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Proprietary information of ConnectiCare. © 2020ConnectiCare,
Inc. & Affiliates Page 1 of 12
Medical Policy:
Foot Surgery-Bunion/Hammertoe/Metatarsophalangeal Joint
(Commercial)
POLICY NUMBER EFFECTIVE DATE APPROVED BY
MG.MM.ME.SU.70 01/01/2020 MPC (Medical Policy Committee)
IMPORTANT NOTE ABOUT THIS MEDICAL POLICY:
Property of ConnectiCare, Inc. All rights reserved. The treating
physician or primary care
provider must submit to ConnectiCare, Inc. the clinical evidence
that the patient meets the
criteria for the treatment or surgical procedure. Without this
documentation and information,
ConnectiCare will not be able to properly review the request for
prior authorization. This clinical
policy is not intended to pre-empt the judgment of the reviewing
medical director or dictate to
health care providers how to practice medicine. Health care
providers are expected to exercise
their medical judgment in rendering appropriate care. The
clinical review criteria expressed below
reflects how ConnectiCare determines whether certain services or
supplies are medically
necessary. ConnectiCare established the clinical review criteria
based upon a review of currently
available clinical information (including clinical outcome
studies in the peer-reviewed published
medical literature, regulatory status of the technology,
evidence-based guidelines of public health
and health research agencies, evidence-based guidelines and
positions of leading national health
professional organizations, views of physicians practicing in
relevant clinical areas, and other
relevant factors). ConnectiCare, Inc. expressly reserves the
right to revise these conclusions as
clinical information changes, and welcomes further relevant
information. Identification of selected
brand names of devices, tests and procedures in a medical
coverage policy is for reference only
and is not an endorsement of any one device, test or procedure
over another. Each benefit plan
defines which services are covered. The conclusion that a
particular service or supply is medically
necessary does not constitute a representation or warranty that
this service or supply is covered
and/or paid for by ConnectiCare, as some plans exclude coverage
for services or supplies that
ConnectiCare considers medically necessary. If there is a
discrepancy between this guideline and
a member's benefits plan, the benefits plan will govern. In
addition, coverage may be mandated
by applicable legal requirements of the State of CT and/or the
Federal Government. Coverage
may also differ for our Medicare members based on any applicable
Centers for Medicare &
Medicaid Services (CMS) coverage statements including including
National Coverage
Determinations (NCD), Local Coverage Determinations (LCD) and/or
Local Medical Review
Policies(LMRP). All coding and web site links are accurate at
time of publication.
Related Medical Guideline
Cosmetic Surgery Procedures
Definitions Hallux valgus (HV)
deformity (aka bunion) Painful bony bump that develops on the
inside of the foot at the big toe
joint.
Pressure on the joint causes the big toe to lean toward the
second toe.
Over time, the normal structure of the bone changes, resulting
in the
bunion bump. The deformity gradually increases causing pain
when
wearing shoes and walking.
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Medical Policy:
Foot Surgery-Bunion/Hammertoe/Metatarsophalangeal
Joint(Commercial)
Hallux rigidus (aka stiff big toe)
A deformity in the joint located at the base of the big toe. It
causes pain
and stiffness in the big toe and, over time, bending the toe
becomes more
and more difficult.
This condition can cause discomfort and even disability, since
this
important toe is used to walk, lean, climb and even stand.
Hallux Rigidus
is a progressive condition in which foot mobility decreases over
time. In its
primary phases, the mobility of the big toe is only somewhat
limited
("Hallux Limitus"); however, with progression, the range of
motion of the
toe decreases until it reaches the final state of "Rigidus,"
which is when
the toe remains stiff or as "frozen."
Bunionette (tailor’s
bunion) Painful bony prominences that occur over the lateral
aspect of the fifth
(little toe) metatarsophalangeal (MTP) joint
Hammertoe A contracture (bending) deformity of one or both
joints of the second,
third, fourth, or fifth (little) toes. This abnormal bending can
put pressure
on the toe when wearing shoes, causing problems to develop.
