Harvard Pilgrim covers partial or total replacement of the first metatarsophalangeal (MTP) joint without prior authorization for certain diseases or disorders that cause painful stiffness or deformation of the big toe. Effective June 1, 2018, Harvard Pilgrim is updating our commercial medical policy to indicate that the following CPT and HCPCS codes will be covered for the partial or total replacement of the first MTP joint only when they are reported with the appropriate ICD-10 diagnosis code from the code range M20.20 – M20.22, Hallux rigidus:
- CPT codes:
- 28291 – Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant
- 26535 – Arthroplasty, interphalangeal joint; each joint
- 26536 – Arthroplasty, interphalangeal joint; with prosthetic implant, each joint
- HCPCS codes:
- L8641 – Metatarsal joint implant
- L8642 – Hallux implant
The criteria also specifies that this procedure is appropriate only if conservative treatment, such as exercise, physiotherapy, and non-steroidal anti-inflammatory drugs, has been tried without success and the patient has persistent symptoms from hallux valgus or hallux ridigus due to degenerative joint disease of the first MTP joint.
Under the updated policy, ceramic implants (for example, Moje prosthesis) and replacement of tarsometatarsal joint will not be eligible for reimbursement.
For complete information, refer to the updated Partial or Total Replacement of the First Metatarsophalangeal Joint Medical Policy.
