Foot Orthotics for Conditions Other Than Diabetes

Policy ID: O-12-037

Section: Orthotic & Prosthetic Devices

Effective Date: November 01, 2019

Revised Date: December 12, 2023

Revision Effective Date: January 01, 2024

Last Reviewed: January 16, 2024

Applies To: Commercial and Medicaid Expansion

Description

Orthotics protect, restore and/or improve the function of moveable parts of the body with orthopedic appliances or apparatus. Orthotic appliances or apparatus support, align, prevent and/or correct deformities.

Criteria

Foot orthotics may be considered medically necessary when ALL of the following criteria are met:

An eligible provider has ordered/prescribed the foot orthotics; and
The foot orthotics are fabricated to meet the needs of the individual.
- Note: This may or may not include the shoe and any modifications and/or transfers necessary to make the orthotic functional and effective.

Foot orthotics may be considered medically necessary for an individual with ANY ONE of the following conditions:

Achilles tendonitis; or
Calcaneal apophysitis; o r
Calcaneal Spur; or
Chondromalacia of the patella secondary to pronation deformity of the foot; or
Degenerative joint disease/osteoarthrosis of ankle and foot; or
Neuroma; or
Plantar fasciitis; or
Posterior tibial insufficiency (Posterior tibial tendon dysfunction; or
Status post recurrent ankle sprain with high calcaneal varus; or
Tibialis anterior tendonitis; or
Tibialis posterior tendonitis; or
Peroneal tendonitis; or
Juvenile osteochondrosis of foot; or
Clubfoot/acquired equinovarus deformity/talipes equinovarus, congenital/talipes; or
Hallus rigidus; or
Hammertoe digit syndrome; or
Limb length discrepancy; or
Metatarsus adductus in children/metatarsus varus, congenital/metatarsus primus varus, congenital; or
Pes cavus deformity; or
Rheumatoid arthritis/Felty's syndrome/polyarthropathies; or
Status post foot surgery for continued correction (e.g., surgically treated fractures); or
Symptomatic hallux valgus/other congenital anomalies of toes; or
Symptomatic intractable plantar keratosis; or
Peripheral neuropathy; or
Vascular ulcers.

Foot orthotics for non-surgically treated fractures is considered not medically necessary unless documentation satisfactorily establishes the medical necessity of the orthotics.

Quantity Level Limits (QLL) for Foot Orthotics for Conditions other than Diabetes

Individuals meeting the above orthotic coverage is limited to:

One (1) orthotic per foot within one (1) calendar year

Foot Orthotics not meeting the criteria as indicated in this policy are considered not medically necessary.

Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as not medically necessary.

Replacement

Replacement of foot orthotics every one (1) calendar year may be considered medically necessary in cases of:

Irreparable damage; or
Wear and tear with normal use: or
When required because of a change in the individual's condition.

Separate foot orthotics for multiple pairs of footwear is considered not medically necessary.

Procedure Codes

L3000

L3001

L3002

L3003

L3010

L3020

L3030

L3031

L3161

L3208

L3209

L3211

L3260

L3340

L3350

L3485

Foot care products that can be purchased over-the-counter without a prescription (e.g., pre-molded arch supports) do not meet the definition of foot orthotics and therefore, are non- covered.

Procedure Codes

L3040

L3050

L3060

L3100

L3170

Orthotic shoes may be considered medically necessary ONLY when they are an integral part of a brace (when reported with a KX modifier).

Orthotic shoes that are not an integral part of a brace are non-covered.

Procedure Codes

L2999

L3201

L3202

L3203

L3212

L3213

L3214

L3215

L3216

L3217

L3219

L3221

L3222

L3224

L3225

L3230

L3251

L3252

L3253

L3254

L3255

L3257

L3265

L3390

L3400

L3410

L3420

L3430

L3440

L3450

L3455

L3460

L3465

L3470

L3480

L3500

L3510

L3520

L3530

L3540

L3550

L3560

L3570

L3580

L3590

L3595

L3600

L3610

L3620

L3630

L3640

L3649

Orthotic Shoes may be considered medically necessary for a diagnosis of clubfoot and must be attached to a brace, including an abduction bar (when reported with a KX modifier).

