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Title of Medical Policy

Bunionectomy (or hallux valgus) Surgery

The services described in Oxford policies are subject to the terms, conditions and limitations of the Member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Oxford Medicare Advantage Members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies.

Certain policies may not be applicable to Self-Funded Members and certain insured products. Refer to the Member's plan of benefits or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit limitations applicable to any of these policies. If there is a difference between any policy and the Member’s plan of benefits or Certificate of Coverage, the plan of benefits or Certificate of Coverage will govern.

Coverage Statement

Policy is applicable to:

    Commercial plans

    Oxford Medicare Advantage® plans, including Medicare Group Accounts (MGA)

Conditions of Coverage

Benefit Type General benefits package
Referral Required
(Does not apply to non-gatekeeper products)
No
Authorization (Precertification always required for inpatient admission) Yes - Outpatient
Yes1 - Office
Precertification with MD Review No
Site(s) of Service
(If not listed, MD Review required)
Outpatient, Office
Special Considerations

1Precertification is required for services covered under the Member's General Benefits package when performed in the office of a participating provider. For Commercial, precertification is not required, but encouraged for out of network services performed in the office that are covered under the Member's General Benefits package. If precertification is not obtained, Oxford may review for medical necessity after the service is rendered.


Description of Service, Assessment, and Background Information

Bunionectomy, or hallux valgus surgery, involves the use of various surgical procedures to alleviate symptoms caused by pathology in the first metatarsal phalangeal joint (the base of the big toe). The diagnosis of hallux valgus denotes deviation of the great toe toward the fibular (outside) border of the foot. This condition may lead to significant foot pain and deformity. A bunion is not synonymous with hallux valgus, but refers to an area of swelling and/or enlargement involving the great toe.

Policy and Rationale

Bunionectomy surgery, including correction of hallux valgus deformities with or without osteotomy (incision of the bone), will be covered when the criteria set forth below in treatment/application guidelines are met. The procedures will be certified when performed to improve symptoms and to restore function. Oxford does not cover bunionectomy surgery for cosmetic effect.

Criteria for Coverage

A Bunionectomy (with or without osteotomy), or hallux valgus surgery, will be covered if all of the following criteria are met:

  1. There is presence of significant and persistent pain at the first metatarsalphalangeal joint which interferes with necessary physical activity e.g. walking, or there is ulcer development at the site of the bunion, the sole of the foot, or at the second toe,

  2. AND
  3. There is persistence of symptoms despite reasonable attempts at 6 months of significant conservative therapy e.g. shoe wear modification, padding/accommodative devices, corticosteroid injections, NSAID therapy, physical therapy or activity modification,

  4. AND
  5. There is, on physical examination and on X-ray, degenerative changes in the 1st MTP joint and/or valgus deformity >15 degrees and / or significant exostosis of the first metatarsal.

Copies of office notes outlining the Member's symptoms, the course of conservative treatment, as well as documentation of the degree of deformity may be requested to document this information.

Applicable ICD-9 Codes

ICD-9 Code Description
727.1 Bunion
735.0 Hallux valgus (acquired)
735.1 Hallux varus (acquired)
735.2 Hallux rigidus
735.3 Hallux malleus
735.4 Other hammer toe
754.52 Congenital metatarsus primus varus
755.66 Other congenital anomaly of toes

Applicable CPT Codes

CPT Code Description
28290 Correction, hallux valgus (bunion), with or without sesamoidectomy; simple exostectomy
28292 Correction, hallux valgus (bunion), with or without sesamoidectomy; Keller, McBride, or Mayo type procedure
28293 Correction, hallux valgus (bunion), with or without sesamoidectomy; resection of joint with implant
28294 Correction, hallux valgus (bunion), with or without sesamoidectomy; with tendon transplants (eg, Joplin type procedure)
28296 Correction, hallux valgus (bunion), with or without sesamoidectomy; with metatarsal osteotomy (eg Mitschell, Chevron, or concentric type procedures)
28297 Correction, hallux valgus (bunion), with or without sesamoidectomy; Lapidus type procedure
28298 Correction, hallux valgus (bunion), with or without sesamoidectomy; by phalanx osteotomy
28299 Correction, hallux valgus (bunion), with or without sesamoidectomy; by other methods (eg double osteotomy)
28306 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal
28307 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; first metatarsal with autograft
28308 Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each
28310 Osteotomy, shortening, angular or rotational correction; proximal phalanx, first toe (separate procedure)
28312 Osteotomy, shortening, angular or rotational correction; other phalanges, any toe

References

  1. AMA Current Procedural Terminology, CPT 2003, Professional Edition. 2002.
  2. Medicare Home Health Agency Manual: Transmittal 299, March 21, 2002.
  3. Richardson, M.L., Hansen, S.T., Kilcoyone, R.F. (1998) Radiographic evaluation of Hallux Valgus.
  4. http://www.rad.washington.edu/anatomy/halluxvalgus.html
  5. Campbell's Operative Orthopedics, Ninth Edition, pp. 1628-1647, 1998.
  6. Myerson, Foot and Ankle Disorders [2000], pages 213-288
  7. Medicare Legal Review, Aug. 13, 2003.

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Effective Date: January 1, 2005