Total Ankle Replacement denials in California external review

What the reviewers wrote

Where the denial was overturned

A 63-year-old female enrollee has requested a total ankle replacement (Scandinavian Total Ankle Replacement - STAR)for treatment of her osteoarthritis of the ankle. Findings: Two physician reviewers found that the patient has failed conservative management. She requires NSAIDs and Vicodin for pain management. The patient’s provider has recommended Scandinavian Total Ankle Replacement (STAR). A well-accepted treatment for end stage ankle arthrosis is ankle arthrodesis. Arthrodesis fuses the ankle joint and places additional stresses on joints below the ankle joint. In many instances, this event may lead to arthrosis of the subtalar joint and midfoot. Total ankle replacements are an alternative to ankle arthrodesis. Saltzman and colleagues published a prospective, controlled trial of the STAR total ankle replacement.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for arthroplasty (total joint replacement) of the right ankle. Nationally recognized evidence based medical guidelines recommend total ankle replacement surgery only for very limited indications. This patient presents with constant right ankle pain, grade 3/10 at rest and grade 8-10/10 with weight bearing. Pain interferes with activities of daily living and work ability. Clinical exam findings have documented painful limited range of motion and crepitus consistent with x-ray findings of end-stage post-traumatic right ankle osteoarthritis, reportedly bone-on-bone. He has had worsening pain despite long-term conservative treatment. The patient’s body mass index is 31. There are no guideline contraindications documented in the medical records.

Where the denial was upheld

Findings: The physician reviewer found that The patient has requested authorization and coverage for total ankle replacement for left ankle. The available records document that this patient is being treated for chronic left ankle and foot pain and osteoarthritis of the left ankle. The patient presented with left ankle pain described as aching in nature and at its worst was rated at 7/10. The patient previously underwent left ankle open reduction with internal fixation (ORIF) many years ago with removal of hardware after one year. Physical examination of the left foot revealed pain with palpation of the left dorsal ankle, with left dorsal ankle with plantar flexion and against resistance with plantarflexion. The patient’s range of motion is full without crepitus or pain.

A 56-year-old male enrollee has requested a total ankle replacement for the treatment of his left ankle pain. Findings: Two physician reviewers found that total ankle replacement procedures have had a high failure rate in the past, but more recent designs and techniques have had more promising results. However, equivalence of arthroplasty with fusion has not yet been sufficiently established (Yalamanchili and colleagues). Reports of short-term results have been encouraging, but reports of mid-term results are few and often have not been validated by independent observers (Cracchiolo and Deorio). According to an article by Marx and Mizel, the role of arthroplasty as a viable alternative to arthrodesis remains the subject of debate. There remains a need for long-term and comparative studies (Haddad and colleagues).

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Total Ankle Replacement, then check the rights and deadlines that apply to your plan.