Hammertoes usually start out as mild deformities and get
progressively
worse over time. In the earlier stages, hammertoes are flexible,
and the
symptoms can often be managed with noninvasive measures. But if
left
untreated, hammertoes can become more rigid and will not respond
to
nonsurgical treatment.
Guideline A. Bunionectomy
B. Hammertoe Repair
C. Metatarsophalangeal Joint Surgical Correction
D. Metatarsophalangeal Joint Replacement
_______________________________________________________________________
A. Bunionectomy (Bunionette, Simple and Bony Correction)
General Criteria
1. Skeletal maturity
2. Symptoms of pain and walking difficulty unresponsive to ≥ 6
months of
conservative therapy (≥ 2 must be applicable):
a. Change in footwear
b. Padding or orthotics (shoe inserts)
c. Nonsteroidal anti-inflammatory drugs (NSAIDS)
d. Local injections to the first metatarsophalangeal joint
(e.g., local
anesthesia or steroid)
Bunionette
Considered medically necessary when the General Criteria above
are met with radiologic
imaging confirmation of a MTP joint of at least 16 degrees and
an Intermetatarsal angle (IMA)
of at least 10 degrees
Simple Bunionectomy (e.g., modified McBride, Silver
Procedure)
Considered medically necessary when the General Criteria above
are met with radiologic
imaging confirmation of a hallux valgus angle (HVA) of at least
15 degrees and one:
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1. Presence of diabetes and ulcers or infection originating from
the bunion
2. Foot pain limiting everyday activity (walking, wearing
reasonable shoes)
3. Chronic big toe inflammation and swelling that does not
improve with rest and
medications
4. Toe deformity that causes drifting in of the big toe toward
smaller toes
5. Toe stiffness that causes inability to bend and straighten
the big toe
Bony Correction Bunionectomy (e.g., Akin, Chevron, Keller,
Lapidus, Mitchell,
proximal metatarsal osteotomy procedures, etc.)
Considered medically necessary when the General Criteria above
are met and both:
1. Radiologic imaging confirmation of a hallux valgus angle
(HVA) of at least 30 degrees
2. Intermetatarsal angle (IMA) of at least 13 degrees and
one:
i. Significant foot pain that limits everyday activities
(walking, wearing reasonable
shoes)
ii. Chronic big toe inflammation and swelling that does not
improve with rest or
medications
iii. Toe deformity that causes a drifting in of the big toe
toward smaller toes
iv. Toe stiffness that causes inability to bend and straighten
the big toe
Limitations/Exclusions
A bilateral bunionectomy done at the same time generally not
considered medically necessary
unless extenuating circumstances are present
Bony correction bunionectomy is considered experimental,
investigational or unproven for all of the
following:
▪ Foot ulcer(s) secondary to peripheral vascular disease
▪ Gangrene of the foot, ankle or lower leg
▪ Non-ambulatory members (unless surgery is to relieve
ulceration due to prominence)
▪ Open blisters, pressure sores, and skin ulceration overlying
the bunion when the
bunion is not the cause of the skin lesion (bony correction may
lead to osteomyelitis)
▪ Poor tissues at the operative site due to excessive scarring
and multiple closely placed
previous incisions
▪ Severe vascular insufficiency significantly impairing
foot-circulation (e.g., absent foot
pulses, intermittent claudication, ankle/arm ratio < 0.6)
▪ Cosmetic appearance of the foot
_______________________________________________________________________
B. Hammertoe Repair (i.e., surgical correction of hammertoe,
claw toe, or mallet toe)
Hammertoe repair is considered medically necessary for members ≥
18 years of age (or
skeletally mature) when ≥ 1 of the following clinical
indications is applicable:
1. Adventitious bursitis on the dorsal surface of the
hammertoe
2. Ankylosis of the distal interphalangeal (DIP) joint or
proximal interphalangeal (PIP)
joint
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3. Inter-digital neuroma caused by the deformity
4. Lateral metatarsophalangeal (MTP) capsular tear caused by the
deformity
5. Painful nail conditions secondary to persistent trauma
