Total Ankle Replacement*

Medical Policy: 07.01.23 
Original Effective Date: May 2002 
Reviewed: September 2008 
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 27700 Arthroplasty, ankle
  • CPT code 27702 Arthroplasty, ankle; with implant (total ankle)
  • CPT code 27703 Arthroplasty, ankle; revision, total ankle  

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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.
  • 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. 

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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.