knee with restrictions. I asked the insurance company for information and they use MCG criteria but they blocked off when this procedure is clinically indicated. They pay a $100,000 to have access to this information so they said they can choose what I can and can’t see, but told me it’s no problem because I would fit the criteria. I have found insurance companies like Aetna and United health have their criteria readily available and I seem to be a match and they deem it a medically necessary procedure. I had to reach out to the Labor Department because a self funded plan is not susceptible to Wisconsin Legislature. I have emailed back and forth with HR and they say talk to insurance and insurance says talk to HR but the plan won’t cover an FDA cleared procedure because they don’t think it’s proven long term efficacy. My doctor mostly deals with professional athletes so I seem to be just a Jo schmo and stuck unless I get a new job. I’m just amazed that the healthcare system I work for that employs this doctor just going to leave me in the dust.
submitted by /u/MasterMarinater
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