Medical Policies Online - Policy #: 05.00.35b

Claim Payment Policy

Title:

Foot Orthotics and Other Podiatric Appliances

Policy #:

05.00.35b

Application of Claim Payment Policy is determined by benefits and contracts. Benefits may vary based on product line, group or contract. Medical necessity determination applies only if the benefit exists and no contract exclusions are applicable. Individual member benefits must be verified.

In products where members are able to self-refer to providers for care and services, members are advised to use participating providers in order to receive the highest level of benefits.When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

For more information on how Claim Payment Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.

Intent

The intent of this policy is to communicate the Company’s coverage and reimbursement positions for foot orthotics and other podiatric appliances.

For information on inserts that are specifically designed for therapeutic shoes and other policies related to this topic, refer to the Cross References Table in this policy.

Description

A foot orthotic is a fitted, custom-fabricated, rigid or semi-rigid device that supports a weak or deformed foot, or restricts or eliminates motion in a diseased or injured foot. Foot orthotics are available only by prescription.

The term foot orthotic does not include items that are carried in stock and sold as over-the-counter items (eg, off-the-shelf arch supports, low-temperature plastic splints) by a drug store, department store, or surgical supply facility.

Other podiatric appliances include shoe inserts such as heel pads, heel cups, and lifts. These items may be obtained only by prescription or over the counter. However, as used in this policy, a podiatric appliance is a supportive device for the foot that is available only by prescription.

For information regarding inserts specifically designed for therapeutic shoes and prosthetic (shoe) inserts, refer to the Cross References Table in this policy.

Over-the-counter refers to prefabricated, mass-produced items that are prepackaged and require no professional advice or judgment in either size selection or use, including generic insoles and arch supports.

Policy

Foot orthotics and other podiatric appliances are, generally, benefit contract exclusions for all products of the Company and are, therefore, not eligible for reimbursement consideration. However, foot orthotics and other podiatric appliances are eligible for coverage and reimbursement consideration when all of the following requirements are met:

The foot orthotic or other podiatric appliance is all of the following:
- A benefit as outlined in the individual's benefit contract
- Available only by prescription and is specifically used for the treatment and/or prevention of a medical condition or disease
- Prescribed by any eligible health care provider who is licensed in the applicable state to prescribe foot orthotics or other podiatric appliances
- Supplied by a durable medical equipment (DME) supplier, orthotist, or prosthetist
One of the following applies:
- The individual is enrolled in a Pennsylvania or Delaware Commercial Product, and the foot orthotic or other podiatric appliance is prescribed and required for the treatment and/or prevention of complications associated with diabetes.
- The state in which the product is based mandates coverage of foot orthotics and other podiatric appliances for conditions other than diabetes.
- An individual group has opted to allow coverage of foot orthotics or other podiatric appliances for conditions other than diabetes.
- The individual is enrolled in a Medicare Advantage Product, and the individual is diagnosed as having diabetes and one of the following complications of diabetes:
  - Previous partial or total amputation of a foot
  - History of previous foot ulceration
  - History of pre-ulcerative foot calluses
  - Peripheral neuropathy with evidence of callus formation
  - Foot deformity
  - Poor circulation (lower extremities)

ADDITIONAL COVERAGE REQUIREMENTS

If the foot orthotic or other podiatric appliance is a replacement for a previously covered orthotic or other podiatric appliance, report the code for the item itself appended with the appropriate modifier.

When a Commercial product includes benefits for foot orthotics and/or other podiatric appliances provided for conditions other than diabetes and/or its complications (eg, peripheral vascular disease), only the items outlined as exceptions to the standard contract exclusion are covered and eligible for reimbursement consideration. Individual member benefits must be verified.

REQUIRED DOCUMENTATION

The individual's medical record must reflect the medical necessity for the care provided. These medical records may include, but are not limited to, records from the physician's office, hospital, nursing home, home health agencies, therapies, other health care professionals, and test reports.

