ModifiedUnitedHealthcarePolicy CSNCT0554.09

Surgery of the Ankle (for North Carolina Only)

UnitedHealthcare Community Plan medical policy applicable only to North Carolina members describing coverage rationale, documentation requirements, applicable procedure codes, and evidence regarding ankle surgeries including arthrodesis, arthroscopy, arthrotomy, total ankle replacement, and osteochondral allograft/autograft transplantation.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Ankle (for North Carolina Only)

Policy CodePolicy CSNCT0554.09

Change TypeModified (03/01/2026)

Effective DateMar 1, 2026

Next Review Date

Key ActionMaintain legible medical record documentation to support medical necessity including relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; make available upon request.

SourceLink

POLICY UPDATE CHANGES

Revised language pertaining to medical necessity clinical coverage criteria and removed reference to certain InterQual custom procedures (Arthroplasty, Ankle (Without Implant) and Arthroplasty, Removal or Revision, Ankle).

Added detailed language to medical records documentation used for reviews outlining requirements that documentation supports medical necessity and may be requested.

Removed CPT codes 27700, 27703, 27704, and 28899 from the applicable codes list.

Updated clinical evidence and references sections to reflect current information; archived previous policy version CSNCT0554.08.

4Procedure categories referenced (Arthrodesis/Arthroscopy/Arthrotomy/TJR)

1Procedures deemed not medically necessary (OAT/OCA)

Coverage Summary

This UnitedHealthcare Community Plan coverage criteria (Policy Number CSNCT0554.09, effective March 1, 2026, last reviewed March 1, 2026) addresses surgery of the ankle for North Carolina members. The policy states that certain ankle procedures (arthrodesis, arthroscopy, arthrotomy, and total ankle replacement) are proven and may be medically necessary when InterQual CP: Procedures criteria are met. Osteochondral allograft or autograft transplantation (OAT/OCA) for cartilage defects of the ankle is considered not medically necessary (unproven) because of insufficient evidence of efficacy.

Key facts: ankle surgery policy

Procedure categories referencedArthrodesis; Arthroscopy; Arthrotomy; Total Joint Replacement (TJR)

Procedures deemed not medically necessaryOsteochondral allograft or autograft transplantation (OAT/OCA)

CPT codes listed (count)10

Coverage stancemixed (some ankle surgeries covered when InterQual criteria met; OAT/OCA not medically necessary)

Scope summaryUnitedHealthcare Community Plan medical policy for North Carolina covering ankle surgeries, documentation requirements, applicable procedure codes, and evidence on osteochondral allograft/autograft transplantation

Effective date2026-03-01

Last review2026-03-01

Medical Necessity / Coverage Rationale

Coverage Rationale / Medical Necessity

Surgery of the ankle is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual CP: Procedures for the listed procedures.

Covered when InterQual criteria met for ANY of the following procedures

Arthrodesis, Ankle (Talotibial Joint): Refer to InterQual CP: Procedures
Arthroscopy, Surgical, Ankle: Refer to InterQual CP: Procedures
Arthrotomy, Ankle: Refer to InterQual CP: Procedures

Not Medically Necessary / Experimental Procedures

The policy position is that osteochondral allograft or autograft transplantation (OAT/OCA) for treating cartilage defects of the ankle is unproven and not medically necessary. This determination is based on evidence summaries and technology assessments finding insufficient quality and quantity of data, predominance of small uncontrolled and retrospective studies, high risk of bias, and lack of randomized controlled trials and long-term comparative data to demonstrate consistent efficacy.

Procedure Codes

Applicable Procedure Codes (reference list)CPT

27685	Lengthening or shortening of tendon, leg or ankle; single tendon (separate procedure).
28446	Open osteochondral autograft, talus (includes obtaining graft[s]).
27702	Arthroplasty, ankle; with implant (total ankle).
29891	Arthroscopy, ankle, surgical; excision of osteochondral defect of talus and/or tibia, including drilling of the defect.
29892	Arthroscopically aided repair of large osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture, with or without internal fixation (includes arthroscopy).
29894	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with removal of loose body or foreign body.
29895	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; synovectomy, partial.
29897	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, limited.
29898	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; debridement, extensive.
29899	Arthroscopy, ankle (tibiotalar and fibulotalar joints), surgical; with ankle arthrodesis.

Removed / Not on NC Medicaid Fee Schedule (not covered by NC Medicaid Fee Schedule)CPTNot Covered

27700	Removed from applicable codes per policy history (previously listed).
27703	Removed from applicable codes per policy history (previously listed).
27704	Removed from applicable codes per policy history (previously listed).
28899	Removed from applicable codes per policy history (previously listed).

Codes Not on NC Medicaid Fee Schedule (may not be covered by NC Medicaid Program)CPT

28446

Open osteochondral autograft, talus (includes obtaining graft[s]). (Marked with asterisk in policy: not on NC Medicaid Fee Schedule)

Provider Actions / Authorization & Documentation

Prior Authorization

Use of InterQual Criteria for Medical Necessity Determination

Coverage determinations for the listed ankle procedures require reference to InterQual CP: Procedures criteria (Arthrodesis, Arthroscopy, Arthrotomy, TJR) to establish medical necessity.

Documentation Required

Medical Records Documentation Required

Maintain legible medical record documentation to support medical necessity including relevant medical history, physical exam, and results of pertinent diagnostic tests or procedures; make available upon request.

Background & Evidence Summary

Osteoarthritis (degenerative arthritis) of the ankle involves progressive wearing of joint cartilage that can lead to pain, loss of joint space, and bony spurs. Posttraumatic arthritis can follow foot or ankle injuries such as fractures or dislocations and may develop years after the initial injury. For osteochondral lesions of the talus and other ankle cartilage defects, the policy notes there is insufficient quality evidence supporting the safety and efficacy of osteochondral allograft or autograft transplantation; higher-quality studies including randomized controlled trials and long-term follow-up are needed.

Evidence Source	Summary
Correia Cardoso et al. (2024)	Systematic review of 50 studies (806 ankles); majority retrospective with high risk of bias; OAT and ACI showed higher improvements, OCA showed no significant improvement in meta-analysis; authors call for cautious interpretation due to study limitations.
Hayes HTAs (2013/2012)	Health technology assessments concluded insufficient evidence to draw definitive conclusions on OCA or OAT effectiveness; studies were small, uncontrolled or low quality, and additional controlled long-term studies are needed.
AOFAS Position Statement (2022)	Supports use of osteochondral autograft and allograft transplantation for OLTs that have failed nonsurgical management, especially large or cystic lesions and those failing prior surgery; considers osteochondral transplantation a treatment option with improved outcomes maintained long term.

Glossary: OAT — Osteochondral autograft transplantation; OCA — Osteochondral allograft transplantation; OLT — Osteochondral lesions of the talus.

Revision History

03/01/2026policy_historyLatest

Revised language pertaining to medical necessity clinical coverage criteria and removed reference to certain InterQual Client Defined custom procedures (Arthroplasty, Ankle (Without Implant) and Arthroplasty, Removal or Revision, Ankle).

03/01/2026codes_removedLatest

Removed CPT codes 27700, 27703, 27704, and 28899 from the applicable codes list.

03/01/2026documentation_added