Total Ankle Replacement

Policy ID: S-9006-02

Section: Surgery

Effective Date: July 01, 2018

Revised Date: November 08, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: November 15, 2023

Applies To: Commercial and Medicaid Expansion

This policy has been Archived effective January 01, 2024. Click the Archive tab above for more information.

Policy ID: S-9006-02

Section: Surgery

Effective Date: July 01, 2018

Revised Date: November 08, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: November 15, 2023

Archived Date: January 01, 2024

Applies To: Commercial and Medicaid Expansion

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 individual 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 six (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 Code

27702

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

Procedure Code

27703

Diagnosis Codes

Covered Diagnosis Codes for Procedure Code 27702

M05.9

M05.40

M05.49

M05.50

M05.59

M05.70

M05.79

M05.80

M05.89

M05.411

M05.412

M05.419

M05.421

M05.422

M05.429

M05.431

M05.432

M05.439

M05.441

M05.442

M05.449

M05.451

M05.452

M05.459

M05.461

M05.462

M05.469

M05.471

M05.472

M05.479

M05.511

M05.512

M05.519

M05.521

M05.522

M05.529

M05.531

M05.562

M05.569

M05.571

M05.572

M05.579

M05.711

M05.712

M05.719

M05.721

M05.722

M05.729

M05.731

M05.732

M05.739

M05.741

M05.742

M05.749

M05.751

M05.752

M05.759

M05.761

M05.762

M05.769

M05.771

M05.772

M05.779

M05.811

M05.812

M05.819

M05.821

M05.822

M05.829

M05.831

M05.832

M05.839

M05.841

M05.842

M05.849

M05.851

M05.852

M05.859

M05.861

M05.862

M05.869

M05.871

M05.872

M05.879

M06.4

M06.9

M06.00

M06.28

M06.29

M06.30

M06.38

M06.39

M06.80

M06.88

M06.89

M06.011

M06.012

M06.019

M06.021

M06.022

M06.029

M06.031

M06.032

M06.039

M06.041

M06.042

M06.049

M06.051

M06.052

M06.059

M06.061

M06.062

M06.042

M06.049

M06.051

M06.052

M06.059

M06.061

M06.062

M06.069

M06.071

M06.072

M06.079

M06.211

M06.212

M06.219

M06.221

M06.222

M06.229

M06.231

M06.232

M06.239

M06.241

M06.242

M06.249

M06.251

M06.252

M06.259

M06.261

M06.262

M06.269

M06.271

M06.272

M06.279

M06.311

M06.312

M06.319

M06.321

M06.322

M06.329

M06.331

M06.332

M06.339

M06.341

M06.342

M06.349

M06.351

M06.352

M06.359

M06.361

M06.362

M06.369

M06.371

M06.372

M06.379

M06.811

M06.812

M06.819

M06.821

M06.822

M06.829

M06.831

M06.832

M06.839

M06.841

M06.842

M06.849

M06.851

M06.852

M06.859

M06.861

M06.862

M06.869

M06.871

M06.872

M06.879

M07.671

M07.672

M07.679

M12.9

M12.00

M12.08

M12.09

M12.011

M12.012

M12.019

M12.021

M12.022

M12.029

M12.031

M12.032

M12.039

M12.041

M12.042

M12.049

M12.051

M12.052

M12.059

M12.061

M12.062

M12.069

M12.071

M12.571

M12.572

M12.579

M12.871

M12.872

M12.879

M13.0

M13.171

M13.172

M13.179

M19.90

M19.071

M19.072

M19.079

M19.171

M19.172

M19.179

M19.271

M19.272

M19.279

Covered Diagnosis Codes for Procedure Code 27703

T84.9XXA

T84.50XA

T84.51XA

T84.52XA

T84.53XA

T84.54XA

T84.59XA

T84.81XA

T84.82XA

T84.83XA

T84.84XA

T84.85XA

T84.86XA

T84.89XA

T84.010A

T84.011A

T84.012A

T84.013A

T84.018A

T84.019A

T84.020A

T84.021A

T84.022A

T84.023A

T84.028A

T84.029A

T84.030A

T84.031A

T84.032A

T84.033A

T84.038A

T84.039A

T84.060A

T84.061A

T84.062A

T84.063A

T84.068A

T84.069A

T84.090A

T84.091A

T84.092A

T84.093A

T84.098A

T84.099A

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-14-2019 Archived, review by Evicore.

Internal Medical Policy Committee 11-19-2020 Annual Review

Internal Medical Policy Committee 11-23-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-29-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 11-15-2023 Archived- Effective January 01, 2024

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

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