6. Presence of co-existing or causative conditions (e.g., tendon
contracture) that need
repair
7. Subluxation or dislocation of the MTP joint
8. Synovitis/capsulitis of the MTP joint
9. Ulceration of the apices
Documentation should detail all:
1. Radiographic confirmation of deformity (i.e., interpretation
and report of anterior/posterior
and lateral views of the affected foot)
2. Skeletal maturity (epiphyseal closure)
3. Symptoms unresponsive to ≥ 3 months of conservative
management directed by a
healthcare professional (≥ 2 must be applicable):
i. Corticosteroid injections ii. Debridement of associated
hyperkeratotic lesions (e.g., corns, calluses)
iii. Foot orthotics (e.g., adaptive footwear such as shoe
inserts, footgear
modifications, corrective splinting)/orthopedic shoes (i.e.,
wide/deep toe box)
(Note: benefit exclusions may apply)
iv. Oral analgesics and/or nonsteroidal anti-inflammatory drugs
(NSAIDs)
v. Protective padding
vi. Taping or adhesive devices
Repeat hammer toe surgery is considered medically necessary
following failure of a previous
surgical procedure
Limitations/Exclusions
Fixation implants are considered experimental, investigational
or unproven (e.g., Acumed
Hammertoe Fusion Set, BME Hammerlock Implant, CannuLink
Intramedullary Fusion Device,
CrossTie Intraosseous Fixation System, Futura Flexible Digital
Implant, Futura LMP Lesser
Phalangeal Joint Implant, HammerFix IP Fusion System, Integra
Hammertoe Implant, OsteoMed
Interflex IPG System, Pro-Toe Hammertoe Implant, Smart Toe,
StayFuse Fusion Device, ToeGrip
Device, Two-Step Hammer Toe Implant, th Weil-Carver Hammertoe
Implant and the Wright Cann
Phalinx System)
______________________________________________________________________
C. Metatarsophalangeal (MTP) Joint — Surgical Correction
Surgical correction (e.g., arthrodesis, cheilectomy, Keller
procedure [resection arthroplasty]) of
the first MTP joint (e.g., hallux rigidus) is considered
medically necessary in skeletally mature
members with osteoarthritis (OA).
Documentation should detail all:
1. Skeletal maturity (epiphyseal closure)
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Medical Policy:
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2. Radiologic confirmation of OA as evidenced by any:
i. Cysts in the metatarsal head
ii. Loss of cartilage between bones
iii. Mild to moderate bony proliferative pathology
3. Symptoms unresponsive to ≥ 6 months of conservative
management directed by a
healthcare professional (≥ 2 must be applicable):
i. Alternative or modified footwear
ii. Corticosteroid injections
iii. Debridement of associated hyperkeratotic lesions (e.g.,
corns, calluses)
iv. Foot orthotics (e.g., adaptive footwear such as shoe
inserts, footgear
modifications, corrective splinting) (Note: benefit exclusions
may apply)
v. Oral analgesics or nonsteroidal anti-inflammatory drugs
(NSAIDS)
vi. Protective cushions/pads
vii. Taping or adhesive devices
__________________________________________________________________________________________
D. Metatarsophalangeal (MTP) Joint — Replacement
Partial or total replacement of the first MTP (hallux rigidus)
joint is considered medically
necessary for disabling arthritis by either hemiarthroplasty or
total prosthetic replacement
arthroplasty with silastic or metallic implants.
Limitations/Exclusions
The following services are considered experimental,
investigational or unproven:
▪ MTP joint replacement for joints other than the first MTP
joint
▪ Ceramic implants (e.g., Moje prosthesis)
▪ Synthetic implants (e.g., Arthrex metatarsal phalangeal joint
implant, Cartiva Synthetic
Cartilage Implant, METIS prosthesis, OsteoMed ReFlexion 1st MTP
Implant System and
the ToeFit-Plus prosthesis)
▪ Interpositional arthroplasty with biologic spacers for hallux
rigidus, degenerative
arthritis, and other indications involving the MTP joints
Applicable Coding To access the codes, please download the
policy to your computer, and click on the paperclip
icon within the policy
Applicable CPT and Diagnosis Codes
References Coughlin MJ, Dorris J, Polk E. Operative repair of
the fixed hammertoe deformity. Foot Ankle. 2000;21:94-104.