The Company may conduct reviews and audits of services to our members, regardless of the participation status of the provider. All documentation is to be available to the Company upon request.

If the foot orthotic or other podiatric appliance is supplied by a durable medical equipment (DME) provider, an order for each item billed must be signed and dated by the physician who is treating the member and kept on file by the supplier. Medical record documentation must reflect the medical necessity of the care and services provided and must include a shipment confirmation or member's receipt of supplies and equipment. All documentation is to be available to the Company upon request. Failure to produce the requested information may result in a denial for the service.

MANDATES

In accordance with the State of New Jersey's orthotic and prosthetic appliances mandate, members who are enrolled in New Jersey commercial products may obtain foot orthotics or other podiatric appliances from any licensed orthotist or prosthetist or certified pedorthotist. The individual's physician must establish that the foot orthotic or other podiatric appliance is medically necessary for the individual.

Guidelines

MEDICARE

This policy is consistent with Medicare's coverage requirements for foot orthotics and other podiatric appliances for the Company's Medicare Advantage members. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, foot orthotics and other podiatric appliances are, generally, benefit contract exclusions for all products of the Company, with the following exceptions:

Foot orthotics are covered for individuals with diabetes and/or its complications under the medical benefits of the Company’s products. Individual member benefits must be verified.
Foot orthotics are a benefit for individuals in accordance with applicable state mandates.

MANDATES

This policy is consistent with applicable state mandates:

The State of New Jersey mandates coverage of foot orthotics for individuals enrolled in New Jersey commercial products when such items are determined to be medically necessary by the individual's physician. This mandate is effective for all newly issued contracts and contracts renewed on or after April 11, 2008.
This policy is consistent with all Delaware, New Jersey, and Pennsylvania diabetes mandates.

References

American Orthopaedic Foot & Ankle Society (AOFAS). Shoes and orthotics for diabetics. [AOFAS Web site.] January 2008. Available at: http://www.aofas.org/Scripts/4Disapi.dll/4DCGI/cms/review.html?Action=CMS_Document&DocID=37&Time=-453586056&SessionID=243891f7v7q3820dxn8of9gn4268f25ulsruobs133ew3v1s06y6yl0v041885h4&MenuKey=123. Accessed October 23, 2008.

Centers for Medicare & Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health services. �120: Prosthetic devices. [CMS Web site]. 10/01/03. Available at: http://www.cms.hhs.gov/manuals/Downloads/bp102c15.pdf. Accessed October 10, 2008.

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD).280.10: Prosthetic shoe. [CMS Web site]. Available at:http://www.cms.hhs.gov/mcd/viewncd.asp?ncd_id=280.10&ncd_version=1&basket=ncd%3A280%2E10%3A1%3AProsthetic+Shoe. Accessed October 10, 2008.

Centers for Medicare & Medicaid Services (CMS). Medicare Learning Matters. MLN Matters.An overview of medicare covered diabetes supplies and services. [CMS Web site]. 12/12/07. Available at: http://www.cms.hhs.gov/MLNMattersArticles/downloads/SE0738.pdf. Accessed October 10, 2008.

Company Benefit Contracts.

Meadows M. Taking care of your feet: orthotic devices. FDA Consumer (serial online). [FDA Web site.] March 2006. Available at: http://www.fda.gov/fdac/features/2006/206_feet.html. Accessed October 10, 2008.

NHIC, Corp. Local Coverage Determination (LCD). L11535: Therapeutic shoes for persons with diabetes. [NHIC Web site]. Original: 05/01/93. (Revised: 07/01/07). Available at: http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/therapeutic%20shoes%20for%20persons%20with%20diabetes%2D07%2D07%2Eshtml. Accessed October 10, 2008.

NHIC, Corp. Local Coverage Determination (LCD). L11464: Lower limb prostheses. [NHIC Web site.] Original: 03/01/95. (Revised: 10/01/08). Available at: http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L11464_2008-10-01_PA_2008-10.shtml. Accessed October 10, 2008.

