Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Total ankle replacement may be considered medically necessary for treatment of debilitating end-stage ankle arthritis when ALL of the following indications are met:
- The patient is skeletally mature (skeletal maturity implies radiographic closure of the epiphyseal growth plates and cessation of vertical growth); and
- There is moderate to severe ankle (tibiotalar) pain that significantly limits daily activity; and
- At least 6 months of conservative treatment (such as anti-inflammatory medication, physical therapy, splints or orthotic devices as indicated) has been tried and has failed to provide improvement; and
- An FDA-approved device is used; and
- At least ONE of the following indications must also be present:
- Arthritis in adjacent joints (i.e., subtalar or midfoot); or
- Severe arthritis of the contralateral ankle; or
- Arthrodesis (fusion) of the contralateral ankle; or
- Inflammatory (e.g., rheumatoid) arthritis
Total ankle replacement is considered not medically necessary when the above indications are not met.
Total ankle replacement is contraindicated, and therefore, considered not medically necessary when any of the following are present:
- Extensive avascular necrosis of the talar dome; or
- Comprised bone stock or soft tissue (including skin and muscle); or
- Severe malalignment (e.g., greater than 15 degrees) not correctable by surgery; or
- Active ankle joint infection; or
- Peripheral vascular disease; or Charcot neuroarthropathy.
Procedure Codes
