Bone Lengthening for Congenital Conditions, Limb Discrepancies and Angular Deformities of Long Bones
DESCRIPTION
Bone lengthening (e.g., Ilizarov technique) involves the application of an external fixator device that attaches to the underlying bone via transfixion wires. A corticotomy (a removal of a piece of bone cortex, without disturbing the intramedullary blood supply) is performed, permitting attachment of the wires. Periodic adjustment of the external fixator produces a distractive lengthening force, which gradually stimulates new bone growth.
POLICY
Bone lengthening for the correction of function related to congenital conditions, post-traumatic limb length discrepancies, and/or angular/rotational deformities of long bones (i.e., humerus, radius, ulna, femur, tibia, and fibula) is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Bone lengthening of less than 3 cm is considered not medically necessary.
Bone lengthening/remodeling for appearance/esthetic purposes (e.g., short stature) is considered cosmetic.
Any device utilized for this procedure must have FDA approval specific to the indication, otherwise it will be considered investigational.
MEDICAL APPROPRIATENESS
Bone lengthening is considered medically appropriate if ANY ONE of the following criteria are met:
There is a demonstrable non-union of a long bone with or without bone loss or infection
Lengthening of an amputated stump is needed for proper fitting of a prosthesis
Leg lengthening is needed to equalize leg length discrepancy greater than 6 cm
The individual has bone defects with or without deformities
IMPORTANT REMINDER
We develop Medical Policies to provide guidance to Members and Providers. This Medical Policy relates only to the services or supplies described in it. The existence of a Medical Policy is not an authorization, certification, explanation of benefits or a contract for the service (or supply) that is referenced in the Medical Policy. For a determination of the benefits that a Member is entitled to receive under his or her health plan, the Member's health plan must be reviewed. If there is a conflict between the Medical Policy and a health plan, the express terms of the health plan will govern.
ADDITIONAL INFORMATION
Bone lengthening of less than 6 cm or greater than 15 cm should be referred for BCBST physician review.
SOURCES
BlueCross BlueShield Association. Medical Policy Reference Manual. (4:2004). Ilizarov bone-lengthening procedure (7.01.11). Retrieved July 21, 2011 from BlueWeb. (4 articles and/or guidelines reviewed)
Choi, I. H., Cho, T. J., & Moon, H. J. (2011). Ilizarov treatment of congenital pseudarthrosis of the tibia: a multi-targeted approach using the Ilizarov technique. Clinics in Orthopedic Surgery, 3 (1), 1-8.
Choi, I. H., Yoo, W. J., Cho, T. J., & Chung, C. Y. (2006). Operative reconstruction for septic arthritis of the hip. The Orthopaedic Clinics of North America, 37(2):173 - 83, vi.
Hasenboehler, E., Smith, W. R., Laudicina, L., Philips, G. C., Stahel, P. F., & Morgan, S. J. (2006). Fatigue behavior of Ilizarov frame versus tibial interlocking nail in a comminuted tibial fracture model: A biomechanical study. Journal of Orthopaedic Surgery and Research, 1, 16.
Heiss, C., Meissner, S. A., Hoesel, L. M., Pfeil, J., & Schnettler, R. (2006). Posteromedial approach to proximal tibia for corticotomy in callus distractions. Clinical Orthopaedics and Related Research, 451, 182-188.
Lie, C. W., & Chow, W. (2009). Limb lengthening in short-stature patients using monolateral and circular external fixators. Hong Kong Medical Journal, 15, (4), 280 - 284. (Level 4 Evidence - Independent study)
Rozbruch, S. R., Segal, K., IIizarov, S., Fragomen, A. T., & IIizarov, G. (2010). Does the Taylor Spatial Frame accurately correct tibial deformities? Clinical Orthopaedics and Related Research, 468 (5), 1352-1361.
Sabharwal, S., Green, S., McCarthy, J., & Handy, R. C. (2011). What's new in limb lengthening and deformity correction. The Journal of Bone and Joint Surgery, 96 (2), 213-221.
Spiegeberg, B., Parratt, T., Dheerendra, S. K., Khan, W. S., Jennings, R., & Marsh, D. R. (2010). Ilizarov principles of deformity correction. Annals of the Royal College of Surgeons of England, 92 (2), 101-105.
U. S. Food and Drug Administration. (2009. June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K090926. Retrieved July 21, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf9/K090926.pdf.
U. S. Food and Drug Administration. (2009. March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K083636. Retrieved July 21, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf8/K083636.pdf.
U. S. Food and Drug Administration. (2005. August). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K052065. Retrieved July 21, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf5/K052065.pdf.
U. S. Food and Drug Administration. (2005, July). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K051180. Retrieved July 21, 2011 from http://www.accessdata.fda.gov/cdrh_docs/pdf5/K051180.pdf.
ORIGINAL EFFECTIVE DATE: 8/1990
MOST RECENT REVIEW DATE: 8/11/2011
ID_BT
Policies included in the Medical Policy Manual are not intended to certify coverage availability. They are medical determinations about a particular technology, service, drug, etc. While a policy or technology may be medically necessary, it could be excluded in a member's benefit plan. Please check with the appropriate claims department to determine if the service in question is a covered service under a particular benefit plan. Use of the Medical Policy Manual is not intended to replace independent medical judgment for treatment of individuals. The content on this Web site is not intended to be a substitute for professional medical advice in any way. Always seek the advice of your physician or other qualified health care provider if you have questions regarding a medical condition or treatment.
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