|Highmark Medical Policy Bulletin|
|Section:||Orthotic & Prosthetic Devices|
|Topic:||Foot Orthotics for Conditions Other Than Diabetes|
|Effective Date:||June 2, 2008|
|Issued Date:||June 30, 2008|
|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:
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.
Reimbursement is limited to one orthotic per foot. Separate orthotics for multiple shoes is not considered medically necessary.
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.
In addition to being covered for the diagnoses listed on this medical policy, heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600-L3640) involving shoes on a covered brace are covered regardless of the diagnosis reported. Inserts and other shoe modifications (L3000-L3170, L3300-L3450, L3465-L3520, L3550-L3595) 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.
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.
Traditional (UCR/Fee Schedule) 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.
Comprehensive / Wraparound / PPO / Major Medical 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
12/1999, Foot orthotics allowed for certain conditions
02/2001, Blue Shield allows foot orthotics when prescribed for surgically treated fractures
12/2003, Blue Shield approves more diagnoses for foot orthotics
12/2004, Foot orthotics covered when prescribed for clubfoot
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