L8642 — Hallux implant
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- - Appropriate ICD-10 diagnosis code: M20.20 - M20.22 (when claiming covered procedures)
- - Operative plan indicating intended procedure (hemiarthroplasty or total prosthetic replacement with silastic implant such as In2Bones RTS) and implant identification (manufacturer/model) when applicable
- - Pre-operative imaging (radiographs and any other relevant imaging) documenting joint degeneration consistent with hallux rigidus
- - Evidence of prior conservative treatment attempts (conservative therapies are emphasized in the background: exercise, physiotherapy, orthoses, NSAIDs, steroid injections) — policy references conservative treatment but does not state an explicit prior-therapy requirement
Key Coverage Criteria
- Arthrodesis (first MPJ arthrodesis): 'remains the gold standard for arthritis and salvage of the painful first MPJ' and 'support the use of arthrodesis for the treatment of stage III hallux rigidus.'
- Interpositional (soft-tissue/biologic spacer) arthroplasty: as a motion-sparing/salvage procedure for severe hallux rigidus to relieve pain while preserving motion (reported in case series and retrospective studies).
- Silicone (silastic) double-stem flexible implants (with titanium grommets) and metallic hemi-arthroplasty: used for replacement arthroplasty of the first MPJ in patients with painful/destroyed joints (historical and investigational use described).
- Disabling arthritis of the first metatarsal phalangeal joint (hallux rigidus)
- Hemiarthroplasty for persons with disabling arthritis of the first metatarsal phalangeal joint (hallux rigidus)
- CPT codes covered if selection criteria are met: 28291 (Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant)
2 Active Policies
CIGNA-0446 — Metatarsophalangeal Joint Replacement - (0446)
AETNA-CPB-0708 — Metatarsal Phalangeal Joint Replacement
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.