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CPT Code Description
28285 Correction, hammertoe (eg, interphalangeal fusion, partial
or total phalangectomy)
28286 Correction, cock-up fifth toe, with plastic skin closure
(eg, Ruiz-Mora type procedure)
28289 Hallux rigidus correction with cheilectomy, debridement
and capsular release of the first metatarsophalangeal joint;
without implant
28291 Hallux rigidus correction with cheilectomy, debridement
and capsular release of the first metatarsophalangeal joint; with
implant
28292
Correction, hallux valgus (bunionectomy), with sesamoidectomy,
when performed; with resection of proximal phalanx base, when
performed, any method
28296 Correction, hallux valgus (bunionectomy), with
sesamoidectomy, when performed; with distal metatarsal osteotomy,
any method
28297
Correction, hallux valgus (bunionectomy), with sesamoidectomy,
when performed; with first metatarsal and medial cuneiform
joint
arthrodesis, any method
28298 Correction, hallux valgus (bunionectomy), with
sesamoidectomy, when performed; with proximal phalanx osteotomy,
any method
28299 Correction, hallux valgus (bunionectomy), with
sesamoidectomy, when performed; with double osteotomy, any
method
G57.60 Lesion of plantar nerve, unspecified lower limb
G57.61 Lesion of plantar nerve, right lower limb
G57.62 Lesion of plantar nerve, left lower limb
G57.63 Lesion of plantar nerve, bilateral lower limbs
L97.501 Non-pressure chronic ulcer of other part of unspecified
foot limited to breakdown of skin
L97.502 Non-pressure chronic ulcer of other part of unspecified
foot with fat layer exposed
L97.503 Non-pressure chronic ulcer of other part of unspecified
foot with necrosis of muscle
L97.504 Non-pressure chronic ulcer of other part of unspecified
foot with necrosis of bone
L97.505 Non-pressure chronic ulcer of other part of unspecified
foot with muscle involvement without evidence of necrosis
L97.506 Non-pressure chronic ulcer of other part of unspecified
foot with bone involvement without evidence of necrosis
L97.508 Non-pressure chronic ulcer of other part of unspecified
foot with other specified severity
L97.509 Non-pressure chronic ulcer of other part of unspecified
foot with unspecified severity
L97.511 Non-pressure chronic ulcer of other part of right foot
limited to breakdown of skin
L97.512 Non-pressure chronic ulcer of other part of right foot
with fat layer exposed
L97.513 Non-pressure chronic ulcer of other part of right foot
with necrosis of muscle
L97.514 Non-pressure chronic ulcer of other part of right foot
with necrosis of bone
L97.515 Non-pressure chronic ulcer of other part of right foot
with muscle involvement without evidence of necrosis
L97.516 Non-pressure chronic ulcer of other part of right foot
with bone involvement without evidence of necrosis
L97.518 Non-pressure chronic ulcer of other part of right foot
with other specified severity
L97.519 Non-pressure chronic ulcer of other part of right foot
with unspecified severity
L97.521 Non-pressure chronic ulcer of other part of left foot
limited to breakdown of skin
L97.522 Non-pressure chronic ulcer of other part of left foot
with fat layer exposed
L97.523 Non-pressure chronic ulcer of other part of left foot
with necrosis of muscle
L97.524 Non-pressure chronic ulcer of other part of left foot
with necrosis of bone
L97.525 Non-pressure chronic ulcer of other part of left foot
with muscle involvement without evidence of necrosis
L97.526 Non-pressure chronic ulcer of other part of left foot
with bone involvement without evidence of necrosis
L97.528 Non-pressure chronic ulcer of other part of left foot
with other specified severity
L97.529 Non-pressure chronic ulcer of other part of left foot
