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Clinical Policy Bulletin:
Wrist Arthroplasty
Number: 0853


Policy

Aetna considers total wrist arthroplasty medically necessary for rheumatoid arthritis affecting the wrist in persons who have radiographic evidence of wrist joint destruction with demonstrated resistance or failure to conservative medical treatment (3 or more months of nonsteroidal antiinflammatory drugs (NSAIDS), disease modifying antirheumatic drugs (DMARDs), and/or glucocorticoids, as appropriate). Total wrist arthroplasty is considered experimental and investigational for diagnoses other than rheumatoid arthritis because there is inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness.



Background

Total wrist arthroplasty involves the implantation of a prosthetic joint, with the goals of reducing pain and preserving or increasing wrist mobility. The procedure is almost always performed to relieve the symptoms of severe arthritis. These components come in extra-small, small, medium, and large sizes to match patient anatomy. To enable movement and prevent dislocation, the polyethylene spacer has a convex end that slides on the surface of a concave plate on the radial component. 

Several wrist implants have been developed since the early 1970s. First-generation were silicone implants, such as those designed by Swanson in the 1980s. Second-generation implants typically included two metal components that articulated by means of a ball-and-socket or a hemispheric design. Many of these early implants were taken off the market because of problems with joint imbalance and dislocation. The third generation of wrist prostheses were developed in an effort to better approximate the center of motion to prevent imbalance and dislocation. Examples include the revised Meuli design (MWP III), as well as the Trispherical, the Universal, and the Biaxial designs, the latter of which has been discontinued.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
25446
ICD-9 codes covered if selection criteria are met:
714.0 Rheumatoid arthritis
714.1 Felty’s syndrome
714.2 Other rheumatoid arthritis with visceral or systemic involvement


The above policy is based on the following references:
  1. Bosco JA et al. Long-term outcome of Volz total wrist arthroplasties. J Arthroplasty, 9(1): 25-31 1994.
  2. Canale & Beaty: Campbell's Operative Orthopedics. Eleventh Edition. 2007.
  3. Ferreres A et al. Universal total wrist arthroplasty: mid-term follow-up study. J Hand Surg Am, 36(6): 967-73  2011.
  4. Frontera: Essentials of Physical Medicine and Rehabilitation. First Edition. 2002.
  5. Goldman: Cecil Medicine. Twenty-third Edition. 2007. Twenty Fourth Edition. 2011
  6. Levadoux M; Legre R. Total wrist arthroplasty with Destot prostheses in patients with posttraumatic arthritis. J Hand Surg[Am], 28(3): 405-13  2003.
  7. Meuli HC; Fernandez DL. Uncemented total wrist arthroplasty. J Hand Surg [Am], 20(1): 115-22  1995.
  8. Skinner: Current Diagnosis and Treatment. Third Edition. 2003.
  9. Slagel BE et al. Management of post-traumatic malunion of fractures of the distal radius. Orthopedic Clinics of North America, Vol 38, Iss 2  2007.
  10. Terral TG; Freeland AE. Early salvage reconstruction of severe distal radius fractures. Clin Orthop, (327): 147-51 1996..
  11. Turner RG et al. Complications of distal radius fractures. Orthopedic Clinics of North America,  Volume 38, Issue 2  2007.
  12. Weiss KE; Rodner CM. Osteoarthritis of the wrist. J Hand Surg, 32A:725-746  2007.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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