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Foot Orthotics for Conditions Other Than Diabetes

Section: Orthotic & Prosthetic Devices
Effective Date: November 01, 2019
Last Reviewed: September 26, 2019

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; 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 will be denied as not medically necessary if the above criteria are not met.

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 L3340 L3350 L3485

Foot care products that can be purchased over-the-counter without a prescription (e.g., premolded 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 above criteria 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.

Any shoe modification not meeting the above criteria is considered not medically necessary.

Procedure Codes

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, 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 M05.751 M05.752 M05.761 M05.762
M05.771 M05.772 M05.79 M05.851 M05.852 M05.861 M05.862
M05.871 M05.872 M05.89 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 M06.851 M06.852 M06.861 M06.862 M06.871 M06.872
M06.88 M06.89 M08.051 M08.052 M08.061 M08.062 M08.071
M08.072 M08.08 M08.09 M08.251 M08.252 M08.261 M08.262
M08.271 M08.272 M08.28 M08.29 M08.3 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 M08.951 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 M19.171 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 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

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