TURNINGPOINT CLINICAL POLICY

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1 1 P a g e NOTE: For services provided on December 3, 2018 and after, Horizon Blue Cross Blue Shield of New Jersey ( Horizon BCBSNJ ) has contracted with TurningPoint Healthcare Solutions, LLC to conduct Prior Authorization and Medical Necessity Determination reviews for certain Orthopedic services ( the Program ) for members enrolled in Horizon BCBSNJ s fully insured plans. The criteria and guidelines included here apply to these members. Click here to access Horizon BCBSNJ s medical policy criteria and guidelines that apply to Horizon BCBSNJ s members in self-insured plans or plans that DO NOT participate in the Program. Policy Number: OR-1030-HZN Policy Name: Ankle Arthrodesis Common Name: Ankle Fusion Definition: Ankle fusion is a type of surgery done to fuse the bones of the ankle into one piece to relieve pain from arthritis or joint deformity. I. Criteria for Inclusion Ankle fusion is considered medically necessary for any of the following: A. Open approach when ALL of the following are met: 1. Fusion is indicated for one of the following: a. Radiographic evidence of end-stage ankle arthritis or deformity due to: i. Primary osteoarthritis or posttraumatic arthritis due to dislocation and/or fracture of ankle or talus; or ii. Inflammatory or infectious process (i.e. septic or rheumatoid arthritis, gout, hemophilic arthropathy, posttraumatic infection causing arthritis); or iii. Neurological or muscular disorders or conditions (i.e. poliomyelitis, Charcot-Marie- Tooth, stroke causing paralysis, Charcot arthropathy, equinus contracture); or b. Fusion is being done as a salvage procedure for failed total ankle arthroplasty; and 2. Documentation of pain relief with a mobilization device; and 3. Documentation of failure of at least 3 months of non-operative treatment, using an appropriate combination of: a. Orthotics b. Medications c. Injections d. Weight reduction as appropriate; i. For patients with BMI 30-35, medical record must document weight discussion ii. For patients with BMI 35-40, medical record must document plan for weight loss iii. BMI > 40 is a contraindication for ankle arthrodesis e. Physical therapy; and 4. Age between 15 and 55 (young patients must have documented closure of growth plates) B. Arthroscopic approach when the criteria are met for open ankle fusion and there is minimal ankle joint deformity (less than 15 degrees of varus or valgus in coronal plane), or when there is a higher risk of wound complications.

2 II. Criteria for Exclusion A. Ankle fusion is considered not medically necessary when the above criteria is not met, or when any of the following is present: 1. Concomitant arthritis of the subtalar joint 2. Smoking within 2 months prior to surgery 3. Insufficient bone quality or quantity 4. Peripheral vascular disease or poor soft tissue quality due to lymphedema, venous disease, uncontrolled diabetes, or other conditions 5. Peripheral or diabetic neuropathy B. For persons with significant co-morbidities or complications, the medical record must contain documentation of the risk/benefit of ankle arthrodesis III. Device Considerations A. Only implants with FDA approval are considered to be medically appropriate IV. Surgical Considerations A. Pre-Operative Considerations: 1. Preoperative care planning needs may include: a. Routine preoperative evaluation. b. Preoperative treatment, procedures, and stabilization, including: i. Ruling out sources of infection, including dental and lower urinary tract infections ii. Dental prophylaxis as indicated iii. Patient education c. Preoperative discharge planning as appropriate. B. Intra-Operative Considerations: 1. Antibacterial wipes 2. Antibacterial nasal swab C. Post-Operative & Inpatient Considerations: 1. Diagnostic test scheduling and completion, including: a. Limb x-ray postoperatively b. Lower extremity Doppler study 2. Treatment and procedure scheduling and completion, including: a. IV antibiotics b. DVT prophylaxis c. Transfusion d. Pain management 3. Consultation, assessment, and other services scheduling and completion, including: a. Physical therapy b. Occupational therapy 2 P a g e

