299 Form

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Medical Policy Subtalar Arthroereisis Table of Contents • Policy: Commercial • Coding Information
• Information Pertaining to All Policies
• Policy: Medicare • Description
• References
• Authorization Information • Policy History

Policy Number: 299

BCBSA Reference Number: 7.01.104 (For Plan internal use only) NCD/LCD: NA Related Policies
N/A Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity
Medicare HMO BlueSM and Medicare PPO BlueSM Members

Subtalar arthroereisis is INVESTIGATIONAL.

Prior Authorization Information
Inpatient • For services described in this policy, precertification/preauthorization IS REQUIRED for all products if the procedure is performed inpatient.
Outpatient • For services described in this policy, see below for products where prior authorization might be required if the procedure is performed outpatient.

Outpatient Commercial Managed Care (HMO and POS) This is not a covered service. Commercial PPO and Indemnity This is not a covered service. Medicare HMO BlueSM This is not a covered service. Medicare PPO BlueSM This is not a covered service. CPT Codes / HCPCS Codes / ICD Codes The following codes are included below for informational purposes. Inclusion or exclusion of a code does not constitute or imply member coverage or provider reimbursement. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage as it applies to an individual member.

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Providers should report all services using the most up-to-date industry-standard procedure, revenue, and diagnosis codes, including modifiers where applicable.

The following codes are included below for informational purposes only; this is not an all-inclusive list.

The following HCPCS code is considered investigational for Commercial Members: Managed Care (HMO and POS), PPO, Indemnity, Medicare HMO Blue and Medicare PPO Blue: HCPCS Codes HCPCS codes: Code Description S2117 Arthroereisis, subtalar

Description Subtalar arthroereisis has been performed for more than 50 years, with a variety of implant designs and compositions. The Maxwell-Brancheau Arthroereisis implant is the most frequently reported, although other devices such as the HyProCure, subtalar arthroereisis peg, and Kalix are also described in the medical literature. The Maxwell-Brancheau Arthroereisis implant is described as reversible and easy to insert, with the additional advantage that it does not require bone cement. In children, insertion of the Maxwell-Brancheau Arthroereisis implant may be offered as a stand-alone procedure, although children and adults often require adjunctive surgical procedures on bone and soft tissue to correct additional deformities. Summary Arthroereisis is a surgical procedure that purposely limits movement across a joint. Subtalar arthroereisis or extraosseous talotarsal stabilization is designed to correct excessive talar displacement and calcaneal eversion by reducing pronation across the subtalar joint. Extraosseous talotarsal stabilization is also being evaluated as a treatment of talotarsal joint dislocation. It is performed by placing an implant in the sinus tarsi, which is a canal located between the talus and the calcaneus. For individuals who have flatfoot who receive subtalar arthroereisis, the evidence includes single-arm observational studies, systematic reviews of observational data, and a small nonrandomized controlled trial comparing subtalar arthroereisis with lateral column calcaneal lengthening. Relevant outcomes are symptoms, functional outcomes, and quality of life. The small nonrandomized comparative trial (N=24 feet) is considered preliminary, and interpretation of the observational evidence is limited by the use of adjunctive procedures in addition to subtalar arthroereisis, creating difficulties in determining the extent to which each modality contributed to the outcomes. Another limitation of the published data is the lack of long-term outcomes, which is of particular importance because the procedure is often performed in growing children. Also, some studies have reported high rates of complications and implant removal. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. For individuals who have talotarsal joint dislocation who receive subtalar arthroereisis, the evidence consists of 1 prospective single-arm study of talotarsal stabilization using HyProCure. Relevant outcomes are symptoms, functional outcomes, and quality of life. Although improvements in pain and function were observed, the current evidence on the use of subtalar arthroereisis for treatment of talotarsal joint dislocation is insufficient to draw conclusions about treatment efficacy with certitude. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome. Policy History Date Action 6/2025 Annual policy review. Summary and references updated. Policy statements unchanged. 6/2024 Annual policy review. References updated. Policy statements unchanged.

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5/2024 Clarified coding information 6/2023 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2022 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2021 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 6/2020 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 5/2019 Annual policy review. Description, summary, and references updated. Policy statements unchanged. 11/2015 Annual policy review. New references added. 6/2014 Updated Coding section with ICD10 procedure and diagnosis codes, effective 10/2015. 11/2011-4/2012 Medical policy ICD 10 remediation: Formatting, editing and coding updates.
No changes to policy statements.
6/2011 Reviewed - Medical Policy Group – Orthopedics, Rehabilitation and Rheumatology. No changes to policy statements. 1/1/2011 New policy describing ongoing non-coverage.
Information Pertaining to All Blue Cross Blue Shield Medical Policies Click on any of the following terms to access the relevant information: Medical Policy Terms of Use Managed Care Guidelines Indemnity/PPO Guidelines Clinical Exception Process Medical Technology Assessment Guidelines

