29894
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
7.17
Facility
$474.96
Non-Facility
$474.96
Documentation Required
- Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage; such documentation does not guarantee coverage.
- Referenced guideline titled 'Medical Records Documentation Used for Reviews' for specifics on required documentation.
- When deciding coverage, the member specific benefit plan document must be referenced (the member specific plan governs in the event of a conflict).
- If applied to Medicare Advantage, determinations may rely on objective evidence-based rationale and applicable Medicare guidance (IOM Pub. No. 100-16, Ch. 4, §90.5); documentation should support applicability of such guidance.
Key Coverage Criteria
- Surgery of the ankle (including arthrodesis, arthroscopy, arthrotomy, and total joint replacement of the ankle) when medically necessary and when the member meets the applicable clinical coverage criteria referenced (InterQual® CP: Procedures: Arthrodesis, Ankle (Talotibial Joint); Arthroscopy, Surgical, Ankle; Arthrotomy, Ankle; Total Joint Replacement (TJR), Ankle).
- Ankle surgery to treat osteoarthritis when clinical criteria for surgical intervention are met.
- Ankle surgery to treat posttraumatic arthritis when clinical criteria for surgical intervention are met.
- Procedures listed in the policy procedure categories (Arthrodesis, Arthroscopy, Arthrotomy, Total Joint Replacement) when the member meets InterQual® clinical criteria (i.e., coverage tied to InterQual® criteria for those procedures).
- Arthroscopically aided repair of the ankle (CPT 29892) for osteochondritis dissecans lesion, talar dome fracture, or tibial plafond fracture is considered medically necessary when ALL of the following criteria have been met: Subjective symptoms include ANY of the following: Painful ankle joint; Joint swelling; Soft-tissue swelling; Stiffness; Catching, locking. [...]
- Endoscopic plantar fasciotomy (CPT 29893) for recalcitrant plantar fasciitis is considered medically necessary when ALL of the following criteria have been met: Subjective symptoms include ANY of the following: Chronic heel pain made worse with continued weight bearing; Heel pain increased with the first few steps in the morning; Non-radiating heel pain. Objective physical exam finding: Tenderness in the area of the medial tubercle of calcaneus. [...]
4 Active Policies
UHC-POL-surgery-ankle — Surgery of the Ankle
UMR-POL-UMR-surgery-ankle — Surgery of the Ankle
SUREST-POL-SUREST-surgery-ankle — Surgery of the Ankle
EVICORE-CMM-406-ARTHROSCOPY-ANKLE_FINAL — CMM-406: Arthroscopy Ankle
Related Codes
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