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| Medical Policy: | O-12-027 |
| Topic: | Foot Orthotics for Conditions Other Than Diabetes |
| Section: | Orthotic & Prosthetic Devices |
| Effective Date: | June 12, 2017 |
| Issue Date: | June 12, 2017 |
| Last Reviewed: | May 2017 |
Orthotics protect, restore and/or improve the function of moveable parts of the body with orthopedic appliances or apparatus. Orthotic appliances or apparatus support, align, prevent and/or correct deformities. |
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Foot orthotics may be considered medically necessary only when they are a benefit of a member’s contract and when prescribed for ANY ONE of these conditions:
- Achilles tendonitis; or
- Calcaneal apophysitis/juvenile osteochondrosis of foot; or
- Calcaneal spur; or
- Chondromalacia of the patella secondary to pronation deformity of the foot; or
- Clubfoot/acquired equinovarus deformity/talipes equinovarus, congenital/talipes; or
- Degenerative joint disease/osteoarthrosis of ankle and foot; or
- Hallus rigidus; or
- Hammertoe digit syndrome; or
- Limb length discrepancy; or
- Metatarsus adductus in children/metatarsus varus, congenital/metatarsus primus varus, congenital; or
- Neuroma; or
- Pes cavus deformity; or
- Plantar fasciitis; or
- Posterior tibial insufficiency (Posterior tibial tendon dysfunction) ; or
- Rheumatoid arthritis/Felty's syndrome/polyarthropathies; or
- Sever's Disease; or
- Status post foot surgery for continued correction (e.g., surgically treated fractures) ; or
- Status post recurrent ankle sprain with high calcaneal varus; or
- Symptomatic hallux valgus/other congenital anomalies of toes; or
- Symptomatic intractable plantar keratosis; or
- Tibialis anterior tendonitis; or
- Tibialis posterior tendonitis.
Foot orthotics prescribed for non-surgically treated fractures are not routinely eligible for reimbursement. Payment will be made only if supporting documentation satisfactorily establishes the orthotic's medical necessity.
Foot orthotics are fabricated to meet specific needs of the patient. An eligible professional provider must order the foot orthotics. They may or may not include the shoe and any modifications and/or transfers necessary to make the orthotic functional and effective. To be eligible for payment, foot orthotics must meet these criteria.
Replacement of foot orthotics is covered in cases of loss or irreparable damage or wear and when required because of a change in the patient's condition.
Foot care products that can be purchased over-the-counter without a prescription, e.g., premolded arch supports, do not meet the definition of foot orthotics. They are not covered.
Orthotic shoes are eligible only when they are an integral part of a brace regardless of whether or not the member has an eligible diagnosis listed on this policy.
Orthotic shoes that are not an integral part of a brace are not covered.
Orthotic Shoes are eligible for payment when prescribed by a physician for a diagnosis of clubfoot. In order for orthotic shoes to be eligible for reimbursement when submitted for a diagnosis of clubfoot, they must be attached to a brace, including an abduction bar.
The Lang Medical Shoe may be considered medically necessary when it is an integral part of a brace and when prescribed by a physician for an eligible condition as listed above.
In addition to being covered for the diagnoses listed on this medical policy, heel replacements, sole replacements, and shoe transfers involving shoes on a covered brace are covered regardless of the diagnosis reported. Inserts and other shoe modifications are also covered if reported with one of the diagnoses listed on this policy or if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace.
Refer to medical policy E-15 Diabetic Services and Supplies for additional information.
Refer to medical policy O-2 Prosthetic Shoe for additional information. Refer to medical policy Z-27 Eligible Providers and Supervision Guidelines for additional information.
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| Place of Service: Outpatient |
The use of foot orthotics for conditions other than diabetes is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.
| The policy position applies to all commercial lines of business |
| FEP Guidelines |
FEP covers routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes. Included are rigid devices attached to the foot or a brace, or placed in a shoe, replacement, repair and adjustment of covered devices and functional foot orthotics when prescribed by a physician. Not covered: Shoes and over-the-counter orthotics, arch supports, heel pads and heel cups. |
| Denial Statements |
Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.
A network provider can bill the member for the non-covered service.
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Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
- Provides free aids and services to people with disabilities to communicate effectively with us, such as:
- Qualified sign language interpreters
- Written information in other formats (large print, audio, accessible electronic formats, other formats)
- Provides free language services to people whose primary language is not English, such as:
- Qualified interpreters
- Information written in other languages
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
Insurance or benefit/claims administration may be provided by Highmark, Highmark Choice Company, Highmark Coverage Advantage, Highmark Health Insurance Company, First Priority Life Insurance Company, First Priority Health, Highmark Benefits Group, Highmark Select Resources, Highmark Senior Solutions Company or Highmark Senior Health Company, all of which are independent licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
