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
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 September 16, 2009 from BlueWeb. (4 articles and/or guidelines reviewed)
Choi, I., Yoo, W., Cho, T., & Chung, C. (2006). Operative reconstruction for septic arthritis of the hip. The Orthopaedic Clinics of North America, 37(2):173 - 83, vi. (Level 5 Evidence)
DeCoster, T., Gehlert, R., Mikola, E., & Pirela-Cruz, M. (2004). Management of posttraumatic segmental bone defects. Journal of American Academy of Orthopaedic Surgeons, 12 (1), 28 - 38. (Level 5 Evidence)
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. (Level 5 Evidence)
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. (Level 2 Evidence)
Lie, C., & Chow, W. (2009). Limb lengthening in short-stature patients using monolateral and circular external fixators. Hong Kong Medical Journal, 15, (4), 280 - 284. (Level 5 Evidence)
Palusaka, S. A. (2004). Osteomyelitis. Clinics in Family Practice, 6 (1), 127-156.
Parsons, B., & Strauss, E. (2004). Surgical management of chronic osteomyelitis. The American Journal of Surgery, 188, 57S - 66S. (Level 5 Evidence)
U. S. Food and Drug Administration. (2002. June). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K012634, Retrieved September 16, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf/k012634.pdf.
U. S. Food and Drug Administration. (2004. October). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K042436, Retrieved September 16, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf4/k042436.pdf.
U. S. Food and Drug Administration. (2005. February). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K043174, Retrieved September 16, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf4/K043174.pdf.
U. S. Food and Drug Administration. (2005. July). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K051180, Retrieved September 16, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf5/K051180.pdf.
U. S. Food and Drug Administration. (2009. March). Center for Devices and Radiological Health. 510(k) Premarket Notification Database. K083636, Retrieved September 16, 2009 from http://www.accessdata.fda.gov/cdrh_docs/pdf8/K083636.pdf.
ORIGINAL EFFECTIVE DATE: 8/1990
MOST RECENT REVIEW DATE: 11/12/2009
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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