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Details on being a Medicaid Expansion provider
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.
Foot orthotics can be custom fabricated, custom fitted, or off-the-shelf (OTS).
Custom-fabricated foot orthoses are individually designed and manufactured to the unique specifications of a single patient. This process utilizes clinically derived data, including casts, tracings, measurements, and/or imaging (e.g., X-rays), to create a device tailored to the individual's specific needs. Fabrication involves significant craftsmanship and may incorporate various materials (plastic, metal, leather, cloth, etc.) that are substantially altered through processes such as vacuum forming, cutting, bending, molding, sewing, drilling, and finishing before fitting.
Custom-fitted foot orthoses are prefabricated devices that may arrive as a kit requiring assembly or the addition of components. While some basic preparation may be involved, these orthoses are distinguished from off-the-shelf (OTS) items by requiring more than minimal self-adjustment to achieve an individualized fit. This fitting process necessitates modifications such as trimming, bending, molding (with or without heat), or other alterations beyond simple self-adjustment and requires the expertise of a certified orthotist or similarly trained professional.
Off-the-shelf (OTS) foot orthoses are prefabricated devices that may be supplied as a kit requiring minor assembly. However, any assembly, addition of components, or basic preparation does not alter their OTS classification. These devices require only minimal self-adjustment for fitting and do not necessitate the expertise of a certified orthotist or similarly trained professional for proper application.
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Coverage is subject to the specific terms of the member's benefit plan.
Foot orthotics may be considered medically necessary when ALL of the following criteria are met:
Foot orthotics not meeting the criteria as indicated in this policy are considered not medically necessary.
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.
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.
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.
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.
Covered Diagnosis Codes for Procedure Codes: L3070; L3080; L3090; L3160; L3201; L3202; L3203; 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
Not Applicable
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
Internal Medical Policy Committee 3-17-2021 Coding update:
Internal Medical Policy Committee 11-23-2021 Revision
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
Internal Medical Policy Committee 1-14-2025 Annual Review-no changes in criteria
Internal Medical Policy Committee 5-13-2025 Revision - Effective July 07, 2025
References (PDF)
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.
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.
Foot orthotics may be considered medically necessary for an individual with ANY ONE of the following conditions:
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:
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:
Separate foot orthotics for multiple pairs of footwear is considered not medically necessary.
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.
Internal Medical Policy Committee 9-21-2020 Coding update;
Internal Medical Policy Committee 1-26-2023 Reviewed policy
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