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Medical Policy: 07.01.23
Original Effective Date: May 2002
Reviewed: April 2007
Revised:
This policy applies to all products unless specific contract
limitations, exclusions or exceptions apply. Please refer to the member's coverage
manual for benefit availability. Managed care guidelines related to referral authorization,
and precertification of inpatient hospitalization, home health, home infusion and
hospice services apply.
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
Policy:
The total ankle replacement may be considered medically necessary for the following conditions:
- Severe rheumatoid arthritis
- Severe osteoarthritis
- Septic arthritis or post traumatic osteoarthritis
And, when the following criteria are met:
- No evidence of osteoporosis or osteopenia
- Patient with low physical demand
- Unimpaired vascular status
- No immunosuppression
- Unimpaired hindfoot-ankle alignment
Prior approval is recommended. Submit a prior approval now.
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Procedure Codes and Billing
Guidelines:
To report provider services, use appropriate CPT** codes, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- CPT code range 27700 through 27703
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Selected References:
- The Medical Policy Reference Manual (MPRM) developed by the Blue Cross Blue Shield Association Health Management Systems, based on the Technology Evaluation Center (TEC) criteria.
- 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.
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New information or technology that would be relevant for Wellmark to consider when this policy is next reviewed may be submitted to:
Wellmark Blue Cross and Blue Shield
Medical Policy Analyst
Station 304
636 Grand Ave
Des Moines, Iowa 50309
*Prior Approval is recommended for this policy.
**Current Procedural Terminology © 2008 American Medical Association. All Rights Reserved.
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.
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