Orthotic shoes not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

L3204

L3206

L3207

L3140

L3150

L3380

Heel replacements, lift elevation(s), sole replacements, and shoe transfers (when reported with a KX modifier) involving shoes on a covered brace may be considered medically necessary.

Inserts and other shoe modifications (when reported with a KX modifier) may be considered medically necessary when they are on a shoe that is an integral part of a covered brace and medically necessary for the proper functioning of the brace.

Inserts and other shoe modifications not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

K1015

L3070

L3080

L3090

L3160

L3300

L3310

L3320

L3330

L3332

L3334

L3360

L3370

L3390

L3400

L3410

L3420

L3430

L3440

L3450

L3455

L3460

L3465

L3470

L3480

L3500

L3510

L3520

L3530

L3540

L3550

L3560

L3570

L3580

L3590

L3595

L3600

L3610

L3620

L3630

L3640

L3649

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes: L3070, L3080, L3090, L3160, L3201, L3202, 3203, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3251, L3252, L3253, L3254, L3255, L3257, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3360, L3370, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649

G57.60

G57.61

G57.62

G57.63

G57.81

G57.82

G57.83

G57.91

G57.92

G57.93

L11.0

L85.0

L85.1

L85.2

L86

L87.0

L87.2

M05.051

M05.052

M05.061

M05.062

M05.071

M05.072

M05.09

M05.151

M05.152

M05.161

M05.162

M05.171

M05.172

M05.19

M05.251

M05.252

M05.261

M05.262

M05.271

M05.272

M05.29

M05.351

M05.352

M05.361

M05.362

M05.371

M05.372

M05.39

M05.451

M05.452

M05.461

M05.462

M05.471

M05.472

M05.49

M05.551

M05.552

M05.561

M05.562

M05.571

M05.572

M05.59

M05.651

M05.652

M05.661

M05.662

M05.671

M05.672

M05.69

M05.7A

M05.751

M05.752

M05.761

M05.762

M05.771

M05.772

M05.79

M05.8A

M05.851

M05.852

M05.861

M05.862

M05.871

M05.872

M05.89

M06.0A

M06.051

M06.052

M06.061

M06.062

M06.071

M06.072

M06.08

M06.09

M06.1

M06.251

M06.252

M06.261

M06.262

M06.271

M06.272

M06.28

M06.29

M06.351

M06.352

M06.361

M06.362

M06.371

M06.372

M06.38

M06.39

M06.4

M06.8A

M06.851

M06.852

M06.861

M06.862

M06.871

M06.872

M06.88

M06.89

M08.0A

M08.051

M08.052

M08.061

M08.062

M08.071

M08.072

M08.08

M08.09

M08.2A

M08.251

M08.252

M08.261

M08.262

M08.271

M08.272

M08.28

M08.29

M08.3

M08.4A

M08.451

M08.452

M08.461

M08.462

M08.471

M08.472

M08.48

M08.851

M08.852

M08.861

M08.862

M08.871

M08.872

M08.89

M08.9A

M08.951

M08.952

M08.961

M08.962

M08.971

M08.972

M08.98

M08.99

M12.051

M12.052

M12.061

M12.062

M12.071

M12.072

M12.09

M19.071

M19.072

M19.09

M19.19

M19.29

M19.171

M19.172

M19.271

M19.272

M19.90

M20.11

M20.12

M20.21

M20.22

M20.30

M20.31

M20.32

M20.41

M20.42

M20.5X1

M20.5X2

M20.5X9

M20.60

M20.61

M20.62

M21.171

M21.172

M21.271

M21.272

M21.279

M21.531

M21.532

M21.539

M21.541

M21.542

M21.549

M21.611

M21.612

M21.621

M21.622

M21.6X1

M21.6X2

M21.751

M21.752

M21.761

M21.762

M21.763

M21.764

M22.41

M22.42

M24.19

M24.29

M24.39

M24.49

M24.59

M24.69

M24.89

M25.69

M67.961

M67.962

M72.2

M76.61

M76.62

M76.71

M76.72

M76.811

M76.812

M76.821

M76.822

M77.31

M77.32

M77.51

M77.52

M92.61

M92.62

M92.71

M92.72

M92.8

Q66.00

Q66.01

Q66.02

Q66.10

Q66.11

Q66.12

Q66.211

Q66.212

Q66.219

Q66.221

Q66.222

Q66.229

Q66.30

Q66.31

Q66.32

Q66.40

Q66.41

Q66.42