3 3 P a g e c. Gait training 4. Monitoring patient's status for deterioration and comorbid conditions; key items include: a. Neurovascular status D. Discharge Planning & Considerations 1. Assessment of needs and planning for care, including: a. Develop treatment plan (involving multiple providers as needed). b. Evaluate and address preadmission functioning as needed. c. Evaluate and address patient or caregiver preferences as indicated. d. Identify skilled services needed at next level of care, with specific attention to: i. Medication management, adherence instruction, and side effects assessment ii. Neurovascular status assessment iii. Pain management iv. Wound or dressing management e. Evaluate and address psychosocial status issues as indicated. 2. Early identification of anticipated discharge destination; options include: a. Home, considerations include: i. Access to follow-up care ii. Home safety assessment. iii. Self-care ability, if appropriate. b. Caregiver need, ability, and availability c. Post-acute skilled care or custodial care, as indicated. 3. Transition of care plan complete, which may include: a. Patient and caregiver education complete. a. Medication reconciliation completion includes: i. Compare patient's discharge list of medications (prescribed and over-the-counter) against physician's admission or transfer orders. ii. Assess each medication for correlation to disease state or medical condition. iii. Report medication discrepancies to prescribing physician, attending physician, and primary care provider, and ensure accurate medication order is identified. iv. Provide reconciled medication list to all treating providers. v. Confirm that patient, family, or caregiver can acquire medication. vi. Educate patient, family, and caregiver. Provide complete medication list to patient, family, or caregiver. Confirm that patient, family, or caregiver understands importance of presenting personal medication list to all providers at each care transition, including all physician appointments. Confirm that patient, family, or caregiver understands reason, dosage, and timing of medication (eg, use "teach-back" techniques). b. Plan communicated to patient, caregiver, and all members of care team, including: i. Inpatient care and service providers ii. Primary care provider iii. All post-discharge care and service providers

4 c. Post-discharge appointment plans made as needed, which may include: i. Primary care provider ii. Anticoagulation monitoring iii. Orthopedic surgeon iv. Rehabilitation therapy services v. Specialists for management of comorbid conditions vi. Other d. Post-discharge testing and procedure plans made, which may include: i. Laboratory testing ii. Other e. Referrals made for assistance or support, which may include: i. Financial, for follow-up care, medication, and transportation ii. Community services iii. Smoking cessation counseling or treatment iv. Other f. Medical equipment and supplies coordinated (ie, delivered or delivery confirmed) which may include: i. Ambulation devices (eg, cane, crutches, walker) ii. Antiembolic or compression stockings iii. Syringes and needles for subcutaneous injections iv. Wound care supplies V. Length of Stay Considerations A. Goal length of stay: not available B. Facility type criteria: not available VI. Coding Services may be Medically Necessary when criteria are met and below coding is used A. CPT Arthrodesis, ankle, open Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis B. HCPCS No HCPCS codes C. ICD-10 Procedure No ICD-10 Procedure codes D. ICD-10 Diagnosis All diagnoses 4 P a g e

5 References 1. Yasui Y, Hannon CP, Seow D, Kennedy JG. Ankle arthrodesis: A systematic approach and review of the literature. World Journal of Orthopedics. 2016;7(11): doi: /wjo.v7.i Abidi NA, Gruen GS, Conti SF. Ankle arthrodesis: Indications and techniques. Journal of the American Academy of Orthopaedic Surgeons.2000;8(3): Boc SF, Norem ND. Ankle arthrodesis. Clinics in Podiatric Medicine and Surgery. 2012;29(1): doi: /j.cpm Mendicino SS, Kreplick AL, Walters JL. Open ankle arthrodesis. Clinics in Podiatric Medicine and Surgery. 2017;34(4): doi: /j.cpm Hutchinson B. Arthroscopic ankle arthrodesis. Clinics in Podiatric Medicine and Surgery. 2016;33(4): doi: /j.cpm Nihal A, Gellman RE, Embil JM, Trepman E. Ankle arthrodesis. Foot and Ankle Surgery. 2008;14:1-10. doi: /j.fas Wheeless CR. Ankle Arthrodesis. [online] Wheeless' Textbook of Orthopaedics. Available at: [Accessed 18 Jan. 2018]. 8. Werner BC, Burrus MT, Looney AM, Park JS, Perumal V, Cooper MT. Obesity is associated with increased complications after operative management of end-stage ankle arthritis. Foot & Ankle International. 2015;36(8): doi: / P a g e

6 Regulatory Data Policy Number/Name: OR-1030 Initial Approval and Effective Date: 1/19/2018 Reviewed Dates: 1/19/2018, 7/23/2018 All Approval Dates: 1/19/2018, 7/23/2018 Approval Authority: Utilization Management Committee Business Owner: Utilization Management Applicable lines of business: All Board approval, if appropriate: N/A Approval Signature: On file URAC Standards: State Requirements: CMS/Federal Requirements: Corresponding policies: 6 P a g e