What are the Chances of MACI Approval in the United States? A Deep Dive into the Insurance Authorization Data.

ObjectiveTo describe recent trends in US MACI (autologous cultured chondrocytes on porcine collagen membrane) insurance approval rates, including the impact of defect location and the number of defects.DesignMyCartilageCare case management team provides insurance prior authorization support for potential MACI patients through Vericel Corporation, the manufacturer of MACI. Data from insurance claims from 2021 to 2022 were assessed for non-military patients aged 17 to 55 years. Insurance outcomes were summarized, with approval defined as pre-authorization or pre-determination for the MACI procedure being secured prior to the initiation of treatment or cases where an estimate of coverage was provided prior to the initiation of treatment, respectively.ResultsA total of 5,158 cases were identified. In total, 87.7% of MACI cases were approved on initial submission, 9.4% were approved on appeal, 2.4% were not appealed, and 0.5% were denied after appeal. A total of 51.4% of cases included a patella defect, with similar rates of approval: 87.4% approved on initial submission, 9.6% approved on appeal, 2.5% not appealed, 0.5% denied after appeal. 29.9% contained more than one defect which were approved at similar rates: 87.1% approved on initial submission, 10.2% approved on appeal, 2.3% not appealed, and 0.5% denied after appeal.ConclusionsMACI claims in the knee cartilage repair treatment algorithm are broadly supported by US third-party payers, with nearly 88% of all knee cartilage patients obtaining insurance approval on their initial submission and 97% of patients obtaining approval in total following appeal of initially denied claims. This is consistent across all groups including patella, non-patella, single, and multiple-defect cases.