Clinical UM Guideline |
Subject: Orthopedic Footwear | |
Guideline #: CG-DME-20 | Publish Date: 06/28/2024 |
Status: Reviewed | Last Review Date: 05/09/2024 |
Description |
This document addresses orthopedic footwear including shoes, inserts and modification to shoes for individuals who do not have diabetes.
Note: Please see the following related document for additional information:
Clinical Indications |
Medically Necessary:
Shoes, inserts, and modifications are considered medically necessary only in the limited circumstances described below:
Not Medically Necessary:
Orthopedic footwear that does not meet the criteria above is considered not medically necessary.
A matching shoe that is not attached to a brace and items related to that shoe are considered not medically necessary.
Shoes are considered not medically necessary when they are put on over partial foot prosthesis or other lower extremity prosthesis that is attached to the residual limb by mechanisms other than being an integral part of the prosthesis.
Coding |
The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.
When services may be Medically Necessary when criteria are met:
HCPCS |
|
L3000-L3031 | Foot insert, removable, molded to patient model [includes codes L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031] |
L3040-L3060 | Foot, arch supports, removable, premolded [includes codes L3040, L3050, L3060] |
L3070-L3090 | Foot, arch supports, non-removable, attached to shoe [includes codes L3070, L3080, L3090] |
L3160 | Foot, adjustable shoe-styled positioning device |
L3170 | Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each |
L3224-L3225 | Orthopedic footwear, used as an integral part of a brace (orthosis) |
L3230 | Orthopedic footwear, custom shoe, depth inlay, each |
L3250 | Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each |
L3251 | Foot, shoe molded to patient model; silicone shoe, each |
L3252 | Foot, shoe molded to patient model; Plastazote (or similar), custom fabricated, each |
L3253 | Foot, molded shoe Plastazote (or similar) custom fitted, each |
L3254 | Non-standard size or width |
L3255 | Non-standard size or length |
L3257 | Orthopedic footwear, additional charge for split size |
L3265 | Plastazote sandal, each |
L3300-L3334 | Lifts [includes codes L3300, L3310, L3320, L3330, L3332, L3334] |
L3340-L3350 | Heel wedges [includes codes L3340, L3350] |
L3360-L3370 | Sole wedges [includes codes L3360, L3370] |
L3390 | Outflare wedge |
L3400-L3410 | Metatarsal bar wedges [includes codes L3400, L3410] |
L3420 | Full sole and heel wedge, between sole |
L3430-L3485 | Heels [includes codes L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485] |
L3500-L3595 | Orthopedic shoe additions [includes codes L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595] |
L3600-L3630 | Transfer of an orthosis from one shoe to another [includes codes L3600, L3610, L3620, L3630] |
|
|
ICD-10 Diagnosis |
|
| All diagnoses |
When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.
Discussion/General Information |
Orthopedic footwear including shoes, inserts and modifications to shoes are utilized for the alignment, support, prevention, or correction of deformities or to improve the function of movable parts of the body. Orthotics includes braces which are used to support a weak joint or joints.
The medical necessity of orthopedic footwear including shoes, inserts and modification to shoes for individuals who do not have diabetes is based on the evaluation of the individual’s needs and capabilities in relation to the following definition of medical necessity (CGS, 2020).
This document is based on peer-reviewed published literature and Medicare criteria.
There is currently no available evidence addressing medical indications for footwear, inserts, and modifications that are not intended to address the alignment, support, prevention, or correction of deformities, or to improve the function of movable parts of the body. This includes shoes not attached to a brace or shoes when put on over partial foot or other lower extremity prosthesis.
References |
Peer Reviewed Publications:
Government Agency, Medical Society, and Other Authoritative Publications:
Index |
Orthopedic Footwear
History |
Status | Date | Action |
Reviewed | 05/09/2024 | Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section. |
Reviewed | 05/11/2023 | MPTAC review. Updated Discussion and References sections. |
Reviewed | 05/12/2022 | MPTAC review. Updated References section. |
Reviewed | 05/13/2021 | MPTAC review. Updated References section. |
Reviewed | 11/05/2020 | MPTAC review. Updated References section. Reformatted Coding section. |
Reviewed | 11/07/2019 | MPTAC review. Updated Discussion/General Information and References sections. |
Reviewed | 01/24/2019 | MPTAC review. Updated References section. |
Reviewed | 02/27/2018 | MPTAC review. The document header wording updated from “Current Effective Date” to “Publish Date.” Updated References section. |
Reviewed | 02/02/2017 | MPTAC review. Updated formatting in Clinical Indications section. Updated Coding, Discussion and Reference sections. |
Reviewed | 11/03/2016 | MPTAC review. Updated Reference section. |
Reviewed | 11/05/2015 | MPTAC review. Updated References. Removed ICD-9 codes from Coding section. |
Reviewed | 11/13/2014 | MPTAC review. Updated References. |
Reviewed | 11/14/2013 | MPTAC review. Description, References and Websites updated. Updated Coding section with 01/01/2014 HCPCS descriptor change for L3170. |
Reviewed | 11/08/2012 | MPTAC review. Updated references and websites. |
Reviewed | 11/17/2011 | MPTAC review. Updated references and websites. |
Reviewed | 11/18/2010 | MPTAC review. References and Websites updated. |
Reviewed | 11/19/2009 | MPTAC review. Place of service removed and references updated |
Reviewed | 11/20/2008 | MPTAC review. References updated. |
Reviewed | 11/29/2007 | MPTAC review. References and coding updated. Minor wording changes. |
Reviewed | 12/07/2006 | MPTAC review. References updated. |
New | 12/01/2005 | MPTAC initial document development. |
Pre-Merger Organizations | Last Review Date | Document Number | Title |
Anthem, Inc. |
|
| No document |
Anthem CO/NV | 10/29/2004 | DME.709 | Orthopedic Footwear |
Anthem CT |
| Benefit Detail | Foot Orthotics |
WellPoint Health Networks, Inc. |
|
| No document |
Federal and State law, as well as contract language including definitions and specific coverage provisions/exclusions, and Medical Policy take precedence over Clinical UM Guidelines and must be considered first in determining eligibility for coverage. The member's contract benefits in effect on the date that services are rendered must be used. Clinical UM Guidelines, which address medical efficacy, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and we reserve the right to review and update Clinical UM Guidelines periodically. Clinical UM guidelines are used when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether or not to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the back of the member's card.
No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.