Connective Tissue Graft for 1st MTP Fusion: Medical Necessity Assessment
The connective tissue graft (C1762) requested for this 1st MTP fusion procedure should be considered experimental and investigational, as there is no established evidence supporting its use in arthrodesis procedures for hallux limitus or post-traumatic arthritis, and the insurance policy explicitly limits coverage to ulcer-related indications.
Evidence-Based Analysis of the Request
Standard of Care for 1st MTP Fusion
The 1st MTP arthrodesis is well-established as the gold standard surgical treatment for end-stage arthritis and severe deformity when conservative measures fail 1, 2. This patient meets clear criteria for fusion:
- Moderate degenerative changes on radiograph 1
- Failed conservative management (shoe modifications, NSAIDs) 1, 2
- Progressive symptoms with decreased range of motion 1
- Post-traumatic arthritis with hallux limitus 3, 4
The arthrodesis procedure itself (CPT 28750) is medically necessary and appropriate 1, 2, 3, 5, 4.
Connective Tissue Graft: Lack of Supporting Evidence
The critical issue is the requested connective tissue graft (C1762). A thorough review of the evidence reveals:
No established role in arthrodesis procedures: The literature on 1st MTP fusion consistently describes standard fixation methods (screws, staples, plates) without routine use of connective tissue grafts 4. When bone defects exist, interposition autograft or allograft bone is used—not soft tissue grafts 4.
Soft tissue grafts serve different purposes: Connective tissue grafts in foot surgery are documented for:
- Soft tissue interposition arthroplasty (a motion-preserving alternative to fusion) 6, 7
- Gingival/periodontal procedures 8
- Socket preservation in dental implants 8
- Root coverage procedures 8
None of these applications involve arthrodesis procedures 6, 7.
Insurance Policy Limitations
The insurance policy scope explicitly restricts connective tissue graft coverage to:
- Ulcers due to diabetes
- Venous ulcers
- Burns
This patient has none of these conditions. The policy does not include arthrodesis or degenerative joint disease as covered indications.
Clinical Decision Algorithm
When Connective Tissue Grafts ARE Indicated in Foot Surgery:
- Interposition arthroplasty (motion-preserving procedure using capsular tissue or tendon as biologic spacer) 6, 7
- Diabetic foot ulcers with limited 1st MTP motion requiring arthroplasty (not fusion) 1, 2
When Bone Grafts ARE Indicated in 1st MTP Fusion:
- Significant bone defects requiring structural support 4
- Revision procedures with bone loss 3
- Use autograft or allograft bone—not soft tissue 4
This Patient's Appropriate Treatment:
Standard 1st MTP arthrodesis with internal fixation alone 5, 4. The radiograph shows "moderate degenerative change" without description of significant bone loss requiring grafting 4.
Critical Pitfalls to Avoid
Do not confuse interposition arthroplasty with arthrodesis: Interposition procedures use soft tissue to preserve motion 6, 7. Arthrodesis eliminates motion through bony fusion 4. These are fundamentally different procedures with different indications.
The surgeon's note mentions "depending on joint surface condition": If intraoperative findings reveal the joint is salvageable, cheilectomy (bone spur removal) would be appropriate 1. If interposition arthroplasty is performed instead of fusion, soft tissue interposition could be justified 6, 7. However, this would require different CPT coding—not 28750 (arthrodesis).
Connective tissue grafts do not enhance fusion rates: The spine surgery literature demonstrates that when grafts are needed for fusion, bone grafts (autograft or allograft) are used—not soft tissue 8. This principle applies to extremity arthrodesis as well 4.
Recommendation for Authorization
Approve: CPT 28750 (1st MTP arthrodesis) - medically necessary 1, 2, 5, 4
Deny: C1762 (connective tissue graft) - experimental/investigational for this indication, not supported by evidence, and outside policy coverage criteria
Alternative consideration: If the surgeon intraoperatively determines that interposition arthroplasty (not fusion) is more appropriate, this would require different authorization with appropriate CPT coding for arthroplasty, at which point soft tissue interposition could be reconsidered 6, 7.