NHIC, Corp. Local Coverage Determination (LCD). L11467: Orthopedic footwear. [NHIC Web site]. Original: 01/01/95. (Revised: 01/01/08). Available at: http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/Orthopedic_Footwear_0308.shtml. Accessed October 10, 2008.

NHIC, Corp. Local Coverage Determination (LCD). L11527: Ankle-foot/knee-ankle-foot orthosis [NHIC Web site]. Original: 10/01/93. (Revised: 01/01/08). Available at: http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/Ankle_Foot_Knee_Ankle_Foot_Orthosis_0308.shtml. Accessed October 10, 2008.

New Jersey (NJ) Department of Banking and Insurance (DOBI). Bulletin NO. 08-10: P.L. 2007, c. 345 – Health benefits coverage for orthotic and prosthetic appliances. [NJ DOBI Web site]. 04/11/08. Available at: http://www.state.nj.us/dobi/bulletins/blt08_10.pdf. October 10, 2008.

New Jersey (NJ) Legislature. �17B:26-2.1z: Individual health insurance policies to provide benefits for orthotic and prosthetic appliances. [NJ State Legislature Web site]. 04/11/08. Available at: http://www.njleg.state.nj.us/. Accessed October 10, 2008.

New Jersey (NJ) Legislature. �17:48-6ff: Hospital service corporation to provide benefits for orthotic and prosthetic appliances. [NJ State Legislature Web site]. 04/11/08. Available at: http://www.njleg.state.nj.us/. Accessed October 10, 2008.

New Jersey (NJ) Legislature. �45:12B-3: Professions and occupations: Definitions relative to orthotics and prosthetics. [NJ State Legislature Web site.] Available at: http://www.njleg.state.nj.us/. Accessed October 10, 2008.

New Jersey (NJ) Legislature. P.L. 2007, Chapter 345. Senate No. 502. Requires health benefits coverage by health insurers and SHBP for orthotic and prosthetic appliances and provides reimbursement therefor. [NJ State Legislature Web site]. 01/13/08. Available at: http://www.njleg.state.nj.us/2006/Bills/AL07/345_.PDF. Accessed October 10, 2008.

Pennsylvania (PA) Act 98 of 1998. Eff 02/12/1999.

Pennsylvania (PA) General Assembly. House Bill 401. An act establishing the state board of orthotics, prosthetics, and pedorthics. [PA General Assembly Web site]. 02/09/05. Available at: http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=HTM&sessYr=2005&sessInd=0&billBody=H&billTyp=B&billnbr=0401&pn=0426. Accessed October 20, 2008.

Pennsylvania (PA) General Assembly. House Bill 656. An act amending the PA Insurance Company Law of 1921 and providing reimbursement for diabetic supplies. [PA General Assembly Web site]. 10/27/97. Available at: Available at: http://www.legis.state.pa.us/CFDOCS/Legis/PN/Public/btCheck.cfm?txtType=PDF&sessYr=1997&sessInd=0&billBody=H&billTyp=B&billNbr=0656&pn=2505. Accessed October 20, 2008.