Q66.70

Q66.71

Q66.72

Q66.81

Q66.82

Q66.89

Q66.90

Q66.91

Q66.92

Q74.2

S93.401D

S93.401S

S93.402D

S93.402S

S93.411D

S93.411S

S93.412D

S93.412S

S96.901D

S96.901S

S96.902D

S96.902S

S96.911D

S96.911S

S96.912D

S96.912S

S96.919A

Covered Diagnosis Codes For Procedure Codes L3140, L3150, L3204, L3206, L3207, and L3380

M21.171

M21.172

M21.541

M21.542

M21.549

Q66.00

Q66.01

Q66.02

Q66.89

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 Coding update

4-1-2020 Added additional Procedure codes to covered Diagnosis codes to match system logic

Internal Medical Policy Committee 9-21-2020 Coding update;

AddedCovered Diagnosis Codes for Procedure Codes: L3070, L3080, L3090, L3160, L3201, L3202, 3203, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3251, L3252, L3253, L3254, L3255, L3257, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3360, L3370, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649: M05.7A; M05.8A; M06.0A; M06.8A; M08.0A; M08.2A; M08.4A; M08.9A; M19.09; M19.19; M19.29; M24.19; M24.29; M24.39; M24.49; M24.59; M24.69; M24.89; and M25.69.

Internal Medical Policy Committee 3-17-2021 Coding update:

Added procedure code K1015

Internal Medical Policy Committee 11-23-2021 Revision

Updated clarifying language

Internal Medical Policy Committee 11-29-2022 Annual Review-no changes in criteria.

Internal Medical Policy Committee 1-26-2023 Reviewed policy

Internal Medical Policy Committee 1-16-2024 Coding update - Effective January 01, 2024

Removed procedure code K1015
Added procedure code L3161

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: O-12-036

Section: Orthotic & Prosthetic Devices

Effective Date: November 01, 2019

Revised Date: October 20, 2021

Revision Effective Date: January 03, 2022

Last Reviewed: May 23, 2023

Archived Date: December 31, 2023

Applies To: Commercial and Medicaid Expansion

Description

Criteria

Foot orthotics may be considered medically necessary when ALL of the following criteria are met:

An eligible provider has ordered/prescribed the foot orthotics; and
The foot orthotics are fabricated to meet the needs of the individual.
- Note: This may or may not include the shoe and any modifications and/or transfers necessary to make the orthotic functional and effective.

Foot orthotics may be considered medically necessary for an individual with ANY ONE of the following conditions:

Achilles tendonitis; or
Calcaneal apophysitis; or
Calcaneal Spur; or
Chondromalacia of the patella secondary to pronation deformity of the foot; or
Degenerative joint disease/osteoarthrosis of ankle and foot; or
Neuroma; or
Plantar fasciitis; or
Posterior tibial insufficiency (Posterior tibial tendon dysfunction; or
Status post recurrent ankle sprain with high calcaneal varus; or
Tibialis anterior tendonitis; or
Tibialis posterior tendonitis; or
Peroneal tendonitis; or
Juvenile osteochondrosis of foot; or
Clubfoot/acquired equinovarus deformity/talipes equinovarus, congenital/talipes; or
Hallus rigidus; or
Hammertoe digit syndrome; or
Limb length discrepancy; or
Metatarsus adductus in children/metatarsus varus, congenital/metatarsus primus varus, congenital; or
Pes cavus deformity; or
Rheumatoid arthritis/Felty's syndrome/polyarthropathies; or
Status post foot surgery for continued correction (e.g., surgically treated fractures) ; or
Symptomatic hallux valgus/other congenital anomalies of toes; or
Symptomatic intractable plantar keratosis; or
Peripheral neuropathy; or
Vascular ulcers.

