Ankle Arthroplasty Form

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Ankle Arthroplasty, Total Medical Guideline

Service: Ankle Arthroplasty, Total (Total Ankle Replacement)

PUM 250-0009

Medical Guideline Committee Approval Q3-2025 Effective Date 03/01/2026

Related Medical Guidelines:

• Non-covered Services and Procedures Medical Guideline

Coverage for Total Ankle Replacements may vary across plans. Refer to the member’s benefit plan document for coverage details.

Description:

Total Ankle Arthroplasty (TAA), also known as Total Ankle Replacement (TAR), is a surgical procedure for arthritis in which the ankle joint is replaced with a man-made (prosthetic) implant.

Note: It is the responsibility of the surgeon to choose a United States Food and Drug Administration (FDA) approved prosthetic implant with proven safety and efficacy, and the one most appropriate for the patient. WPS does not cover non-FDA approved devices.

Indications of Coverage:

A. Total ankle arthroplasty with an FDA approved prosthetic implant is considered medically necessary in a skeletally mature individual when BOTH criteria (1 and 2 below) are met:

1. The individual has arthritis of the ankle with moderate to severe pain and loss of function or mobility of the ankle joint to be treated.

2. The individual has completed a two-week trial of non-steroidal anti-inflammatory (NSAID) drugs (or other pain medication if NSAIDS are not tolerated/indicated).

   B. Total Ankle Arthroplasty revision is considered medically necessary for individuals with a failed total ankle prosthesis (e.g., loosening / malposition/ periprosthetic fracture/ or infection), provided that the original replacement was an FDA-approved implant.

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Limitations of Coverage:

Benefit Limitations: Please note that in listing services or examples, when we say “this includes,” it is not our intent to limit the description to that specific list. When we do intend to limit a list of services or examples, we state specifically that the list “is limited to.”

A. Review health plan and endorsements for exclusions and prior authorization or benefit requirements.

B. If requested/used for a condition or diagnosis other than is listed in the Indications of Coverage, it will be considered experimental, investigational, and unproven to affect health outcomes.

C. If requested/used for a condition or diagnosis that is listed in the Indications of Coverage; but the criteria are not met, it will be considered not medically necessary.

D. Total Ankle Arthroplasty will be considered experimental, investigational, and unproven to affect health outcomes when ANY of the following (1 through 15) is present:

1. Active or prior deep infection in the ankle joint or adjacent bones

2. Avascular necrosis of the talus

3. Charcot joint of the affected ankle

4. Hindfoot or forefoot malalignment preventing plantigrade foot.

5. Insufficient ligament support that cannot be corrected with soft tissue stabilization.

6. Peripheral Arterial Disease affecting the lower extremity targeted for surgery.

7. Neuromuscular disease resulting in lack of normal muscle function about the affected ankle.

8. Poor skin and soft tissue quality about the surgical site.

9. Prior surgery or injury that has adversely affected ankle bone quality.

10. Psychiatric problem(s) that hinder(s) adequate cooperation during the perioperative period.

11. Severe osteoporosis, osteopenia, or other conditions resulting in poor bone quality, as this may result in inadequate bony fixation.

12. Significant mal alignment of the knee joint.

13. Skeletal maturity not yet reached.

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14. Subtalar arthroereisis (subtalar joint implantation).

    E. Intraoperative surgical navigation or robotic assistance for ankle arthroplasty are deemed integral to the surgical procedure.

    F. Viscosupplementation injections (e.g., Hyaluronan, Hyalgan and hylan-GF-20, Synvisc) are considered experimental, investigational, and unproven to affect health outcomes. Synvisc is not approved by the FDA for use in the ankle.

    G. Zilretta (triamcinolone acetonide extended-release injectable suspension) injections are considered not medically necessary.

    Documentation Required:

    • Standard Written Order (SWO), prescribed by a qualified healthcare provider concerning the member’s diagnosis.
    • Medical record information (including continued need/use if applicable) and medical necessity. Office notes documenting the physical findings, pain, functional/mobility limitations due to ankle, diagnosis, conservative treatment history, and history of ankle injury and/or ankle surgery. • Correct coding for the item/service that meets all the coding guidelines.

