Kotlier Jacob L, Fathi Amir, Ong Meng-Yung, Yazditabar Josh M, Panoussi Ethan E, Mayfield Cory K, Petrigliano Frank A, Liu Joseph N, Peterson Alexander B, Tan Eric W
Keck School of Medicine of USC, Los Angeles, CA, USA.
Foot Ankle Orthop. 2024 Mar 24;9(1):24730114241239310. doi: 10.1177/24730114241239310. eCollection 2024 Jan.
Total ankle arthroplasty (TAA), first developed as an alternative to ankle arthrodesis, has become an increasingly popular management option for end-stage ankle arthritis. Prior studies have shown commercial insurance payers base their coverage criteria on limited and low level of evidence research. This study aims to quantify and describe the evidence insurance companies use to support TAA coverage policies.
The top 11 national commercial health insurance payers for TAA were identified. A google search was performed to identify payer coverage policies. Policy documents were examined and cited references were classified by type of reference as well as reviewed for level of evidence (LOE). Specific coverage criteria for each individual payer were then extracted. Criteria were compared to assess for similarities among commercial payers. Finally, all references cited by each payer were examined to determine whether they mentioned the specific payer criteria.
Six of the 11 payers had accessible coverage policies. The majority of cited references were primary journal articles (145, 60.9%) and the majority of references cited (179, 75.2%) were level III or level IV evidence. We found significant homogeneity in coverage criteria among payers. In addition, cited sources inconsistently mentioned specific payer coverage criteria.
This study demonstrates that commercial insurance payers rely on the relatively low level of currently available scientific evidence when formulating coverage policies for TAA use and adopt criteria that have not been thoroughly analyzed in the literature. More high level of evidence research is needed to help clinicians and insurance companies further refine indications for TAA so that patients who might benefit from the procedure are adequately covered.
Level IV, review.
全踝关节置换术（TAA）最初是作为踝关节融合术的替代方法而开发的，现已成为终末期踝关节炎越来越受欢迎的治疗选择。先前的研究表明，商业保险支付方的覆盖标准基于有限且证据水平较低的研究。本研究旨在量化和描述保险公司用于支持TAA覆盖政策的证据。
确定了全国11家TAA商业健康保险支付方。通过谷歌搜索确定支付方的覆盖政策。检查政策文件，并将引用的参考文献按参考文献类型分类，并评估证据水平（LOE）。然后提取每个支付方的具体覆盖标准。比较这些标准以评估商业支付方之间的相似性。最后，检查每个支付方引用的所有参考文献，以确定它们是否提及了具体的支付方标准。
11家支付方中有6家有可获取的覆盖政策。引用的参考文献大多数是主要期刊文章（145篇，60.9%），引用的参考文献大多数（179篇，75.2%）是III级或IV级证据。我们发现支付方之间的覆盖标准存在显著的同质性。此外，引用的来源不一致地提及具体的支付方覆盖标准。
本研究表明，商业保险支付方在制定TAA使用的覆盖政策时依赖于目前可用的相对较低水平的科学证据，并采用了尚未在文献中进行充分分析的标准。需要更多高水平的证据研究来帮助临床医生和保险公司进一步完善TAA的适应症，以便使可能从该手术中受益的患者得到充分覆盖。
IV级，综述。
