Highmark Medical Policy Bulletin

Section: Orthotic & Prosthetic Devices
Number: O-12
Topic: Foot Orthotics for Conditions Other Than Diabetes
Effective Date: May 14, 2001
Issued Date: May 14, 2001
Date Last Reviewed:

General Policy Guidelines

Orthotics serve to protect or restore/improve function of moveable parts of the body with orthopedic appliances or apparatus which support, align, or prevent/correct deformities. Foot orthotics are ordered by a physician and fabricated to meet specific needs of the patient and may or may not include the shoe and any modifications and/or transfers necessary to make the orthotic functional and effective. Therefore, when a benefit, foot orthotics which meet the above definition are covered when prescribed for the following conditions:

Achilles tendonitis (726.71)
Calcaneal spur (726.73)
Chondromalacia of the patella secondary to pronation deformity of the foot
Degenerative joint disease (715.17)
Hallus rigidus (735.2, 755.66)
Hammertoe digit syndrome (735.4, 755.66)
Limb length discrepancy (736.81)
Metatarsus adductus in children (754.52-754.53)
Neuroma (355.6)
Pes cavus deformity (754.71, 736.73)
Plantar faciitis (728.71)
Rheumatoid arthritis (714-714.9)
Status post foot surgery for continued correction (e.g., surgically treated fractures)
Status post recurrent ankle sprain with high calcaneal varus
Symptomatic hallux valgus (735.0, 755.66)
Symptomatic intractable plantar keratosis
Tibialis anterior tendonitis (726.72)
Tibialis posterior tendonitis (726.72)

(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 in the case at hand.)

However, foot care products which can be purchased over-the-counter without a prescription, e.g., premolded arch supports, (L3040-L3090), do not meet the definition of foot orthotics and are not covered.

Orthotic shoes are eligible only when they are an integral part of a brace (L3224 and L3225) and when prescribed by a physician for an eligible condition as listed above. Orthotic shoes not an integral part of a brace, (L3201-L3223, L3230, and L3251-L3255) are noncovered.

NOTE: The Lang Medical Shoe (L2999) is eligible for payment when it is an integral part of a brace AND when prescribed by a physician for an eligible condition as listed above.

Modifications (L3000-L3030, and L3300-L3595) and transfers (L3600-L3640) to foot orthotics are eligible, whether or not the foot orthotic is an integral part of a brace, when the diagnosis reported is one for which foot orthotics are eligible. Procedure codes L3100-L3170 and L3257- L3265 represent other foot orthotic services, e.g. abduction/adduction devices, and are eligible when reported with an eligible diagnosis/condition.

For information on orthotic footwear for diabetic patients, see Medical Policy E-15, Diabetic Services and Supplies.

For information on the prosthetic shoe (L3250), see Medical Policy O-2, Prosthetic Shoe.

Procedure Codes


Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

Comprehensive/Wraparound/PPO Guidelines

Refer to General Policy Guidelines

Managed Care (HMO/POS) Guidelines

Refer to General Policy Guidelines


PRN References

12/1999, Foot orthotics allowed for certain conditions
02/2001, Blue Shield allows foot orthotics when prescribed for surgically treated fractures


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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.

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.