Clinical UM Guideline



Subject: Orthopedic Footwear
Guideline #:  CG-DME-20 Current Effective Date:    03/29/2017
Status: Reviewed Last Review Date:    02/02/2017

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 (NGS, 2016).

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 December 20, 2016.
  2. CGS Administrators, LLC. Jurisdictions B and C. Local Coverage Determination for Orthopedic Footwear (L33641). Revised 07/01/2016. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on December 20, 2016.
  3. Noridian Administrative Services. Jurisdictions A and D. Local Coverage Determination for Orthopedic Footwear (L33641). Revised 07/01/2016. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on December 20, 2016.
Index

Orthopedic Footwear

History
Status Date Action
Reviewed 02/02/2017 Medical Policy & Technology Assessment Committee (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