CurrentKaiser PermanentePolicy N/A

Total Ankle Arthroplasty (TAA/TAR) — Coverage Criteria

Medical necessity criteria, indications, contraindications, and supporting clinical evidence for total ankle arthroplasty (TAA/TAR) for Kaiser Permanente Georgia region utilization management staff and treating providers.

Policy Summary

PayerKaiser Permanente

PolicyTotal Ankle Arthroplasty (TAA/TAR) — Coverage Criteria

Policy CodePolicy N/A

Change TypeReviewed/Revised

Effective DateMar 10, 2014

Next Review DateApr 3, 2025

Key ActionObtain prior authorization and document at least 6 months of failed conservative management before requesting TAA.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsMinimum conservative management

250 lbsWeight contraindication

4 codesProcedure codes listed

Page 1 of 10Document pages

1970sTAR introduced

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inv-01: Medically necessary indications — Covered when ALL of the following are met

Covered when ALL of the following are met:

Primary coverage criteria for TAA: 1) Use of a Food and Drug Administration–cleared implant (examples include Agility LP, Eclipse, INBONE, STAR, Salto Talaris, Zimmer Trabecular Metal); 2) Skeletally mature person; 3) Moderate or severe pain with loss of ankle mobility and function due to osteoarthritis, post‑traumatic arthritis, or rheumatoid arthritis; 4) Failure of at least 6 months of conservative management, including physical therapy, nonsteroidal antiinflammatory drugs (NSAIDs), and orthoses as indicated.none

Examples of FDA‑cleared implants listed in source.

inv-02: Provider referral/endorsement requirement — single top-level node

Referral and Letter of Agreement: If clinically indicated, members should be referred to Dr. Arrow Bailey at Resurgence with an endorsement from the Chief of Podiatry; a Letter of Agreement (LOA) will be required for the procedure.none

Operational referral/endorsement requirement.

inv-03: Selection and comparative evidence

Selection considerations and comparative evidence

Candidate evaluation: A surgeon experienced in total ankle surgery should determine candidacy by careful history and physical evaluation, ensure patients are informed of alternative treatments and expected outcomes, and plan any adjunctive procedures needed to ensure proper device function.

Surgeon experience and preoperative counseling emphasized.

Procedure choice considerations: Choice between total ankle replacement (TAR/TAA) and ankle arthrodesis depends on patient factors: younger, heavy, physically active males may be better candidates for arthrodesis; patients with preexisting subtalar arthritis or hip/knee impairment that would be worsened by loss of ankle motion may be better candidates for TAR.

Based on limited comparative evidence; randomized trials lacking.

Implant generation and expectations: Third‑generation TAR systems have improved designs; several systems have received FDA approval since 2005. TAR can improve function and reduce pain in select patients, but long‑term comparative evidence versus arthrodesis is limited.

Historical context and evidence limitations noted.

The policy lists explicit contraindications that make total ankle arthroplasty (TAA/TAR) inappropriate. Contraindications include absence of the medial or lateral malleolus; active or prior deep infection of the ankle joint or adjacent bones; avascular necrosis of the talus; Charcot joint; hindfoot or forefoot malalignment precluding a plantigrade foot; insufficient bone or musculature for proper component positioning; insufficient ligament support not amenable to repair; lower extremity vascular insufficiency; neuromuscular disease causing loss of normal muscle function; osteonecrosis; peripheral neuropathy; poor skin or soft tissue quality around the surgical site; prior ankle arthrodesis; prior surgery or injury adversely affecting bone quality; psychiatric conditions that prevent perioperative cooperation; severe anatomic deformity of adjacent structures; severe ankle deformity; severe osteoporosis or osteopenia; significant knee malalignment; skeletal immaturity; and weight greater than 250 lbs.

Within the excerpt reviewed there are no stated procedural exclusions beyond the listed clinical contraindications; the document does not identify specific procedures or supply codes that are categorically excluded from coverage in the policy text provided.

The evidence summary references another payer’s policy (Aetna) and notes that Aetna considers TAA experimental and investigational for indications not explicitly listed as medically necessary and for patients with one or more of the listed contraindications.

The literature comparing total ankle replacement (TAR) and ankle arthrodesis is limited and methodologically heterogeneous. A 2014 systematic review found only three retrospective studies and a single nonrandomized prospective study; results were inconsistent (two studies favored TAR, two found no difference), and multiple methodological problems were identified. Because of these limitations the policy highlights that there is no conclusive evidence favoring one procedure over the other and emphasizes careful patient selection and the need for randomized trials to confirm comparative outcomes.

