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Clinical Policy Bulletin:
Elbow Arthroplasty
Number: 0857


Policy

Aetna considers total elbow arthroplasty medically necessary for the treatment of pain unresponsive to medical therapy, when radiographs demonstrate destruction of articular cartilage or gross deformity, inability to use the extremity for functions of daily living because of pain, motion loss, or instability, refractory sepsis, elbow ankylosis after sepsis or trauma and salvage/revision of a failed implant.

Aetna considers arthroplasty with a metal radial head medically necessary in the treatment of an unreconstructible comminuted fracture of the radial head; the clinical literature has shown that silicone implants are not resistant to wear.



Background

Arthroplasty is the surgical reconstruction or replacement of a malformed or degenerated joint that is done to relieve pain and restore range of motion to the joint.Total elbow arthroplasty is indicated for the treatment of pain unresponsive to medical therapy, when radiographs demonstrate destruction of articular cartilage or gross deformity, inability to use the extremity for functions of daily living because of pain, motion loss, or instability, refractory sepsis, elbow ankylosis after sepsis or trauma and salvage/revision of a failed implant.

A fracture of the radial head is a complete or incomplete break in the radius occurring at its head, the disc-shaped portion of the bone closest to the elbow. A comminuted fracture involves the entire radial head, which separates into discrete fragments. This type of fracture involves the head of the radius, the elbow joint, and the soft tissue surrounding the fracture site, including nerves, tendons, ligaments, blood vessels, cartilage, and muscles. The mechanism of injury is usually indirect, resulting from a fall onto the palm of the hand, in which the upper limb is in a variable position of flexion of the elbow, and the forearm in pronosupination. Patients present with pain, swelling, limited motion, especially forearm rotation. 

Based on the clinical evidence, arthroplasty with a metal radial head is an acceptable alternative in the treatment of an unreconstructible comminuted fracture. The clinical literature has shown that silicone implants are not resistant to wear.

 
CPT Codes / HCPCS Codes / ICD-9 Codes
CPT codes covered if selection criteria are met:
24360
24361
24362
24363
24365
24366
24370
24371
ICD-9 codes covered if selection criteria are met:
711.02 Pyogenic [septic] arthritis [elbow]
718.52 Ankylosis of joint [elbow]
718.82 Other joint derangement, not elsewhere classified [instability of elbow joint]
719.42 Pain in joint [elbow]
813.05 Fracture radial head
996.40 - 996.49 Mechanical complication of internal orthopedic device, implant and graft
996.66 Infection due to internal joint prosthesis


The above policy is based on the following references:
  1. Canale: Campbell's Operative Orthopaedics. Tenth Edition. 2003.
  2. Current Diagnosis and Treatment in Orthopedics. Second Edition. 2000.
  3. Ruddy: Kelley's Textbook of Rheumatology. Sixth Edition. 2001.
  4. Bain GI et al. Management of Mason type-III radial head fractures with a titanium prosthesis, ligament repair, and early mobilization. Surgical technique. J Bone Joint Surg Am, 87 Suppl 1(Pt 1): 136-47  2005.
  5. Browner: Skeletal Trauma: Basic Science, Management and Reconstruction. Third Edition. 2003. Fourth Edition. 2008.
  6. Calfee R et al. Radial head arthroplasty. J Hand Surg [Am], 31(2): 314-21  2006.
  7. Canale: Campbell’s Operative Orthopaedics. Tenth Edition. 2003. Eleventh Edition. 2007.
  8. Chapman CB et al. Vitallium radial head prosthesis for acute and chronic elbow fractures and fracture-dislocations involving the radial head. J Shoulder Elbow Surg, 15(4): 463-73  2006.
  9. Doornberg JN et al. Radial head arthroplasty with a modular metal spacer to treat acute traumatic elbow instability. J Bone Joint Surg Am, 89:1075-1080  2007.
  10. Grewal R et al. Comminuted radial head fractures treated with a modular metallic radial head arthroplasty. Study of outcomes. J Bone Joint Surg Am, 88: 2192-2200  2006.
  11. Harrington IJ et al. The functional outcome with metallic radial head implants in the treatment of unstable elbow fractures: a long-term review. J Trauma, 50(1): 46-52  2001.
  12. King GJ. Management of comminuted radial head fractures with replacement arthroplasty. Hand Clin, 20(4): 429-41, vi  2004.
  13. Kuntz DG; Baratz ME. Fractures of the elbow. Orthopedic Clinics of North America, 30(1)   1999.
  14. Martinelli B. Silicone-implant replacement arthroplasty in fractures of the radial head. A follow-up report. Bull Hosp Jt Dis Orthop Inst, 45(2): 158-61  1985.
  15. Moro JK et al. Arthroplasty with a metal radial head for unreconstructible fractures of the radial head. J Bone Joint Surg Am, 83-A(8): 1201-11  2001.
  16. Rizzo M; Nunley JA. Fractures of the elbow’s lateral column radial head and capitellum. Hand Clin, 18(1): 21-42  2002.
  17. Rosenblatt Y et al. Current Recommendations for the Treatment of Radial Head Fractures. Orthopedic Clinics of North America, Volume 39, Issue 2 (April 2008).
  18. Swanson AB et al. Comminuted fractures of the radial head. The role of silicone-implant replacement arthroplasty. J Bone Joint Surg Am, 63(7): 1039-49  1981.
  19. U.S. Food & Drug Administration website.


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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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