Print

Date Printed: May 24, 2018: 11:41 AM

Private Property of Blue Cross and Blue Shield of Florida.
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.

02-99221-15

Original Effective Date: 02/15/10

Reviewed: 04/26/18

Revised: 05/15/18

Subject: Total Ankle Replacement

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.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Update    
           

DESCRIPTION:

Total ankle replacement (TAR), also known as total ankle arthroplasty, is the replacement of an injured or diseased ankle joint with a prosthetic device. TAR has been used as an alternative to ankle arthrodesis (ankle fusion) in patients with medically refractory, end-stage degenerative joint disease from conditions such as rheumatoid arthritis, osteoarthritis, or post-traumatic arthritis.

Ankle arthrodesis involves the removal of the articular surfaces of the ankle joint and the fusion of the tibia bone to the talus bone which limits side-to-side and up & down motion. The goal of TAR is to relieve pain without limiting range of motion, reduce development of arthritis in adjacent joints. Since 2005, several total ankle replacement system designs, including mobile-bearing and fixed-bearing, have received approval from the U.S. Food & Drug Administration (FDA).

POSITION STATEMENT:

Total ankle replacement using an FDA-approved device meets the definition of medical necessity in skeletally mature members with ankle pain that limits activities of daily living, documented failure of at least 6 consecutive months of conservative treatment (such as physical therapy, anti-inflammatory medication, splints or orthotic devices), and ONE of the following conditions:

AND NO evidence of the following:

NOTE: Optimal candidates for total ankle replacement are considered to be older (age older than 50), thin, low-demand individuals with minimal deformity and no functional barriers to participation in a rehabilitation program.

Total ankle replacement is considered experimental or investigational for all other indications. The evidence is insufficient to determine the effects of the technology on health outcomes.

Revision or replacement of the implant, using an FDA-approved device, meets the definition of medical necessity when the device has failed and all medical necessity criteria outlined above (excluding 6 consecutive months of conservative treatment) are met.

BILLING/CODING INFORMATION:

CPT Coding:

27702

Arthroplasty ankle, with implant, total ankle

27703

Arthroplasty, ankle, revision total ankle

ICD-10 Diagnoses Codes That Support Medical Necessity:

M05.071 – M05.079

Felty’s Syndrome, ankle and foot

M05.171 – M05.179

Rheumatoid lung disease with rheumatoid arthritis of ankle and foot

M05.271 – M05.279

Rheumatoid vasculitis with rheumatoid arthritis of ankle and foot

M05.371 – M05.379

Rheumatoid heart disease with rheumatoid arthritis of ankle and foot

M05.471 – M05.479

Rheumatoid myopathy with rheumatoid arthritis of ankle and foot

M05.571 – M05.579

Rheumatoid polyneuropathy with rheumatoid arthritis of ankle and foot

M05.671 – M05.679

Rheumatoid arthritis of ankle and foot with involvement of other organs and systems

M05.771 – M05.779

Rheumatoid arthritis with rheumatoid factor of ankle and foot without organ or systems involvement

M05.871 – M05.879

Other rheumatoid arthritis with rheumatoid factor of ankle and foot

M06.071 – M06.079

Rheumatoid arthritis without rheumatoid factor, ankle and foot

M06.871 – M06.879

Other specified rheumatoid arthritis, ankle and foot

M07.671 – M07.679

Enteropathic arthropathies, ankle and foot

M12.071

Chronic postrheumatic arthropathy [Jaccoud], right ankle and foot

M12.072

Chronic postrheumatic arthropathy [Jaccoud], left ankle and foot

M12.571 – M12.579

Traumatic arthropathy, ankle and foot

M12.871 – M12.879

Other specific arthropathies, not elsewhere classified, ankle and foot

M13.171 – M13.179

Monoarthritis, not elsewhere classified, ankle and foot

M19.071 – M19.079

Primary osteoarthritis ankle and foot

M19.171 – M19.179

Post-traumatic osteoarthritis, ankle and foot

M19.271 – M19.279

Secondary osteoarthritis, ankle and foot

T84.018A-T84.018S

Broken internal joint prosthesis, other site

T84.028A-T84.028S

Dislocation of other internal joint prosthesis

T84.038A-T84.038S

Mechanical loosening of other internal prosthetic joint

T84.068A-T84.068S

Wear of articular bearing surface of other internal prosthetic joint

T84.098A-T84.098S

Other mechanical complication of other internal joint prosthesis

LOINC Codes:

The following information may be required documentation to support medical necessity: Physician history and physical, attending physician treatment plan, progress notes, and treatment notes including documentation of symptoms, failure of at least 6 consecutive months of conservative treatment, and radiology reports (if applicable).

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician visit notes

18733-6

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Treatment plan

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Radiology

18726-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Current, discharge, or administered medications

34483-8

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Reimbursement for the revision or replacement of a total ankle device is made only if the procedure was initially allowed.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

Arthrodesis: The surgical fixation of a joint to promote bone fusion.

Charcot neuroarthropathy: Charcot's joint (neuropathic osteoarthropathy) is a progressive condition affecting the musculoskeletal system and is characterized by joint dislocation, pathologic fractures, and often debilitating deformities.

RELATED GUIDELINES:

Subtalar Arthroereisis, 02-99221-17

OTHER:

None applicable.

