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

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

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

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

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

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

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

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

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.