Appeal type: Experimental/Investigational
Decision: Overturned

Diagnosis: Right ankle pain.
Treatment: Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702))
The insurer denied the Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)).
The denial is upheld.

The patient is a male. Radiographs of the right ankle and right foot obtained  demonstrated loss of tibiotalar joint space anteriorly.  There were large marginal osteophytes arising from the anterior tibiotalar joint.  Findings were consistent with severe degenerative changes at the tibiotalar joint.

An office visit note dated stated that the patient had chronic right ankle instability.  The patient was one year status post a right ankle ligament reconstruction.  Patient reported that his pain at times was severely limiting.  Patient's symptoms had been worsening over the past few months.  Patient had tried bracing.  Patient did not like to take anti-inflammatories.  Physical examination of the right foot demonstrated a mild cavus foot with a neutral to slight valgus heel.  There was 10 degrees of ankle dorsiflexion and 30 degrees of plantarflexion.  There was no instability on examination.  There were mild restrictions of subtalar joint range of motion.  There was a palpable dorsalis pedis pulse.  There were no sensory deficits.  Radiographs of the right foot and ankle demonstrated a cavus foot with end-stage osteoarthritis of the ankle.  There was also osteoarthritis of the subtalar joint.  The patient was diagnosed with right ankle osteoarthritis.  Treatment options were discussed to include further bracing with use of an Arizona brace versus total ankle arthroplasty versus fusion.  Plan was for a total ankle arthroplasty.

No, the health plan should not cover the Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)).

Per Official Disability Guidelines: Ankle and Foot: Arthroplasty, Ankle (TAR) for Ankle and Foot Conditions, Criteria for Total Ankle Replacement (TAR) Surgery:

TAR is supported in well selected patients; however because of the increased risks associated with this procedure, appropriate candidates should meet ALL of the following:

1) Age > 50 with end-stage ankle osteoarthritis, post-traumatic arthritis and rheumatoid arthritis, experiencing daily moderate-to-severe pain, loss of mobility, and poor ankle function.
2) Completion of > 6 months conservative treatment, including medications, physical therapy, and bracing
3) Uncompromised vascular perfusion and soft-tissue ankle coverage
4) Normal bone stock, without talar dome avascular necrosis
5) No prior history of ankle arthrodesis on the same ankle
6) Absence of any active regional bone/joint infection
7) Ankle malalignment > 15 degrees, not correctable at surgery
8) BMI <30
9) Absence of major deformity above or below ankle
10) No history of diabetes, peripheral vascular disease, or Charcot neuroarthropathy
11) No psychiatric conditions that could hinder adequate perioperative cooperation
12) Workers must have a light duty job to return to (PDL [physical demand level] medium and heavy laborers should only consider arthrodesis)

The patient does not meet the Official Disability Guidelines indications for the requested total ankle arthroplasty. There is no documentation of a completion of more than six months of conservative treatment, including medications, physical therapy, and bracing.

Per AIM Specialty Health Clinical Appropriateness Guidelines Musculoskeletal Program Appropriate Use Criteria: Small Joint Surgery, Ankle Arthritis Total Ankle Arthroplasty:

Total ankle arthroplasty may be considered medically necessary in skeletally mature patients when ALL of the following criteria are met:

Radiographic confirmation of advanced/end-stage arthritis of the tibiotalar joint
Significant pain and functional impairment due to arthritis of the ankle that persists after at least 6 months of conservative management
Documentation of adequate lower extremity vascular perfusion (e.g., strong, palpable pedal pulses)
Device is FDA [Food and Drug Administration] approved
At least ONE of the following is present:
Moderate-to-severe adjacent joint (subtalar or midfoot) arthritis
Inflammatory arthritis

The patient does not meet the AIM Specialty Health Clinical Appropriateness Guidelines Musculoskeletal Program Appropriate Use Criteria: Small Joint Surgery Ankle Arthritis Total Ankle Arthroplasty indications for the requested total ankle arthroplasty. There is no documentation of a failure of at least six months of conservative care. There is no documentation of moderate-to-severe adjacent joint (subtalar or midfoot) arthritis.

No, the Surgery (right ankle total arthroplasty/total ankle replacement (CPT 27702)) is not likely to be more beneficial for the enrollee than any available standard therapy.

The requested therapy would not be considered medically appropriate without documentation of a failure of an adequate trial of conservative care.