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Foot Orthotics and Other Podiatric Appliances
05.00.35f

Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

Foot orthotics and other podiatric appliances are not covered by the Company because they are a benefit contract exclusion. Therefore, they are not eligible for reimbursement consideration, except for the following circumstances:

INDIVIDUALS ENROLLED IN PENNSYLVANIA PLANS
  • In accordance with the Commonwealth of Pennsylvania's mandate, orthotics used for the treatment of diabetes are covered when prescribed by an eligible professional provider for individuals enrolled in Pennsylvania Commercial plans that are subject to Pennsylvania's insurance law.
    • State mandates do not automatically apply to self-funded groups, but may be included or excluded at the option of the group; therefore, individual group benefits must be verified.
  • For individuals with a benefit that allows for the coverage of orthotics and podiatric appliances for the prevention of complications associated with diabetes.
INDIVIDUALS ENROLLED IN NEW JERSEY PLANS
  • In accordance with the State of New Jersey's orthotic and prosthetic appliances mandate, individuals who are enrolled in New Jersey commercial plans may obtain an orthotic appliance from any licensed orthotist prosthetist, or certified pedorthist, as determined medically necessary and prescribed by a professional provider. These appliances will be covered by the Company accordingly.
    • State mandates do not automatically apply to self-funded groups, but may be included or excluded at the option of the group; therefore, individual group benefits must be verified.
  • For individuals who are enrolled in New Jersey plans, certain foot orthotics and podiatric appliances may be prescribed and obtained from a New Jersey podiatrist (refer to the coding for a list of the foot orthotics and podiatric appliances).
ADDITIONAL COVERAGE REQUIREMENTS ​

A foot orthotic is a fitted, custom-fabricated device only available by prescription. Items available over-the-counter do not meet the Company's definition of an orthotic.

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 product includes benefits for foot orthotics and/or other podiatric appliances provided for conditions other than diabetes and/or its complications (e.g., 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 Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The durable medical equipment (DME) supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.

Guidelines

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 laws of the state where the group benefit contract is issued determine the mandated coverage.
  • 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 New Jersey and Pennsylvania mandates for coverage of diabetic supplies.
  • In accordance with the State of Pennsylvania's mandate, for orthotics related to the treatment of diabetes illness and benefit contracts, members who are enrolled in Pennsylvania commercial plans subject to Pennsylvania's insurance law may obtain foot orthotics and other podiatric appliances for the prevention and treatment of diabetes illness, when prescribed by an eligible professional provider.

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 (e.g., off-the-shelf arch supports, low-temperature plastic splints).

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.

Other podiatric appliances include shoe inserts such as heel pads, heel cups, and lifts. These items may be obtained 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 section in this policy.

References

American Orthopaedic Foot & Ankle Society (AOFAS). Shoes and orthotics for diabetics. [AOFAS Web site.] Available at: http://www.aofas.org/footcaremd/conditions/diabetic-foot/Pages/Shoes-and-Orthotics-for-Diabetics.aspx. Accessed March 02, 2020.

Company Benefit Contracts.

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]. 05/29/2008. Available at: http://www.state.nj.us/dobi/bulletins/blt08_10.pdf Accessed Accessed March 02, 2020.

New Jersey (NJ) Legislature.P.L.2007, chapter.345 (C.17:48-6ff).Senate, No. 2882. Introduced May 14, 2015. An act concerning health benefits coverage for orthotic and prosthetic appliances from podiatrists and amending P.L.2007, c.345.) [NJ State Legislature Web site].
Available at: http://www.njleg.state.nj.us/2014/Bills/S3000/2882_I1.PDF. Accessed March 02, 2020.

Pennsylvania (PA) Act 98 of 1998. 10/16/1998. Available at: http://www.legis.state.pa.us/WU01/LI/LI/US/HTM/1998/0/0098..HTM. Accessed March 02, 2020.

Pennsylvania (PA) General Assembly. House Bill 401. An act establishing the state board of orthotics, prosthetics, and pedorthotics. [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 March 02, 2020.

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: 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 March 02, 2020.

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
See Attachment A.
HCPCS Level II Code Number(s)
MEDICALLY NECESSARY

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 orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, each

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

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

For individuals who are enrolled in New Jersey plans, the following foot orthotics and podiatric appliances may be prescribed and obtained from a New Jersey podiatrist.

L3000 Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each

L3020 Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each

L3030 Foot insert, removable, formed to patient foot, 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

BENEFIT EXCLUSION

L3100 Hallus-valgus night dynamic splint, prefabricated, off-the-shelf

L3170 Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each
Revenue Code Number(s)
N/A

Modifiers

WHEN THERE IS NO SPECIFIC HCPCS CODE FOR THE REPAIR OR REPLACEMENT OF A FOOT ORTHOSIS, THE FOLLOWING MODIFIERS ARE APPENDED TO THE HCPCS CODE FOR THE DEVICE ITSELF

RA Replacement of a DME, orthotic or prosthetic item

RB Replacement of a part of a DME, orthotic or prosthetic item furnished as part of a repair

Coding and Billing Requirements

Policy History

Revisions From 05.00.35e:

06/15/2022

This policy has been reissued in accordance with the Company's annual review process.

05/04/2020

This version of the policy will become effective 05/04/2020.

The following HCPCS code has been removed from the coding table under the heading Medical Necessary: L3170.

The following HCPCS codes were added to the coding table as a benefit exclusion: L3100 and L3170.

Effective 10/05/2017 this policy has been updated to the new policy template format.
5/4/2020
5/4/2020
6/15/2022
05.00.35
Claim Payment Policy Bulletin
Commercial
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No