with unspecified severity
M12.271 Villonodular synovitis (pigmented), right ankle and
foot
M12.272 Villonodular synovitis (pigmented), left ankle and
foot
M12.279 Villonodular synovitis (pigmented), unspecified ankle
and foot
M19.071 Primary osteoarthritis, right ankle and foot
M19.072 Primary osteoarthritis, left ankle and foot
M19.079 Primary osteoarthritis, unspecified ankle and foot
M19.171 Post-traumatic osteoarthritis, right ankle and foot
M19.172 Post-traumatic osteoarthritis, left ankle and foot
M19.179 Post-traumatic osteoarthritis, unspecified ankle and
foot
M20.10 Hallux valgus (acquired), unspecified foot
M20.11 Hallux valgus (acquired), right foot
M20.12 Hallux valgus (acquired), left foot
M20.20 Hallux rigidus, unspecified foot
M20.21 Hallux rigidus, right foot
M20.22 Hallux rigidus, left foot
M20.40 Other hammer toe(s) (acquired), unspecified foot
Foot Surgery-Bunion/Hammertoe/Metatarsophalangeal Joint Coding
Criteria:
ICD-10 Diagnosis Codes
Proprietary information of ConnectiCare. © 2020 ConnectiCare,
Inc. Affiliates 1 of 3
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M20.41 Other hammer toe(s) (acquired), right foot
M20.42 Other hammer toe(s) (acquired), left foot
M20.5x1 Other deformities of toe(s) (acquired), right foot
M20.5X2 Other deformities of toe(s) (acquired), left foot
M20.5X9 Other deformities of toe(s) (acquired), unspecified
foot
M20.60 Acquired deformities of toe(s), unspecified, unspecified
foot
M20.61 Acquired deformities of toe(s), unspecified, right
foot
M20.62 Acquired deformities of toe(s), unspecified, left
foot
M21.611 Bunion of right foot
M21.612 Bunion of left foot
M21.619 Bunion of unspecified foot
M21.621 Bunionette of right foot
M21.622 Bunionette of left foot
M21.629 Bunionette of unspecified foot
M21.6X1 Other acquired deformities of right foot
M21.6X2 Other acquired deformities of left foot
M21.6X9 Other acquired deformities of unspecified foot
M24.574 Contracture, right foot
M24.575 Contracture, left foot
M24.576 Contracture, unspecified foot
M24.671 Ankylosis, right ankle
M24.672 Ankylosis, left ankle
M24.673 Ankylosis, unspecified ankle
M24.674 Ankylosis, right foot
M24.675 Ankylosis, left foot
M24.676 Ankylosis, unspecified foot
M65.871 Other synovitis and tenosynovitis, right ankle and
foot
M65.872 Other synovitis and tenosynovitis, left ankle and
foot
M65.879 Other synovitis and tenosynovitis, unspecified ankle and
foot
M67.00 Short Achilles tendon (acquired), unspecified ankle
M67.01 Short Achilles tendon (acquired), right ankle
M67.02 Short Achilles tendon (acquired), left ankle
M77.50 Other enthesopathy of unspecified foot and ankle
M77.51 Other enthesopathy of right foot and ankle
M77.52 Other enthesopathy of left foot and ankle
M77.9 Enthesopathy, unspecified [synovitis/capsulitis]
Q66.6 Other congenital valgus deformities of feet
Q66.7 Congenital pes cavus [claw toe, congenital]
Q66.89 Other specified congenital deformities of feet
Q74.2 Other congenital malformations of lower limb(s), including
pelvic girdle [subluxation or dislocation MP joint]
S93.101A Unspecified subluxation of right toe(s), initial
encounter
S93.101D Unspecified subluxation of right toe(s), subsequent
encounter
S93.101S Unspecified subluxation of right toe(s), sequela
S93.102A Unspecified subluxation of left toe(s), initial
encounter
S93.102D Unspecified subluxation of left toe(s), subsequent
encounter
S93.102S Unspecified subluxation of left toe(s), sequela
S93.103A Unspecified subluxation of unspecified toe(s), initial
encounter
S93.103D Unspecified subluxation of unspecified toe(s),
subsequent encounter
S93.103S Unspecified subluxation of unspecified toe(s),
sequela
