Total Ankle Replacement

Section: Surgery
Effective Date: July 01, 2018
Revised Date: November 14, 2019
Last Reviewed: November 14, 2019

Description

Total ankle replacement, or arthroplasty, involves the surgical removal of a dysfunctional and painful ankle joint and replacement with a prosthetic ankle.

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person’s unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

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

27702

Revision to an existing prosthetic ankle implant may be considered medically necessary when there is infection, inflammatory reaction, mechanical or other complication.

Procedure Codes

27703

  Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 27702

M05.9M05.40M05.49M05.50M05.59M05.70M05.79
M05.80M05.89M05.411M05.412M05.419M05.421M05.422
M05.429M05.431M05.432M05.439M05.441M05.442M05.449
M05.451M05.452M05.459M05.461M05.462M05.469M05.471
M05.472M05.479M05.511M05.512M05.519M05.521M05.522
M05.529M05.531M05.562M05.569M05.571M05.572M05.579
M05.711M05.712M05.719M05.721M05.722M05.729M05.731
M05.732M05.739M05.741M05.742M05.749M05.751M05.752
M05.759M05.761M05.762M05.769M05.771M05.772M05.779
M05.811M05.812M05.819M05.821M05.822M05.829M05.831
M05.832M05.839M05.841M05.842M05.849M05.851M05.852
M05.859M05.861M05.862M05.869M05.871M05.872M05.879
M06.4M06.9M06.00M06.28M06.29M06.30M06.38
M06.39M06.80M06.88M06.89M06.011M06.012M06.019
M06.021M06.022M06.029M06.031M06.032M06.039M06.041
M06.042M06.049M06.051M06.052M06.059M06.061M06.062
M06.042M06.049M06.051M06.052M06.059M06.061M06.062
M06.069M06.071M06.072M06.079M06.211M06.212M06.219
M06.221M06.222M06.229M06.231M06.232M06.239M06.241
M06.242M06.249M06.251M06.252M06.259M06.261M06.262
M06.269M06.271M06.272M06.279M06.311M06.312M06.319
M06.321M06.322M06.329M06.331M06.332M06.339M06.341
M06.342M06.349M06.351M06.352M06.359M06.361M06.362
M06.369M06.371M06.372M06.379M06.811M06.812M06.819
M06.821M06.822M06.829M06.831M06.832M06.839M06.841
M06.842M06.849M06.851M06.852M06.859M06.861M06.862
M06.869M06.871M06.872M06.879M07.671M07.672M07.679
M12.9M12.00M12.08M12.09M12.011M12.012M12.019
M12.021M12.022M12.029M12.031M12.032M12.039M12.041
M12.042M12.049M12.051M12.052M12.059M12.061M12.062
M12.069M12.071M12.071M12.071M12.071M12.571M12.572
M12.579M12.871M12.872M12.879M13.0M13.171M13.172
M13.179M19.90M19.071M19.072M19.079M19.171M19.172
M19.179M19.271M19.272M19.279

Covered Diagnosis Codes for Procedure Code 27703

T84.9XXAT84.50XAT84.51XAT84.52XAT84.53XAT84.54XAT84.59XA
T84.81XAT84.82XAT84.83XAT84.84XAT84.85XAT84.86XAT84.89XA
T84.010AT84.011AT84.012AT84.013AT84.018AT84.019AT84.020A
T84.021AT84.022AT84.023AT84.028AT84.029AT84.030AT84.031A
T84.032AT84.033AT84.038AT84.039AT84.060AT84.061AT84.062A
T84.063AT84.068AT84.069AT84.090AT84.091AT84.092AT84.093A
T84.098AT84.099A

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