Foot orthotics for non-surgically treated fractures is considered not medically necessary unless documentation satisfactorily establishes the medical necessity of the orthotics.

Quantity Level Limits (QLL) for Foot Orthotics for Conditions other than Diabetes

Individuals meeting the above orthotic coverage is limited to:

One (1) orthotic per foot within one (1) calendar year

Foot Orthotics not meeting the criteria as indicated in this policy are considered not medically necessary.

Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as not medically necessary.

Replacement

Replacement of foot orthotics every one (1) calendar year may be considered medically necessary in cases of:

Irreparable damage; or
Wear and tear with normal use: or
When required because of a change in the individual’s condition.

Separate foot orthotics for multiple pairs of footwear is considered not medically necessary.

Procedure Codes

L3000

L3001

L3002

L3003

L3010

L3020

L3030

L3031

L3208

L3209

L3211

L3260

L3340

L3350

L3485

Foot care products that can be purchased over-the-counter without a prescription (e.g., pre-molded arch supports) do not meet the definition of foot orthotics and therefore, are non- covered.

Procedure Codes

L3040

L3050

L3060

L3100

L3170

Orthotic shoes may be considered medically necessary ONLY when they are an integral part of a brace (when reported with a KX modifier).

Orthotic shoes that are not an integral part of a brace are non-covered.

Procedure Codes

L2999

L3201

L3202

L3203

L3212

L3213

L3214

L3215

L3216

L3217

L3219

L3221

L3222

L3224

L3225

L3230

L3251

L3252

L3253

L3254

L3255

L3257

L3265

L3390

L3400

L3410

L3420

L3430

L3440

L3450

L3455

L3460

L3465

L3470

L3480

L3500

L3510

L3520

L3530

L3540

L3550

L3560

L3570

L3580

L3590

L3595

L3600

L3610

L3620

L3630

L3640

L3649

Orthotic Shoes may be considered medically necessary for a diagnosis of clubfoot and must be attached to a brace, including an abduction bar (when reported with a KX modifier).

Orthotic shoes not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

L3204

L3206

L3207

L3140

L3150

L3380

Heel replacements, lift elevation(s), sole replacements, and shoe transfers (when reported with a KX modifier) involving shoes on a covered brace may be considered medically necessary.

Inserts and other shoe modifications not meeting the criteria as indicated in this policy are considered not medically necessary.