REFERENCES:

  1. American College of Foot and Ankle Surgeons™ (ACFAS), Position Statement: Total Ankle Replacement Surgery, July 2016; accessed at acfas.org.
  2. American Orthopaedic Foot & Ankle Society, Position Statement: The Use of Total Ankle Replacement for the Treatment of Arthritic Conditions of the Ankle.Accessed, 2014; accessed at aofas.org.
  3. Barg A, Knupp M, et al, Total ankle Replacement in Patients with Gouty Arthritis, J Bone Joint Surg Am. 2011; 93:357-66.
  4. Barg A, Wimmer MD, Wiewiorski M, et al. Total ankle replacement. Dtsch Arztebl Int. 2015;112(11):177-184.
  5. Besse JL, et al, Total Ankle Arthroplasty in France, Orthopaedics & Traumatology: Surgery & Research (2010 96, 291-303.)
  6. Blue Cross Blue Shield Association, Total Ankle Replacement, 7.01.77, 08/13 (archived 2014).
  7. Bonnin M, et al, The Salto Total Ankle Arthroplasy, Clin Orthop Relat Res, 07/01/10.
  8. ClinicalTrials.gov: Canadian Orthopaedic Foot and Ankle Society Surgical Treatment of Ankle Arthritis Outcome Study, sponsored by Ross Leighton.
  9. ClinicalTrials.gov: Prospective Randomized Evaluation Of A Two And Three Piece Total Ankle Replacement, sponsored by Duke University.
  10. ClinicalTrials.gov: A Randomised, Multi-centre, Non-blinded, Prospective, Parallel Group Trial of Total Ankle Replacement (TAR) Versus Ankle Arthrodesis in Patients With End Stage Ankle Osteoarthritis, Comparing Clinical Outcomes and Cost-effectiveness, sponsored by University College, London.
  11. ClinicalTrials.gov: Total Ankle Replacement for Ankle Arthritis, sponsored by Duke University.
  12. Doets HC, Zurcher AW, Salvage Arthrodesis for Failed Total Ankle Arthroplasty – clinical Outcome and Influence of Method of Fixation on Union Rate in 18 Ankles Followed for 3-12 Years, Acta Orthopaedica 2010; 81(1): 142-147.
  13. Giannini S, et al, Total Ankle Replacement Compatible with Ligament Function Produces Mobility, Good Clinical Scores, and Low Complication Rates, Clin Orthop Relat Res (2010) 468:2746-2753.
  14. Gougoulias N, et al, How Successful are Current Ankle Replacements? Clin Orthop Relat Res (2010) 468: 199-208.
  15. Guyer AJ, Richardson G, Current Concepts Review: Total Ankle Arthroplasty, Foot Ankle Int 2008: 29(2): 256-64.
  16. Karantana A, et al, The Scandinavian Total Ankle Replacement, Clin Orthop Relat Res (2010) 468: 951-957.
  17. Koivu H, Kohonen I, Sipola E, et al, Severe Periprosthetic Osteolytic Lesions After the Ankle Evolutive System Total Ankle Replacement, J Bone Joint Surg Br. 2009 Jul; 91(7): 907-14.
  18. Krause FG, et al, Impact of Complications in Total Ankle Replacement and Ankle Arthrodesis Analyzed with a Validated Outcome Measurement, J Bone Joint Surg Am. 2011; 93:830-9.
  19. 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.
  20. Mann JA, et al, STAR™ Ankle: Long-Term Results, Foot & Ankle International, Vol. 32, No. 5, May 2011.
  21. Saltzman CL, Mann RA, Ahrens JE, et al, Prospective Controlled Trial of STAR Total Ankle Replacement Versus Ankle Fusion: Initial Results, Foot & Ankle International, American Orthopaedic Foot & Ankle Society, 2009.
  22. Schipper ON, Denduluri SK, et al. Effect of Obesity on Total Ankle Arthroplasty Outcomes. Foot Ankle Int. 2016 Jan;37(1):1-7.
  23. Skytta ET, et al, Total Ankle Replacement: A Population-Based Study of 515 Cases from the Finnish Arthroplasty Register, Acta Orthopaedica 2010; 81(1): 114-118.
  24. U.S. Food & Drug Administration (FDA), accessed at fda.gov.
  25. Wood PL, Sutton C, Mishra V, et al, A Randomised, Controlled Trial of Two Mobile-Bearing Total Ankle Replacements, 2009 Journal of bone and Joint Surgery, British Volume, Vol 91-B, Issue 1, 69-74.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 04/26/18.

GUIDELINE UPDATE INFORMATION:

02/15/10

New Medical Coverage Guideline.

12/15/10

Annual review; revised position statement to include medical necessity criteria; updated coding section, reimbursement section and references; related ICD-10 codes added; and formatting changes.

09/15/11

Annual review; position statements maintained, references updated, and formatting changes.

10/15/12

Annual review: position statements maintained and references updated.

10/15/13

Annual review; position statements maintained, program exception section and references updated.

10/15/14

Annual review; position statements maintained and references updated.

05/15/15

Annual review; position statements maintained and references updated.

10/01/15

Revision; ICD9 & ICD10 coding sections updated.

11/01/15

Revision: ICD-9 Codes deleted.

10/01/16

Revision; formatting changes.

05/15/18

Review; description, position statements, coding, and references updated.

Date Printed: May 24, 2018: 11:41 AM