Highmark Medical Policy Bulletin

Section: Orthotic & Prosthetic Devices
Number: O-12
Topic: Foot Orthotics for Conditions Other Than Diabetes
Effective Date: January 1, 2004
Issued Date: January 5, 2004
Date Last Reviewed:

General Policy Guidelines

Indications and Limitations of Coverage

Foot orthotics are covered only when they are a benefit of a member’s contract and when prescribed for these conditions:

Achilles tendonitis (726.71)
Calcaneal apophysitis (732.5)
Calcaneal spur (726.73)
Chondromalacia of the patella secondary to pronation deformity of the foot
Degenerative joint disease (715.17, 715.27, 715.37, 715.97)
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)
Posterior tibial insufficiency (Posterior tibial tendon dysfunction)
Rheumatoid arthritis (714-714.9)
Sever's Disease (732.5)
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.

Foot orthotics are fabricated to meet specific needs of the patient. A physician 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, (L3040-L3090), 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 (L3224 and L3225), 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, (L3201-L3222, L3230, and L3251-L3255) are not covered. In these instances, a participating, preferred, or network provider can bill the member for the denied service.

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-L3031, 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. They are eligible when reported with an eligible diagnosis/condition.

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

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

Coverage for Prosthetics and Orthotics is determined according to individual or group customer benefits.


Orthotics protect, restore or improve function of moveable parts of the body with orthopedic appliances or apparatus. Orthotic appliances or apparatus support, align, prevent 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.

Procedure Codes


Traditional (UCR/Fee Schedule) Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

Comprehensive / Wraparound / PPO / Major Medical Guidelines

Refer to General Policy Guidelines

Any reference in this bulletin to non-billable services by a network provider may not be applicable to Major Medical.

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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[Version 006 of O-12]
[Version 005 of O-12]
[Version 004 of O-12]
[Version 003 of O-12]
[Version 002 of O-12]
[Version 001 of O-12]

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Procedure Code Attachment


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.