Coverage criteria policies

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Prior authorization is required for total ankle replacement (TAR).

Total ankle replacement (TAR) is generally covered subject to the indications listed below and per your plan documents.

Indications that are covered

TAR is covered when all of the following criteria are met:

1. Skeletally mature person; and
2. Moderate or severe chronic pain with loss of ankle mobility and function that limits activities of daily living; and
3. The condition is due to:
1. Osteoarthritis, or
2. post-traumatic arthritis, or
3. severe inflammatory arthritis / rheumatoid arthritis, and
4. Reports of radiographic studies such as CT, MRI or x-rays are submitted which confirm one of the conditions listed above; and
5. Clinical information documents at least 6 months of specific conservative therapies tried and failed, such as physical therapy, medication, injections, and/or orthotic devices; and
6. No medical contraindications exist, including, but not limited to:
1. Prior infection of the affected joint
2. Severe extremity neuropathy
3. Severe vasculopathy
4. Severely compromised soft tissue envelope

Indications that are not covered

TAR is not covered for any additional indication.

Total ankle replacement involves the surgical removal of a dysfunctional painful ankle joint and its replacement with prosthetic parts. The purpose of total ankle replacement is to relieve pain and restore joint function in patients with medically refractory, end-stage degenerative joint disease resulting from conditions such as osteoarthritis, post-traumatic osteoarthritis, or rheumatoid arthritis.

Arthrodesis is the fusion of a joint. This is an alternative procedure to the total ankle replacement. It does not require prior approval.

Arthroplasty is surgery to relieve pain and restore range of motion by realigning or reconstructing a joint.

Orthosis (plural orthoses) / orthotic – an orthopedic appliance or apparatus used to support, align, prevent, or correct deformities or to improve function of movable parts of the body. Some people with ankle conditions will use orthoses before moving to a surgical alternative.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

References

1. Daniels, T. R., Younger, A. S. E., Penner, M., Wing, K., Dryden, P. J., Wong, H., & Glazebrook, M. (2014). Intermediate-term results of total ankle replacement and ankle arthrodesis. A COFAS multicenter study. The Journal of Bone Joint Surgery, Incorporated.96, 135-42.
2. Daniels, T. R., Mayich, D. J., & Penner, M. J. (2015). Intermediate to long-term outcomes of total ankle replacement with the Scandinavian Total Ankle Replacement (STAR). The Journal of Bone and Joint Surgery, Incorporated. 97, 895-903.
3. ECRI Institute. (2013). Total Ankle Replacement for Treating Degenerative Ankle Disease. Plymouth Meeting, PA: ECRI Institute.
4. Hayes, Inc. Hayes Medical Technology Directory Report. Total Ankle Replacement: A Review of Reviews. Lansdale, PA: Hayes, Inc.; December 2017.
5. Reeves, C.l., Shane, A.M., & Vazales, R. (2017). Current Concepts Regarding Total Ankle Replacement as a Viable Treatment Option for Advanced Ankle Arthritis. Clinics in Podiatric Medicine and Surgery, Volume 34, Issue 4, Pages 515-527.
6. Weisman, M. & Rinaldi, R., Total joint replacement for severe rheumatoid arthritis. In: UpToDate, Maini, R., (Ed), UpToDate, Waltham, MA. (Accessed on May 23, 2018.)

Effective – 1/1/2014; Revised, 6/6/2018; Annual review – 9/2014, 9/2015, 7/2016, 7/2017, 7/2018