Foot Orthotics for Conditions Other Than Diabetes

Policy ID: O-12-033

Section: Orthotic & Prosthetic Devices

Effective Date: November 01, 2019

Revised Date: October 16, 2020

Revision Effective Date: November 02, 2020

Last Reviewed: September 21, 2020

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	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 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, 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; added the following:
- 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.

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.

Section: Orthotic & Prosthetic Devices

Effective Date: November 01, 2019

Revised Date: September 26, 2019

Archived Date: September 30, 2020

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 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.

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: L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, 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, L3340, L3350, 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	M05.751	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

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

Links

References (PDF)

Disclaimer

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Fargo (Headquarters)
4510 13th Ave. S.
Fargo, North Dakota 58121

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