Coding Table

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

Code System	Code Number(s) and Narrative(s)
CPT	N/A
ICD Procedure	N/A
ICD Diagnosis	REPORT THE APPROPRIATE DIABETES DIAGNOSIS CORRESPONDING TO THE INDIVIDUAL'S DIABETIC CONDITION 249.00: Secondary diabetes mellitus without mention of complication, not stated as uncontrolled, or unspecified 249.01: Secondary diabetes mellitus without mention of complication, uncontrolled 249.10: Secondary diabetes mellitus with ketoacidosis, not stated as uncontrolled, or unspecified 249.11: Secondary diabetes mellitus with ketoacidosis, uncontrolled 249.20: Secondary diabetes mellitus with hyperosmolarity, not stated as uncontrolled, or unspecified 249.21: Secondary diabetes mellitus with hyperosmolarity, uncontrolled 249.31: Secondary diabetes mellitus with other coma, uncontrolled 249.40: Secondary diabetes mellitus with renal manifestations, not stated as uncontrolled, or unspecified 249.41: Secondary diabetes mellitus with renal manifestations, uncontrolled 249.50: Secondary diabetes mellitus with ophthalmic manifestations, not stated as uncontrolled, or unspecified 249.51: Secondary diabetes mellitus with ophthalmic manifestations, uncontrolled 249.60: Secondary diabetes mellitus with neurological manifestations, not stated as uncontrolled, or unspecified 249.61: Secondary diabetes mellitus with neurological manifestations, uncontrolled 249.70: Secondary diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled, or unspecified 249.71: Secondary diabetes mellitus with peripheral circulatory disorders, uncontrolled 249.80: Secondary diabetes mellitus with other specified manifestations, not stated as uncontrolled, or unspecified 249.81: Secondary diabetes mellitus with other specified manifestations, uncontrolled 249.90: Secondary diabetes mellitus with unspecified complication, not stated as uncontrolled, or unspecified 249.91: Secondary diabetes mellitus with unspecified complication, uncontrolled 250.00: Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled 250.01: Diabetes mellitus without mention of complication, type I [juvenile type], not stated as uncontrolled 250.02: Diabetes mellitus without mention of complication, type II or unspecified type, uncontrolled 250.03: Diabetes mellitus without mention of complication, type I [juvenile type], uncontrolled 250.10: Diabetes with ketoacidosis, type II or unspecified type, not stated as uncontrolled 250.11: Diabetes with ketoacidosis, type I [juvenile type], not stated as uncontrolled 250.12: Diabetes with ketoacidosis, type II or unspecified type, uncontrolled 250.13: Diabetes with ketoacidosis, type I [juvenile type], uncontrolled 250.20: Diabetes with hyperosmolarity, type II or unspecified type, not stated as uncontrolled 250.21: Diabetes with hyperosmolarity, type I [juvenile type], not stated as uncontrolled 250.22: Diabetes with hyperosmolarity, type II or unspecified type, uncontrolled 250.23: Diabetes with hyperosmolarity, type I [juvenile type], uncontrolled 250.30: Diabetes with other coma, type II or unspecified type, not stated as uncontrolled 250.31: Diabetes with other coma, type I [juvenile type], not stated as uncontrolled 250.32: Diabetes with other coma, type II or unspecified type, uncontrolled 250.33: Diabetes with other coma, type I [juvenile type], uncontrolled 250.40: Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled 250.41: Diabetes with renal manifestations, type I [juvenile type], not stated as uncontrolled 250.42: Diabetes with renal manifestations, type II or unspecified type, uncontrolled 250.43: Diabetes with renal manifestations, type I [juvenile type], uncontrolled 250.50: Diabetes with ophthalmic manifestations, type II or unspecified type, not stated as uncontrolled 250.51: Diabetes with ophthalmic manifestations, type I [juvenile type], not stated as uncontrolled 250.52: Diabetes with ophthalmic manifestations, type II or unspecified type, uncontrolled 250.53: Diabetes with ophthalmic manifestations, type I [juvenile type], uncontrolled 250.60: Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled 250.61: Diabetes with neurological manifestations, type I [juvenile type], not stated as uncontrolled 250.62: Diabetes with neurological manifestations, type II or unspecified type, uncontrolled 250.63: Diabetes with neurological