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Medical Policy: 07.01.23
Original Effective Date: May 2002
Reviewed: September 2011
Revised: February 2010
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
The ankle joint is a comparatively small joint and it must withstand weight bearing and torque. These two factors make the total ankle joint replacement challenging. The main surgical alternative to total ankle replacement is arthrodesis. While both procedures are designed to reduce pain, the total ankle replacement is also intended to improve function.
Although primary osteoarthritis in the ankle joint is rare, rheumatoid arthritis and posttraumatic arthritis commonly involve the ankle and can cause severe pain and disability. Non operative treatment of ankle arthritis includes oral nonsteroidal anti-inflammatory medication, analgesics, and use of a brace. When this fails, ankle arthrodesis remains the "gold standard" for post traumatic arthritis, especially in young patients or those who place a high physical demand on their ankle joint.
Total ankle replacement is contraindicated under the following conditions:
- Neuroarthropathic degenerative joint disease (Charcot's ankle)
- Active or recent infection
- Avascular necrosis of talus
- Severe benign joint hypermobility syndrome (Ehlers-Danlos syndrome)
- Non reconstructible malalignment
- Severe soft tissue problems around ankle including severe vascular disease
- Sensory or motor dysfunction of the foot to leg
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Prior Approval:
Not applicable
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Policy:
Total ankle replacement using a FDA-approved device may be considered medically necessary in skeletally mature patients with moderate to severe ankle (tibiotalar) pain that limits daily activity and who have the following conditions:
- Severe rheumatoid arthritis; or
- Severe osteoarthritis; or
- Septic arthritis or post traumatic osteoarthritis; or
- Arthritis in adjacent joints (i.e., subtalar or mid foot); or
- Severe arthritis in the contralateral ankle; or
- Arthrodesis of the contralateral ankle
And, when the following criteria are met:
- No evidence of:
- osteoporosis, or
- osteopenia, or
- Charcot neuroarthropathy, or
- active ankle joint infection, or
- extensive avascular necrosis of the talar dome
- Patient with low physical demand
- Unimpaired vascular status
- No immunosuppression
- Unimpaired hindfoot-ankle alignment
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Procedure Codes and Billing Guidelines:
To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- 27700 Arthroplasty, ankle
- 27702 Arthroplasty, ankle; with implant (total ankle)
- 27703 Arthroplasty, ankle; revision, total ankle
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Selected References:
- Saltzman CL. Perspective on total ankle replacement. Foot and Ankle Clinics 2000;5(4):761-774.
- Saltzman CL, McCliff TE, Buckwalter JA, Brown TD. Total ankle replacement revisited. Journal of Orthopaedic and Sports Physical Therapy2000;30(2):56-67.
- Lachiewicz PF. Total ankle arthroplasty: indications, techniques and results. Orthopedic Review 1994;23(4):315-320.
- Pyevich MT, Saltzman CL, Callaghan JJ, Alvine FG.Total ankle arthroplasty: a unique design. Two to twelve-year follow-up. Journal of Bone and Joint Surgery 2000Aug;82-A(8):1205.
- Saltzman CL Amendola A, Anderson R, et al. Surgeon training and complications in total ankle arthroplasty. Foot Ankle Int. 2003 Jun:24(6):514-8.
- Myerson MS, Mroczek K. Perioperative complications of total ankle arthroplasty, Foot Ankle Int. 2003 Jan;24(1): 17-21.
- SooHoo NF, Zingmond DS, Ko CY. Comparison of reoperation rates following ankle arthrodesis and total ankle arthroplasty. J Bone Joint Surg Am. 2007 Oct;89(10):2143-9.
- Haddad SL, Coetzee JC, Estok R, Fahrbach K, Banel D, Nalysnyk L. Intermediate and long-term outcomes of total ankle arthroplasty and ankle arthrodesis. A systematic review of the literature. J Bone Joint Surg Am. 2007 Sep;89(9):1899-905.
- ECRI Institute. Total Ankle Replacement System or Degenerative Ankle Disease. Plymouth Meeting (PA): ECRI Institute; 2008 Nov 11. 8 p. [ECRI hotline response]. Also available: http://ecri.org.
- Easley ME, Adams SB, Hembree C et al. Results of Total Ankle Arthroplasty: Current Concepts Review. J Bone Joint Surg AM. 2011; 93:1455-68. doi: 10.2106/JBJSJ.00126.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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