Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2024 Mar 24;9(1):24730114241239310.
doi: 10.1177/24730114241239310. eCollection 2024 Jan.

Evidence Guiding Commercial Payer Coverage Criteria for Total Ankle Arthroplasty

Jacob L Kotlier  1 , Amir Fathi  1 , Meng-Yung Ong  1 , Josh M Yazditabar  1 , Ethan E Panoussi  1 , Cory K Mayfield  1 , Frank A Petrigliano  1 , Joseph N Liu  1 , Alexander B Peterson  1 , Eric W Tan  1
Affiliations

Evidence Guiding Commercial Payer Coverage Criteria for Total Ankle Arthroplasty

Jacob L Kotlier et al. Foot Ankle Orthop. .

Abstract

Background: Total ankle arthroplasty (TAA), first developed as an alternative to ankle arthrodesis, has become an increasingly popular management option for end-stage ankle arthritis. Prior studies have shown commercial insurance payers base their coverage criteria on limited and low level of evidence research. This study aims to quantify and describe the evidence insurance companies use to support TAA coverage policies.

Methods: The top 11 national commercial health insurance payers for TAA were identified. A google search was performed to identify payer coverage policies. Policy documents were examined and cited references were classified by type of reference as well as reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted. Criteria were compared to assess for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria.

Results: Six of the 11 payers had accessible coverage policies. The majority of cited references were primary journal articles (145, 60.9%) and the majority of references cited (179, 75.2%) were level III or level IV evidence. We found significant homogeneity in coverage criteria among payers. In addition, cited sources inconsistently mentioned specific payer coverage criteria.

Conclusion: This study demonstrates that commercial insurance payers rely on the relatively low level of currently available scientific evidence when formulating coverage policies for TAA use and adopt criteria that have not been thoroughly analyzed in the literature. More high level of evidence research is needed to help clinicians and insurance companies further refine indications for TAA so that patients who might benefit from the procedure are adequately covered.

Level of evidence: Level IV, review.

Keywords: commercial payer; coverage criteria; coverage policy; indications; references; total ankle arthroplasty; total ankle replacement.

PubMed Disclaimer

Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Figures

Figure 1.
Figure 1.
Reference level of evidence by payer.
Figure 2.
Figure 2.
Number and percentage of references cited by each payer that mention their specific coverage criteria.
See this image and copyright information in PMC

References

    1. Austin MS, Ashley BS, Bedard NA, et al.. What is the level of evidence substantiating commercial payers’ coverage policies for total joint arthroplasty? J Arthroplasty. 2021;36(8):2665-2673.e8. doi:10.1016/j.arth.2021.03.036 - DOI - PubMed
    1. Bagheri K, Anastasio AT, Poehlein E, et al.. Outcomes after total ankle arthroplasty with an average follow-up of 10 years: a systematic review and meta-analysis. Foot Ankle Surg. 2024;30(1):64-73. doi:10.1016/j.fas.2023.09.007 - DOI - PubMed
    1. Chen AF, Bloomfield MR, Lichstein PM, Yates AJ, Jr, Austin MS. What is the level of evidence substantiating the Medicare local coverage determinations? J Arthroplasty. 2015;30(3):356-360. doi:10.1016/j.arth.2014.10.003 - DOI - PubMed
    1. Flavin R, Coleman SC, Tenenbaum S, Brodsky JW. Comparison of gait after total ankle arthroplasty and ankle arthrodesis. Foot Ankle Int. 2013;34(10):1340-1348. doi:10.1177/1071100713490675 - DOI - PubMed
    1. Glazebrook M, Burgesson BN, Younger AS, Daniels TR. Clinical outcome results of total ankle replacement and ankle arthrodesis: a pilot randomised controlled trial. Foot Ankle Surg. 2021;27(3):326-331. doi:10.1016/j.fas.2020.10.005 - DOI - PubMed

LinkOut - more resources