manifestations, type I [juvenile type], uncontrolled 250.70: Diabetes with peripheral circulatory disorders, type II or unspecified type, not stated as uncontrolled 250.71: Diabetes with peripheral circulatory disorders, type I [juvenile type], not stated as uncontrolled 250.72: Diabetes with peripheral circulatory disorders, type II or unspecified type, uncontrolled 250.73: Diabetes with peripheral circulatory disorders, type I [juvenile type], uncontrolled 250.80: Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled 250.81: Diabetes with other specified manifestations, type I [juvenile type], not stated as uncontrolled 250.82: Diabetes with other specified manifestations, type II or unspecified type, uncontrolled 250.83: Diabetes with other specified manifestations, type I [juvenile type], uncontrolled 250.90: Diabetes with unspecified complication, type II or unspecified type, not stated as uncontrolled 250.91: Diabetes with unspecified complication, type I [juvenile type], not stated as uncontrolled 250.92: Diabetes with unspecified complication, type II or unspecified type, uncontrolled 250.93: Diabetes with unspecified complication, type I [juvenile type], uncontrolled 648.00: Maternal diabetes mellitus, complicating pregnancy, childbirth, or the puerperium, unspecified as to episode of care 648.01: Maternal diabetes mellitus with delivery 648.02: Maternal diabetes mellitus with delivery, with current postpartum complication 648.03: Maternal diabetes mellitus, antepartum 648.04: Maternal diabetes mellitus, previous postpartum condition
HCPCS Level II	THE FOLLOWING HCPCS CODES REPRESENT ORTHOTICS AND OTHER PODIATRIC APPLIANCES FOR THE FEET, WHICH ARE ONLY ELIGIBLE FOR COVERAGE FOR THE TREATMENT AND/OR PREVENTION OF COMPLICATIONS OF DIABETES: A9283: Foot pressure off loading/supportive device, any type, each L3000: Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each L3001: Foot insert, removable, molded to patient model, Spenco, each L3002: Foot insert, removable, molded to patient model, Plastazote or equal, each L3003: Foot insert, removable, molded to patient model, silicone gel, each L3010: Foot insert, removable, molded to patient model, longitudinal arch support, each L3020: Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each L3030: Foot insert, removable, formed to patient foot, each L3031: Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite L3040: Foot, arch support, removable, premolded, longitudinal, each L3050: Foot, arch support, removable, premolded, metatarsal, each L3060: Foot, arch support, removable, premolded, longitudinal/metatarsal, each L3070: Foot, arch support, nonremovable, attached to shoe, longitudinal, each L3080: Foot, arch support, nonremovable, attached to shoe, metatarsal, each L3090: Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each L3170: Foot, plastic, silicone or equal, heel stabilizer, each L3300: Lift, elevation, heel, tapered to metatarsals, per in. L3310: Lift, elevation, heel and sole, neoprene, per in. L3320: Lift, elevation, heel and sole, cork, per in. L3330: Lift, elevation, metal extension (skate) L3332: Lift, elevation, inside shoe, tapered, up to one-half in. L3334: Lift, elevation, heel, per in. L3340: Heel wedge, SACH L3350: Heel wedge L3360: Sole wedge, outside sole L3370: Sole wedge, between sole L3380: Clubfoot wedge L3390: Outflare wedge L3400: Metatarsal bar wedge, rocker L3410: Metatarsal bar wedge, between sole L3420: Full sole and heel wedge, between sole L3430: Heel, counter, plastic reinforced L3440: Heel, counter, leather reinforced L3450: Heel, SACH cushion type L3455: Heel, new leather, standard L3460: Heel, new rubber, standard L3465: Heel, Thomas with wedge L3470: Heel, Thomas extended to ball L3480: Heel, pad and depression for spur L3485: Heel, pad, removable for spur

Revenue Codes	N/A

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

Cross References

Cross Reference Policies

05.00.05f:

Equipment, Supplies, and Pharmaceuticals for the Treatment of Diabetes

05.00.11d:Therapeutic Shoes and Orthopedic Shoes

05.00.21i:Durable Medical Equipment (DME)

05.00.39h:Ankle-Foot/Knee-Ankle-Foot Orthoses

05.00.45f:Repair or Replacement of an External Prosthetic Device

05.00.59e:Lower Limb Prostheses

12.05.01f:Outpatient Diabetes Education and Self-Management Training

Version Effective Date: 03/18/2009