Clinical UM Guideline


Subject:  Orthopedic Footwear
Guideline #:  CG-DME-20Current Effective Date:  01/01/2014
Status:ReviewedLast Review Date:  11/14/2013

Description

This document addresses orthopedic footwear including shoes, inserts and modification to shoes for individuals who do not have diabetes.

Note: Please see the following related document for additional information:

Clinical Indications

Medically Necessary: 

Shoes, inserts, and modifications are considered medically necessary only in the limited circumstances described below: 

Not Medically Necessary:

Orthopedic footwear that does not meet the criteria above is considered not medically necessary.

A matching shoe that is not attached to a brace and items related to that shoe are considered not medically necessary.

Shoes are considered not medically necessary when they are put on over partial foot prosthesis or other lower extremity prosthesis that is attached to the residual limb by mechanisms other than being an integral part of the prosthesis.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS 
L3000-L3031Foot insert, removable, molded to patient model [includes codes L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031]
L3040-L3060Foot, arch supports, removable, premolded [includes codes L3040, L3050, L3060]
L3070-L3090Foot, arch supports, non-removable, attached to shoe [includes codes L3070, L3080, L3090]
L3160Foot, adjustable shoe-styled positioning device
L3170Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each
L3224-L3225Orthopedic footwear, used as an integral part of a brace (orthosis)
L3230Orthopedic footwear, custom shoe, depth inlay, each
L3250Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
L3251Foot, shoe molded to patient model; silicone shoe, each
L3252Foot, shoe molded to patient model; Plastazote (or similar), custom fabricated, each
L3253Foot, molded shoe Plastazote (or similar) custom fitted, each
L3254Non-standard size or width
L3255Non-standard size or length
L3257Orthopedic footwear, additional charge for split size
L3265Plastazote sandal, each
L3300-L3334Lifts [includes codes L3300, L3310, L3320, L3330, L3332, L3334]
L3340-L3350Heel wedges [includes codes L3340, L3350]
L3360-L3370Sole wedges [includes codes L3360, L3370]
L3390Outflare wedge
L3400-L3410Metatarsal bar wedges [includes codes L3400, L3410]
L3420Full sole and heel wedge, between sole
L3430-L3485Heels [includes codes L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485]
L3500-L3595Orthopedic shoe additions [includes codes L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595]
L3600-L3630Transfer of an orthosis from one shoe to another [includes codes L3600, L3610, L3620, L3630]
  
HCPCS Modifiers 
LTLeft side
RTRight side
  
ICD-9 Diagnosis[For dates of service prior to 10/01/2014]
 All diagnoses
  
ICD-10 Diagnosis[For dates of service on or after 10/01/2014]
 All diagnoses
  
Discussion/General Information

This clinical guideline is based on Centers for Medicare and Medicaid Services (CMS) criteria.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. Centers for Medicare and Medicaid Services (CMS). National Coverage Determination: Durable medical equipment reference list. NCD #280.1. 05/05/2005. Available at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on September 05, 2013.
  2.  CGS Administrators, LLC. Jurisdiction C. Local Coverage Determination for Orthopedic Footwear (L11445). Revised 03/29/2013. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on September 05, 2013.
  3.  National Government Services, Inc. Jurisdiction B. Local Coverage Determination for Orthopedic Footwear (L27220). Revised 03/29/2013. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on September 05, 2013.
  4. NIHC Corp. Jurisdiction A. Local Coverage Determination for Orthopedic Footwear (L11467). Revised 03/29/2013. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on September 05, 2013.
  5. Noridian Administrative Services. Jurisdiction D. Local Coverage Determination for Orthopedic Footwear (L11456). Revised 03/30/2013. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on September 05, 2013.
Index

Orthopedic Footwear

History
StatusDateAction
Reviewed11/14/2013Medical Policy & Technology Assessment Committee (MPTAC) review. Description, References and Websites updated.  Updated Coding section with 01/01/2014 HCPCS descriptor change for L3170.
Reviewed11/08/2012MPTAC review. Updated references and websites.
Reviewed11/17/2011MPTAC review. Updated references and websites.
Reviewed11/18/2010MPTAC review. References and Websites updated.
Reviewed11/19/2009MPTAC review. Place of service removed and references updated
Reviewed11/20/2008MPTAC review. References updated.
Reviewed11/29/2007MPTAC review. References and coding updated. Minor wording changes.
Reviewed12/07/2006MPTAC review. References updated.
New12/01/2005MPTAC initial document development.
Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 No document
Anthem CO/NV

10/29/2004

DME.709Orthopedic Footwear
Anthem CT

 

Benefit DetailFoot Orthotics
WellPoint Health Networks, Inc.

 

 No document