Fighting For Subtalar Arthroereisis Insurance Coverage

Patrick DeHeer DPM FACFAS

Insurance companies are up there on my list of least favorites along with malpractice attorneys, plaintiff professional expert witnesses and foot and ankle orthopedic surgeons who initiate lawsuits against podiatrists. I have written about the latter groups already (see http://tinyurl.com/7mocb9t ). The insurance companies are next and I have a specific bone to pick with several of them including the gargantuan Anthem/Blue Cross.

In Indiana, Anthem has stopped paying for subtalar arthroereisis procedures, claiming they are investigational and not medically necessary. The reality is that in order to subsidize obscene bonuses for their respective CEOs or to build skyscrapers in major cities, most of the leading insurance companies simply carve a once reimbursed medical procedure from the ever shortening list.

I am going to quote the Anthem Medical Policy from 2010 to summarize its logic:

“In summary, the evidence in the peer-reviewed published literature is insufficient to draw conclusions as to the safety and effectiveness of subtalar arthroereisis with a surgically placed implant for the treatment of flatfoot deformity. Further research is required in the form of prospective controlled studies with long-term follow-up of functional improvement. This is particularly important given that the procedure is often performed in growing children.”1

The insurance company proceeds to quote two passages from the American College of Foot and Ankle Surgeons guidelines on adult and pediatric flatfoot to establish validity to its stance.2,3 The passages are as follows.

“… arthroereisis is seldom implemented as an isolated procedure. Because of the long-term compensation and adaptation of the foot and adjunctive structures for flatfoot function, other ancillary procedures are usually used for appropriate stabilization. Long-term results of arthroereisis in the adult flexible flatfoot patient have not been established. Some surgeons advise against the subtalar arthroereisis procedure because of the risks associated with implantation of a foreign material, the potential need for further surgery to remove the implant, and the limited capacity of the implant to stabilize the medial column sag directly (Lee, 2005).”2

“Proponents of this procedure (arthroereisis) argue that it is a minimally invasive technique that does not distort the normal anatomy of the foot. Others have expressed concern about placing a permanent foreign body into a mobile segment of a child's foot. The indication for this procedure remains controversial in the surgical community (Harris, 2004).”3

The Anthem/Blue Cross policy references several articles yet complains about the lack of peer-reviewed literature and the lack of randomized clinical trials consisting of reconstructive surgery without subtalar arthroereisis.1 The policy also criticizes the study sizes and complication rates. It points to a lack of data on symptom and functional improvement, noting that primarily retrospective studies are used to support the procedure. Finally, the insurance company references a lack of isolated contribution of subtalar arthroereisis on the overall treatment effect.

Practitioners have performed subtalar arthroereisis for more than 40 years and published 76 studies through 2010 on pediatric flatfoot and several others on adult flatfoot deformity.3 The statement of “the literature being insufficient to draw conclusions on safety and effectiveness” is completely untrue. Claiming that there is a lack of literature supporting isolated subtalar arthroereisis in comparison to other flatfoot procedures is ridiculous.

In most cases, one should not perform this procedure as a stand-alone procedure. Most of the cases requiring subtalar arthroereisis will have an equinus deformity that one must correct concurrently. In adults and older children, when there has been adaption of the midfoot and forefoot to the everted rearfoot position, surgeons must perform some type of medial column procedure to get the forefoot parallel to the corrected rearfoot position.

There has been controversy over subtalar arthroereisis since its inception but controversy does not make this an invalid procedure. The fact that the procedure has persisted and evolved for more than 40 years shows there must be something to it.

One particular article I would like to highlight is by Metcalfe and colleagues in Foot and Ankle International from 2011. This was a level 2 meta-analysis of 76 peer-reviewed journal articles.4 The conclusion of this article makes some profound statements.

• “Several studies have demonstrated significant improvements in key radiographic parameters reflecting both increased arch height and improved joint congruency following arthroereisis.”
• “Arthroereisis is an established yet evolving technique for the management of pediatric flatfoot deformity.”
• “The technical simplicity of arthroereisis does not imply lack of corrective power, nor longevity of correction.”4

I have performed hundreds of these procedures over 20 years, starting with the STA-Peg (Wright Medical) procedure and evolving to the various models of modern implants. When surgeons perform subtalar arthroereisis in appropriate cases and use it in conjunction with adjunctive procedures to correct additional deformities such as equinus and forefoot varus, it provides excellent deformity correction and symptom resolution.

This fight needs to be fought. We have to engage patients to hold their insurance companies accountable and demand they provide coverage for subtalar arthroereisis. We need to continue to produce studies that make this procedure irrefutable. We owe it to the pioneers in our profession who first developed the procedure. We owe it to our profession. Most importantly, we owe it to our patients.

References

1. Available at http://www.anthem.com/medicalpolicies/policies/mp_pw_b094101.htm .

2. Lee MS, Vanore JV, Thomas JL, et al. Clinical Practice Guideline Adult Flatfoot Panel: American College of Foot and Ankle Surgeons (ACFAS). Diagnosis and treatment of adult flatfoot. J Foot Ankle Surg. 2005; 44(2):78-113.

3. Harris EJ, Vanore JV, Thomas JL, et al. Clinical Practice Guideline Pediatric Flatfoot Panel: American College of Foot and Ankle Surgeons (ACFAS). Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg. 2004; 43(6):341-373.

4. Metcalfe SA, Bowling FL, Reeves ND. Subtalar joint arthroereisis in the management of pediatric flexible flatfoot: a critical review of the literature. Foot Ankle Int. 2011; 32(12):1127-39.

Comments

Thank you for your information and clarity of thought regarding fighting the systematic denial of claims for a valid and useful procedure. Like you, I use this procedure as an indicated procedure to correct the pathology that is manifested by dislocation of the talus from its normal anatomic position and therefore its normal function.

As I am preparing an appeal, I have found that the National Guideline Clearinghouse of the AHRQ Agency for Healthcare Research & Quality has a Guideline Archive that lists guidelines that have been withdrawn from the NGC Web site "because the guidelines they represent no longer meet the NGC Inclusion Criteria or the guidelines developer indicated that the guideline should be withdrawn." This applies to the guideline that appears in the insurance company's statement regarding the position statement from Harris et al.

If I can be of any assistance in this battle, please let me know. I hope my meta-analysis is helpful in summarizing the current evidence on this topic.

Kind regards from a wet U.K.

Stuart Metcalfe
Consultant Podiatrist
Clinic Lead Allied Health Professions, Solent NHS Trust
Honorary Lecturer, University of Southampton

Thank you Stuart. I do believe your meta-analysis provides the kind of data we need to fight this fight. Best wishes.

Patrick A. DeHeer, DPM

The same justification could be used to carve out ALL surgical procedures, treatments or drugs. There is never enough good clinical proof. That's why the communities continue to do studies. While physicians hold to the motto of "first do no harm," the insurance companies hold to the motto "first pay no claim."

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