Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Physician 1: The patient is a 55-year-old male with bilateral ankle arthritis. He underwent left ankle debridement is 2002. The patient has been evaluated by multiple providers who have recommended ankle arthroplasty over fusion. The Health Plan indicates there is insufficient scientific evidence supporting the safety and efficacy of the requested procedure. Therefore, the Health Plan has determined the requested procedure is considered experimental. The standard of care for the surgical treatment of severe osteoarthritis of the ankle joint is fusion therapy. This is clearly and thoroughly supported in the literature. Additionally, the results of ankle fusion are very good for pain relief and restoration of function. Total ankle arthroplasty is not currently the standard of care for severe osteoarthritis as there is not sufficient peer-reviewed data establishing the long-term efficacy of ankle arthroplasty. Therefore, I have determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. As such, the Health Plans denial should be upheld.Physician 2: The patient is a 55-year-old male with severe ankle arthritis. He has failed conservative treatment. The patient has three treatment options: live with the pain, ankle fusion or ankle arthroplasty.  The patient is unable to tolerate the pain and has attempted numerous conservative measures to alleviate his discomfort, all of which have failed. In addition, the patient has tried an ankle brace, which replicates a fusion; this also caused pain. Furthermore, the patient indicates he would be unable to perform his job if he underwent a fusion. Therefore, the patient has requested authorization and coverage for ankle arthroplasty. The Health Plan has denied this request.Prior to end stage, ankle arthritis is treated with conservative measures including medications, bracing, etc. At end stage, the most common procedure has been ankle fusion; however, certain patients benefit from ankle arthroplasty. The only viable treatment alternative for this patient is total ankle arthroplasty. Total ankle arthroplasty is an accepted alternative procedure to ankle fusion. The patients providers have provided appropriate reasoning as to why this patient should be treated with replacement as opposed to fusion. The information provided indicates that replacement is the more appropriate procedure for this patient.Based upon the information set forth above, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Physician 3: The patient is a 55-year-old male with severe disabling bilateral ankle arthrosis. He has been examined by multiple physicians and has undertaken his own research in terms of his treatment options. The patients profession is that of a helicopter pilot. He indicates it is absolutely essential he maintain some degree of ankle motion in order to continue his current employment. For this reason, the patient has decided to purse ankle arthroplasty. The Health Plan has denied coverage for ankle arthroplasty on the basis it is considered experimental for treatment of the patients condition.Total ankle arthroplasty has been performed worldwide for approximately 30 years. Though results of total ankle arthroplasty described in the literature have been mixed, the Buechel-Pappas ankle appears to be quite successful according to several reports. This patient is an appropriate candidate for total ankle arthroplasty. The patients alternative is ankle fusion, which often results in transfer arthritis of the subtalar joint and other joints of the foot. Therefore, I have determined that the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be overturned.