Humana Hammer Toe Surgical Treatments Form

Description

Deformities of the lesser (2 through 5) toes are generally known as hammer toe, claw toe and mallet toe. Hammer toe refers to an abnormal flexion posture at the proximal interphalangeal (PIP) joint of one or more of the lesser four toes. The most commonly affected toe is the second, although multiple toes can be involved. If the flexion contracture is severe and of long duration, associated hyperextension of the metatarsophalangeal (MTP) joint and extension of the distal interphalangeal (DIP) joint may occur. Hammer toes are classified as either flexible (passively correctable) or rigid (not passively correctable to the neutral position). In claw toe, there is hyperextension of the proximal phalanx on the MTP joint and plantar flexion of the PIP and DIP joints. Mallet toes demonstrate a flexion contracture of the DIP joint.

Hammer Toe Surgical Treatments

Effective Date: 02/02/2023
Revision Date: 02/02/2023
Review Date: 02/02/2023
Policy Number: HUM-0542-008

Humana's documents are updated regularly online.

When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Surgical procedures utilized for the correction of hammer toe include, but may not be limited to, amputation for severe deformity, arthrodesis, arthroplasty, flexor to extensor tendon transfer, partial or total phalangectomy or tenotomy. Kirschner wires may be used as fixation devices for arthrodesis and arthroplasty.

Implants have been developed to stabilize the PIP joint, purportedly to promote fusion. Such implants are not universally accepted and are exceedingly difficult to remove should the surgery fail. Their removal could lead to substantial bone loss, making subsequent revision procedures challenging. (Refer to Coverage Limitations section)

For information regarding bunion and bunionette surgical treatments, please refer to Bunion and Bunionette Surgical Treatments Medical Coverage Policy.

Coverage Determination

Humana members may be eligible under the Plan for hammer toe surgical treatment when the following criteria are met:

• Radiographic* confirmation of hammer toe deformity; AND
• 18 years of age or older or documentation of skeletal maturity**; AND
• Documentation of persistent pain and difficulty walking despite at least 3 months of conservative treatment under the direction of a healthcare professional with ALL of the following:
  1. Alternative or modified footwear; AND
  2. Corticosteroid injections if medically appropriate and not contraindicated. Steroid injections should be avoided 3 months prior to planned hammer toe surgery; AND
  3. Foot orthotics (shoe inserts) (generally excluded by certificate);

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

• Nonsteroidal anti-inflammatory drugs (NSAIDS) or oral analgesics if medically appropriate and not contraindicated; AND
• Protective cushions/pads; AND
• Taping;

AND any of the following:

• Adventitious bursa on the hammertoe; OR
• Ankyloses of the PIP and/or DIP joints; OR
• Interdigital neuroma caused by the deformity; OR
• Lateral MTP capsular tear caused by the deformity; OR
• Subluxation or dislocation of the MTP joint caused by the deformity; OR
• Synovitis/capsulitis of the MTP joint; OR
• Ulceration caused by the deformity;

*Radiographic confirmation must include interpretation of anterior/posterior and lateral views of the affected foot.
**Skeletally mature refers to a system of fused skeletal bones which occurs when bone growth ceases.

Humana members may be eligible under the Plan for repeat hammer toe surgical treatment following failure of a previous surgical procedure.

Coverage Limitations

Humana members may NOT be eligible under the Plan for hammer toe surgical treatment for any indications other than those listed above. All other indications are considered not medically necessary as defined in the member’s individual certificate. Please refer to the member's individual certificate for the specific definition.

Hammer Toe Surgical Treatments Effective Date: 02/02/2023
Revision Date: 02/02/2023
Review Date: 02/02/2023
Policy Number: HUM-0542-008
Page: 4 of 6

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may NOT be eligible under the Plan for a joint fixation implant or replacement (e.g., InterPhlex hammertoe system, OSSIOfiber hammertoe fixation implant, Smart Toe II device, StayFuse device, ToeGrip device). This is considered experimental/investigational as it is not identified as widely used and generally accepted for the proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Additional information about hammer toe deformities may be found from the following websites:

• American College of Foot and Ankle Surgeons
• National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.