Provider Requirements, Documentation, and Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required for total ankle arthroplasty (TAA). Requests must specify the use of an FDA‑cleared implant system.

Affected codes: CPT 27702, 27703, 27870; HCPCS L8699

Note

Candidate Selection — Specialist Consultation Recommended

Not every patient with end‑stage ankle arthritis is an appropriate candidate for total ankle replacement. Candidate selection should be made by a surgeon experienced in total ankle surgery (board certified/board qualified in foot and ankle surgery when possible) after careful history and physical examination. Surgeons should counsel patients on alternative treatments (including ankle arthrodesis), adjunctive procedures that may be required, and realistic expected outcomes.

Documentation Required

Conservative Management Required

Conservative management is required prior to consideration of TAA. Document at least 6 months of nonoperative therapy (as appropriate) including physical therapy, non‑steroidal anti‑inflammatory drugs, and orthoses. Records should detail duration, modalities tried, and response to treatment.

Documentation Required

Required Clinical and Preoperative Documentation

Providers must document prior conservative management of at least 6 months and clearly state clinical indications for TAA. Preoperative documentation should include history and physical exam, discussion of alternatives (including ankle arthrodesis), expected outcomes, and any planned adjunctive procedures. Presence of any listed contraindication should be highlighted and may preclude approval.

Required documentation: prior conservative therapy details, indication for surgery, implant system (FDA‑cleared) specified, surgeon qualifications, preoperative discussion of alternatives and outcomes

Denial Risk

Contraindications — May Preclude Approval

If any contraindication to TAA exists (see policy contraindications), highlight this in the submission. Contraindications may preclude approval.

Note

Consider Alternatives and Counsel Patients

Consider alternatives to total ankle replacement, including ankle arthrodesis (fusion), and ensure patients are counseled about comparative outcomes and potential need for future procedures.

Definitions and Terminology

Total ankle arthroplasty (TAA) / Total ankle replacement (TAR) — definition and purpose

DefinitionSurgical replacement of the ankle joint with metallic and polyethylene (plastic) prosthetic components to restore motion and relieve pain in skeletally mature patients with end‑stage ankle arthritis (osteoarthritis, post‑traumatic arthritis, or rheumatoid arthritis).

Primary purposeProvide pain relief and improve ankle mobility and function when conservative management (including physical therapy, NSAIDs, and orthoses) has failed for at least 6 months.

When consideredMay be considered medically necessary when an FDA‑cleared implant is used in a skeletally mature person with moderate or severe pain and loss of ankle mobility/function who has failed ≥6 months of conservative therapy.

Alternative toAnkle arthrodesis (ankle fusion) for select patients; TAA aims to preserve ankle range of motion rather than fuse the joint.

Typical perioperative coursePerformed under general or spinal anesthesia with a 1–4 day hospitalization in many cases; postoperative physical therapy and a period of limited activity are commonly required.

Total ankle replacement (TAR) — implant system generations and components summary

Implant generationsThree generations of TAR implants have been developed since the procedure was introduced in the 1970s; several systems received FDA approval beginning in 2005.

Third‑generation design featuresA metallic tibial baseplate fixed to the tibia, a domed talar component resurfacing the talus, and an interposed polyethylene bearing surface between the two components.

Examples of FDA‑cleared systems (document lists)Agility LP, Eclipse, INBONE, STAR, Salto Talaris, Zimmer Trabecular Metal Total Ankle.

Clinical expectationImproved function and reduced pain in select patients, though long‑term durability data are limited compared with arthrodesis.

Ankle arthrodesis (AA) — definition as surgical fusion and historical treatment of choice

DefinitionSurgical fusion of the ankle joint to produce a stable, pain‑free ankle by eliminating motion at the tibiotalar joint.

Historical roleHas been the traditional and treatment‑of‑choice method for relief of severe ankle and hindfoot pain (for example in rheumatoid arthritis) prior to the development and wider use of TAR.

Functional effectEliminates ankle motion but can improve pain and stability; may lead to later degeneration (arthrosis) in adjacent joints such as the subtalar joint.

Comparison with TARArthrodesis provides a stable, pain‑free ankle but sacrifices motion; TAR aims to preserve motion and potentially protect adjacent joints, though comparative long‑term evidence is limited.

OpenPayer

Total Ankle Arthroplasty (TAA/TAR) — Coverage Criteria

Coverage and Medical Necessity Criteria

Procedure and Supply Codes

Provider Requirements, Documentation, and Authorization

Definitions and Terminology

Background and Evidence Summary

27702
27703
27870
L8699