A54.40 — Gonococcal infection of musculoskeletal system, unspecified
ICD-10-CM
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Informed consent documentation that discusses limited long-term durability, complication and revision risks, and alternative (ankle arthrodesis) including potential impact on adjacent joints.
- Device-specific requirements where applicable (e.g., manufacturer instructions for use, and, for STAR, participation in post-marketing surveillance as required by FDA — though this is manufacturer obligation, not patient documentation).
- If infection is suspected intra-operatively, documentation of intra-operative cultures and any fresh frozen section (FFS) results if performed (FFS sensitivity/specificity discussed in background).
- Studies used pre- and post-operative clinical and radiographic examinations (examples: VAS, AOFAS Ankle Hindfoot Score, SF-12, JSSF scale, FAOS) to document outcomes.
Key Coverage Criteria
- Total ankle arthroplasty (TAA) using a Food and Drug Administration-cleared implant medically necessary when the following criteria are met: TAA is used to replace an arthritic or severely degenerated ankle
- Member is skeletally mature
- Member has moderate or severe pain with loss of ankle mobility and function
- Arthritic or degenerated ankle is due to osteoarthritis (degenerative arthritis), post-traumatic arthritis and rheumatoid arthritis
- Member has have failed at least 6 months of conservative management (including physical therapy, non-steroidal anti-inflammatory drugs, and orthoses as indicated)
- End-stage ankle arthritis (end-stage ankle osteoarthritis/OA) — TAR/TAA as a treatment option
1 Active Policy
AETNA-CPB-0645 — Total Ankle Arthroplasty
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