S93.104A Unspecified dislocation of right toe(s), initial
encounter
S93.104D Unspecified dislocation of right toe(s), subsequent
encounter
S93.104S Unspecified dislocation of right toe(s), sequela
S93.105A Unspecified dislocation of left toe(s), initial
encounter
S93.105D Unspecified dislocation of left toe(s), subsequent
encounter
S93.105S Unspecified dislocation of left toe(s), sequela
S93.106A Unspecified dislocation of unspecified toe(s), initial
encounter
S93.106D Unspecified dislocation of unspecified toe(s),
subsequent encounter
S93.106S Unspecified dislocation of unspecified toe(s),
sequela
S93.111A Dislocation of interphalangeal joint of right great
toe, initial encounter
S93.111D Dislocation of interphalangeal joint of right great
toe, subsequent encounter
S93.111S Dislocation of interphalangeal joint of right great
toe, sequela
S93.121A Dislocation of metatarsophalangeal joint of right great
toe, initial encounter
S93.121D Dislocation of metatarsophalangeal joint of right great
toe, subsequent encounter
S93.121S Dislocation of metatarsophalangeal joint of right great
toe, sequela
S93.122A Dislocation of metatarsophalangeal joint of left great
toe, initial encounter
S93.122D Dislocation of metatarsophalangeal joint of left great
toe, subsequent encounter
S93.122S Dislocation of metatarsophalangeal joint of left great
toe, sequela
S93.123A Dislocation of metatarsophalangeal joint of unspecified
great toe, initial encounter
S93.123D Dislocation of metatarsophalangeal joint of unspecified
great toe, subsequent encounter
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S93.123S Dislocation of metatarsophalangeal joint of unspecified
great toe, sequela
S93.124A Dislocation of metatarsophalangeal joint of right
lesser toe(s), initial encounter
S93.124D Dislocation of metatarsophalangeal joint of right
lesser toe(s), subsequent encounter
S93.124S Dislocation of metatarsophalangeal joint of right
lesser toe(s), sequela
S93.125A Dislocation of metatarsophalangeal joint of left lesser
toe(s), initial encounter
S93.125D Dislocation of metatarsophalangeal joint of left lesser
toe(s), subsequent encounter
S93.125S Dislocation of metatarsophalangeal joint of left lesser
toe(s), sequela
S93.126A Dislocation of metatarsophalangeal joint of unspecified
lesser toe(s), initial encounter
S93.126D Dislocation of metatarsophalangeal joint of unspecified
lesser toe(s), subsequent encounter
S93.126S Dislocation of metatarsophalangeal joint of unspecified
lesser toe(s), sequela
S93.129A Dislocation of metatarsophalangeal joint of unspecified
toe(s), initial encounter
S93.129D Dislocation of metatarsophalangeal joint of unspecified
toe(s), subsequent encounter
S93.129S Dislocation of metatarsophalangeal joint of unspecified
toe(s), sequela
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File AttachmentFoot Surgery_ CPT_ DX Coding Critieria
01_2020.pdf
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Van Wyngarden TM. The painful foot, part I: Common forefoot
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Oliver TP, Armstrong DG, Harkless LB, Krych SM. The combined
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Autologous Chondrocyte Implantation
(Commercial)
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Gallentine JW, DeOrio JK. Removal of the second toe for severe
hammertoe deformity in elderly patients. Foot Ankle Int.
2005;26(5):353-358. Pietrzak WS, Lessek TP, Perns SV. A
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joint (hammer toe) arthrodesis: Biomechanical testing in a
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Specialty-matched clinical peer review.
Revision history
DATE REVISION
01/01/2020 • New policy