Clinical UM Guideline

 

Subject: Orthopedic Footwear
Guideline #:  CG-DME-20 Publish Date:    03/29/2018
Status: Reviewed Last Review Date:    02/27/2018

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:

  1. Shoes are considered medically necessary if they are an integral part of a leg brace that is medically necessary.
  2. Heel replacements, sole replacements and shoe transfers involving shoes on a medically necessary leg brace are also considered medically necessary.
  3. Inserts and other shoe modifications (such as lifts, wedges, arch supports and other additions) are considered medically necessary if they are on a shoe that is an integral part of a medically necessary leg brace, if they are medically necessary for the proper functioning of the brace.
  4. Prosthetic shoes are considered medically necessary if they are an integral part of a prosthesis for individuals with a partial foot amputation.

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.

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

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, 2017).

The Centers for Medicare and Medicaid Services (CMS) criteria was utilized in the development of this document.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Durable medical equipment reference list. NCD #280.1. 05/05/2005. Available at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on February 13, 2018.
  2. CGS Administrators, LLC. Jurisdictions B and C. Local Coverage Determination for Orthopedic Footwear (L33641). Revised 01/01/2017. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on February 13, 2018.
  3. Noridian Administrative Services. Jurisdictions A and D. Local Coverage Determination for Orthopedic Footwear (L33641). Revised 01/01/2017. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on February 13, 2018.
Index

Orthopedic Footwear

History

Status

Date

Action

Reviewed

02/27/2018

Medical Policy & Technology Assessment Committee (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