    Disclaimer: This guideline is for informational purposes only and does not constitute medical advice, plan authorization, an explanation of benefits, or a guarantee of payment. Benefit plans vary in coverage and some plans may or may not provide coverage for all services listed in this guideline. Coverage decisions are subject to all terms and conditions of the applicable benefit plan, including specific exclusions and limitations, and to applicable state and federal law. Some benefit plans administered by the organization may not utilize Medical Affairs medical guideline in all their coverage determinations. Contact customer services as listed on the member card for specific plan, benefit, and network status information.

    Medical guidelines are based on constantly changing medical science and are reviewed annually and subject to change. The organization uses tools developed by third parties, such as the evidence-based clinical guidelines developed by MCG to assist in administering health benefits. This medical guideline and MCG guidelines are intended to be used in conjunction with the independent professional medical judgment of a qualified health care provider. To obtain additional information about MCG, email medical.policies@wpsic.com. Coverage of all services is subject to medical necessity and services deemed experimental, investigational, and/or unproven are therefore not considered medically necessary under the terms of the clinical guidelines and will not be covered.

    Total Ankle Arthroplasty is considered medically necessary only when indicated per the most current medical references and specialty society guidelines, such as MCG, NCCN, etc.

    State mandates, laws or benchmark supersede this medical guideline.

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Guideline Review History:

Implemented 10/01/15, 10/01/16, 10/01/17, 10/01/18, 10/01/19, 06/01/20, 06/01/21, 03/01/22, 03/01/23, 03/01/24, 03/01/26 Medical Guideline Committee Approval 06/12/15, 06/16/17, 06/15/18, 06/21/19, 01/31/20, 02/25/21, 02/24/22, 02/23/23, 02/28/24, Q3 2025 Reviewed

06/03/16, 06/15/18*, 06/21/19, 01/31/20, 02/25/21, 02/24/22, 02/23/23, 02/28/24, Q3 2025 Revised 06/15/18, 06/21/19, 01/31/20, 02/25/21, 02/24/22 Developed 06/12/15

*Note: Guideline name changed from Total Ankle Arthroplasty (Total Ankle Replacement) to Ankle Arthroplasty, Total (Total Ankle Replacement)

Approved by the Medical Director

Codes: The following codes for treatments and procedures applicable to this document are included below for informational purposes.

Code Description 20985 COMPUTER-ASSISTED SURGICAL NAVIATIONAL PROCEDURE FOR MUSCULOSKELETAL PROCEDURES, IMAGE-LESS (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) 27700 ARTHROPLASTY, ANKLE; 27702 ARTHROPLASTY, ANKLE; WITH IMPLANT (TOTAL ANKLE) 27703 ARTHROPLASTY, ANKLE; REVISION, TOTAL ANKLE 0SRF0J9 REPLACEMENT OF RIGHT ANKLE JOINT WITH SYNTHETIC SUBSTITUTE, CEMENTED, OPEN APPROACH 0SRF0JA REPLACEMENT OF RIGHT ANKLE JOINT WITH SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH 0SRF0JZ REPLACEMENT OF RIGHT ANKLE JOINT WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0SRG0J9 REPLACEMENT OF LEFT ANKLE JOINT WITH SYNTHETIC SUBSTITUTE, CEMENTED, OPEN APPROACH 0SRG0JA REPLACEMENT OF LEFT ANKLE JOINT WITH SYNTHETIC SUBSTITUTE, UNCEMENTED, OPEN APPROACH

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0SRG0JZ REPLACEMENT OF LEFT ANKLE JOINT WITH SYNTHETIC SUBSTITUTE, OPEN APPROACH 0SWF0JZ REVISION OF SYNTHETIC SUBSTITUTE IN RIGHT ANKLE JOINT, OPEN APPROACH 0SWG0JZ REVISION OF SYNTHETIC SUBSTITUTE IN LEFT ANKLE JOINT, OPEN APPROACH C1713 ANCHOR/SCREW FOR OPPOSING BONE-TO-BONE OR SOFT TISSUE-TO-BONE (IMPLANTABLE) C1776 JOINT DEVICE (IMPLANTABLE)