References

1. Galán-Olleros M, Del Baño Barragán L, Figueroa MJ, et al. Outcomes of the "Calcaneo-stop" procedure for treating symptomatic flexible flatfoot in children: A systematic review and meta-analysis of 2394 feet. Foot Ankle Surg. Oct 2024; 30(7): 535-545. PMID 38714453
2. Metcalfe SA, Bowling FL, Reeves ND. Subtalar joint arthroereisis in the management of pediatric flexible flatfoot: a critical review of the literature. Foot Ankle Int. Dec 2011; 32(12): 1127-39. PMID 22381197
3. Chong DY, Macwilliams BA, Hennessey TA, et al. Prospective comparison of subtalar arthroereisis with lateral column lengthening for painful flatfeet. J Pediatr Orthop B. Jul 2015; 24(4): 345-53. PMID 25856275
4. Silva S, Tavernini T, Bruschi A, et al. Calcaneo-stop for paediatric idiopathic flexible flatfoot: High functional results and return to sport in 644 feet at mid-term follow-up. J Exp Orthop. Jan 2025; 12(1): e70182. PMID 39980608
5. Graham ME, Jawrani NT, Chikka A. Extraosseous talotarsal stabilization using HyProCure® in adults: a 5-year retrospective follow-up. J Foot Ankle Surg. 2012; 51(1): 23-9. PMID 22196455
6. Moraca G, Martinelli N, Bianchi A, et al. Subtalar arthroereisis with metallic implant is a safe and effective treatment for pediatric patients with symptomatic flexible flatfeet. A 10-year clinical and radiographic follow-up. Foot Ankle Surg. Jan 2025; 31(1): 31-37. PMID 38972783
7. Vedantam R, Capelli AM, Schoenecker PL. Subtalar arthroereisis for the correction of planovalgus foot in children with neuromuscular disorders. J Pediatr Orthop. 1998; 18(3): 294-8. PMID 9600551
8. Nelson SC, Haycock DM, Little ER. Flexible flatfoot treatment with arthroereisis: radiographic improvement and child health survey analysis. J Foot Ankle Surg. 2004; 43(3): 144-55. PMID 15181430
9. Needleman RL. A surgical approach for flexible flatfeet in adults including a subtalar arthroereisis with the MBA sinus tarsi implant. Foot Ankle Int. Jan 2006; 27(1): 9-18. PMID 16442023

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10. Cicchinelli LD, Pascual Huerta J, García Carmona FJ, et al. Analysis of gastrocnemius recession and medial column procedures as adjuncts in arthroereisis for the correction of pediatric pes planovalgus: a radiographic retrospective study. J Foot Ankle Surg. 2008; 47(5): 385-91. PMID 18725117
11. Lucaccini C, Zambianchi N, Zanotti G. Distal osteotomy of the first metatarsal bone in association with sub-talar arthroerisis, for hallux valgus correction in abnormal pronation syndrome. Chir Organi Mov. Dec 2008; 92(3): 145-8. PMID 19082522
12. Scharer BM, Black BE, Sockrider N. Treatment of painful pediatric flatfoot with Maxwell-Brancheau subtalar arthroereisis implant a retrospective radiographic review. Foot Ankle Spec. Apr 2010; 3(2): 67-72. PMID 20400415
13. Brancheau SP, Walker KM, Northcutt DR. An analysis of outcomes after use of the Maxwell- Brancheau Arthroereisis implant. J Foot Ankle Surg. 2012; 51(1): 3-8. PMID 22196453
14. Bresnahan PJ, Chariton JT, Vedpathak A. Extraosseous talotarsal stabilization using HyProCure®: preliminary clinical outcomes of a prospective case series. J Foot Ankle Surg. 2013; 52(2): 195-202. PMID 23313499
15. Scher DM, Bansal M, Handler-Matasar S, et al. Extensive implant reaction in failed subtalar joint arthroereisis: report of two cases. HSS J. Sep 2007; 3(2): 177-81. PMID 18751791
16. Saxena A, Nguyen A. Preliminary radiographic findings and sizing implications on patients undergoing bioabsorbable subtalar arthroereisis. J Foot Ankle Surg. 2007; 46(3): 175-80. PMID 17466243
17. Cook EA, Cook JJ, Basile P. Identifying risk factors in subtalar arthroereisis explantation: a propensity-matched analysis. J Foot Ankle Surg. 2011; 50(4): 395-401. PMID 21708340
18. National Institute for Health and Care Excellence (NICE). Sinus Tarsi Implant Insertion for Mobile Flatfoot [IPG305]. 2009; https://www.nice.org.uk/guidance/IPG305. Accessed March 2024.
19. Piraino JA, Theodoulou MH, Ortiz J, et al. American College of Foot and Ankle Surgeons Clinical Consensus Statement: Appropriate Clinical Management of Adult-Acquired Flatfoot Deformity. J Foot Ankle Surg. 2020; 59(2): 347-355. PMID 32131002