Procedure Codes

K1015

L3070

L3080

L3090

L3160

L3300

L3310

L3320

L3330

L3332

L3334

L3360

L3370

L3390

L3400

L3410

L3420

L3430

L3440

L3450

L3455

L3460

L3465

L3470

L3480

L3500

L3510

L3520

L3530

L3540

L3550

L3560

L3570

L3580

L3590

L3595

L3600

L3610

L3620

L3630

L3640

L3649

Diagnosis Codes

G57.60

G57.61

G57.62

G57.63

G57.81

G57.82

G57.83

G57.91

G57.92

G57.93

L11.0

L85.0

L85.1

L85.2

L86

L87.0

L87.2

M05.051

M05.052

M05.061

M05.062

M05.071

M05.072

M05.09

M05.151

M05.152

M05.161

M05.162

M05.171

M05.172

M05.19

M05.251

M05.252

M05.261

M05.262

M05.271

M05.272

M05.29

M05.351

M05.352

M05.361

M05.362

M05.371

M05.372

M05.39

M05.451

M05.452

M05.461

M05.462

M05.471

M05.472

M05.49

M05.551

M05.552

M05.561

M05.562

M05.571

M05.572

M05.59

M05.651

M05.652

M05.661

M05.662

M05.671

M05.672

M05.69

M05.7A

M05.751

M05.752

M05.761

M05.762

M05.771

M05.772

M05.79

M05.8A

M05.851

M05.852

M05.861

M05.862

M05.871

M05.872

M05.89

M06.0A

M06.051

M06.052

M06.061

M06.062

M06.071

M06.072

M06.08

M06.09

M06.1

M06.251

M06.252

M06.261

M06.262

M06.271

M06.272

M06.28

M06.29

M06.351

M06.352

M06.361

M06.362

M06.371

M06.372

M06.38

M06.39

M06.4

M06.8A

M06.851

M06.852

M06.861

M06.862

M06.871

M06.872

M06.88

M06.89

M08.0A

M08.051

M08.052

M08.061

M08.062

M08.071

M08.072

M08.08

M08.09

M08.2A

M08.251

M08.252

M08.261

M08.262

M08.271

M08.272

M08.28

M08.29

M08.3

M08.4A

M08.451

M08.452

M08.461

M08.462

M08.471

M08.472

M08.48

M08.851

M08.852

M08.861

M08.862

M08.871

M08.872

M08.89

M08.9A

M08.951

M08.952

M08.961

M08.962

M08.971

M08.972

M08.98

M08.99

M12.051

M12.052

M12.061

M12.062

M12.071

M12.072

M12.09

M19.071

M19.072

M19.09

M19.19

M19.29

M19.171

M19.172

M19.271

M19.272

M19.90

M20.11

M20.12

M20.21

M20.22

M20.30

M20.31

M20.32

M20.41

M20.42

M20.5X1

M20.5X2

M20.5X9

M20.60

M20.61

M20.62

M21.171

M21.172

M21.271

M21.272

M21.279

M21.531

M21.532

M21.539

M21.541

M21.542

M21.549

M21.611

M21.612

M21.621

M21.622

M21.6X1

M21.6X2

M21.751

M21.752

M21.761

M21.762

M21.763

M21.764

M22.41

M22.42

M24.19

M24.29

M24.39

M24.49

M24.59

M24.69

M24.89

M25.69

M67.961

M67.962

M72.2

M76.61

M76.62

M76.71

M76.72

M76.811

M76.812

M76.821

M76.822

M77.31

M77.32

M77.51

M77.52

M92.61

M92.62

M92.71

M92.72

M92.8

Q66.00

Q66.01

Q66.02

Q66.10

Q66.11

Q66.12

Q66.211

Q66.212

Q66.219

Q66.221

Q66.222

Q66.229

Q66.30

Q66.31

Q66.32

Q66.40

Q66.41

Q66.42

Q66.70

Q66.71

Q66.72

Q66.81

Q66.82

Q66.89

Q66.90

Q66.91

Q66.92

Q74.2

S93.401D

S93.401S

S93.402D

S93.402S

S93.411D

S93.411S

S93.412D

S93.412S

S96.901D

S96.901S

S96.902D

S96.902S

S96.911D

S96.911S

S96.912D

S96.912S

S96.919A

Covered Diagnosis Codes For Procedure Codes L3140, L3150, L3204, L3206, L3207, and L3380

M21.171

M21.172

M21.541

M21.542

M21.549

Q66.00

Q66.01

Q66.02

Q66.89

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 9-26-2019 Coding update

4-1-2020 Added additional Procedure codes to covered Diagnosis codes to match system logic

Internal Medical Policy Committee 9-21-2020 Coding update;

Added Covered Diagnosis Codes for Procedure Codes: L3070, L3080, L3090, L3160, L3201, L3202, 3203, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, L3224, L3225, L3230, L3251, L3252, L3253, L3254, L3255, L3257, L3265, L3300, L3310, L3320, L3330, L3332, L3334, L3360, L3370, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649: M05.7A; M05.8A; M06.0A; M06.8A; M08.0A; M08.2A; M08.4A; M08.9A; M19.09; M19.19; M19.29; M24.19; M24.29; M24.39; M24.49; M24.59; M24.69; M24.89; and M25.69.

Internal Medical Policy Committee 3-17-2021 Coding update:

Added procedure code K1015

Internal Medical Policy Committee 11-23-2021 Revision

Updated clarifying language

Internal Medical Policy Committee 11-29-2022 Annual Review-no changes in criteria.

Internal Medical Policy Committee 1-26-2023 Reviewed policy

Internal Medical Policy Committee 5-23-2023 Annual Review-no changes in criteria

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