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Date Printed: October 17, 2017: 04:23 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

02-99221-17

Original Effective Date: 09/15/12

Reviewed: 09/28/17

Revised: 10/15/17

Subject: Subtalar Arthroereisis

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
           
   
           

DESCRIPTION:

Flexible flatfoot is a common disorder, anatomically described as excessive pronation during weight bearing due to anterior and medial displacement of the talus. It may be congenital in nature or it may be acquired in adulthood due to posterior tibial tendon dysfunction, which in turn may be caused by trauma, overuse, and inflammatory disorders, among others. Symptoms include dull, aching and throbbing, cramping pain, which in children may be described as growing pains. Additional symptoms include refusal to participate in athletics or walking long distances. Conservative treatments include orthotics or shoe modifications. Surgical approaches for painful flatfoot deformities include tendon transfers, osteotomy, and arthrodesis. Arthroereisis with a variety of implant designs has also been investigated.

Arthroereisis (also referred to as arthrosis) is the limitation of excessive movement across a joint. Subtalar arthroereisis (STA) or extrosseous talotarsal stabilization is designed to correct excessive talar displacement and calcaneal eversion by reducing pronation across the subtalar joint. Extraosseous talotarsal stabilization is also being evaluated as a treatment of talotarsal joint dislocation. It is performed by placing an implant in the sinus tarsi, which is a canal located between the talus and the calcaneus. Several implants have been cleared for marketing by the U.S. Food and Drug Administration (FDA) through the 510(k) process.

POSITION STATEMENT:

Subtalar arthroereisis is considered experimental or investigational for all indications. The evidence is insufficient to determine the effects of the technology on health outcomes.

BILLING/CODING INFORMATION:

CPT Coding:

28725

Arthrodesis; subtalar (investigational)

29907

Arthroscopy, subtalar joint, surgical; with subtalar arthrodesis (investigational)

0335T

Extra-osseous subtalar joint implant for talotarsal stabilization (investigational)

HCPCS Coding:

S2117

Arthroereisis, subtalar (investigational)

REIMBURSEMENT INFORMATION:

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products: The following Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date: Noncovered Services (L33777) located at fcso.com.

DEFINITIONS:

Calcaneus: The largest tarsal bone situated at the lower and back part of the foot, forming the heel.

Flatfoot: A condition in which one or more of the arches of the foot have flattened out.

Talus: A small bone that sits between the calcaneus (heel bone) and the tibia and fibula to form the ankle joint.

RELATED GUIDELINES:

Total Ankle Replacement, 02-99221-15

OTHER:

Other names or key words used to report subtalar arthroereisis and/or subtalar implants include, but are not limited to:

Note: The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

Arthroereisis, Subtalar

Extraosseous Talotarsal Stabilization (EOTTS)

HyProCure® Subtalar Implant System

ProStop Plus™

SubFix™ Implant

Subtalar MBA®

Talar-FIT™

REFERENCES:

  1. American Academy of Orthopedic Surgeons (AAOS), AAOS Now- Treatment for Pediatric Pes Planus Debated, May 2011. Accessed at aaos.org.
  2. Blue Cross Blue Shield Association Medical Policy Reference Manual, 7.01.104 Subtalar Arthroereisis, 08/17.
  3. Centers for Medicare & Medicaid Services (CMS), MLN Fact Sheet: Medicare Podiatry Services:Information for Medicare Fee-For-Service Health Care Professionals, accessed at cms.gov 09/18/14. Graham ME, et al, Extraosseous Talotarsal Stabilization Using HyProCure┬« in Adults: A 5-year Retrospective Follow-up, The Journal of Foot & Ankle Surgery 51 (2012) 23–29.
  4. First Coast Service Options, Inc. (FCSO) Local Coverage Determination (LCD): Noncovered Services (L33777); accessed at fcso.com 08/10/17.
  5. Graham ME, et al, Radiographic Evaluation of Navicular Position in the Sagittal Plane- Correction Following an Extraosseous Talotarsal Stabilization Procedure, The Journal of Foot & Ankle Surgery 50 (2011) 551-557.
  6. Harris EJ, Vanore JV, Thomas JL, et al. Clinical Practice Guideline Pediatric Flatfoot Panel: American College of Foot and Ankle Surgeons (ACFAS). Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg. Nov-Dec 2004;43(6):341-373.
  7. Koning PM, Heesterbeek PJ, et al, Subtalar arthroereisis for pediatric flexible pes planovalgus: fifteen years experience with the cone-shaped implant. J Am Podiatr Med Assoc. 2009 Sep-Oct;99(5):447-53.
  8. Lawton CD, Butler BA, et al, Total ankle arthroplasty versus ankle arthrodesis-a comparison of outcomes over the last decade. J Orthop Surg Res. 2017 May 18;12(1):76.
  9. Lee MS, Vanore JV, Thomas JL, et al. Clinical Practice Guideline Adult Flatfoot Panel: American College of Foot and Ankle Surgeons (ACFAS). Diagnosis and treatment of adult flatfoot. J Foot Ankle Surg. Mar-Apr 2005;44(2):78-113.
  10. National Institute for Clinical Excellence (NICE). Sinus Tarsi Implant Insertion for Mobile Flatfoot: Interventional Procedure Guidance 305. 2009; accessed at nice.org.uk/guidance.
  11. U.S. Food and Drug Administration (FDA), 510(k) Premarket Notification Database, accessed at accessdata.fda.gov.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/28/17.

GUIDELINE UPDATE INFORMATION:

09/15/12

New Medical Coverage Guideline.

10/15/13

Annual Review; position statement maintained, program exception and references updated.

01/01/14

Annual HCPCS update. Added code 0335T.

11/15/14

Annual review; no change to position statement; references updated.

11/01/15

Revision: ICD-9 Codes deleted.

11/15/15

Annual review; position statement maintained; references updated.

10/15/17

Review; investigational position maintained; guideline description, coding, and references updated.

Date Printed: October 17, 2017: 04:23 PM