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HealthPartners

Coverage criteria policies

Orthotics / braces / shoes – Minnesota Health Care Programs

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for orthotics or braces.

Prior authorization is not applicable for an electronic /microprocessor-controlled orthotic.

Prior authorization is not required for orthopedic/ therapeutic shoes and inserts.

Coverage

Orthotics, braces, and orthopedic/ therapeutic shoes are generally covered subject to the indications listed below and per your plan documents.

An electronic/ microprocessor-controlled orthotic is not covered.

Indications that are covered

Orthotics and Braces

Orthotics for the spine

An orthotic for the spine is considered medically necessary:

  1. To facilitate healing of the spine or related soft tissues.
  2. To reduce pain by restricting mobility.
  3. To support weak spinal muscles or a deformed spine.
  4. To treat scoliosis.

Orthotics for the hip

An orthotic for the hip is considered medically necessary:

  1. To stabilize the hip.
  2. To correct and maintain hip abduction.

Lower limb orthotics

A lower limb orthotic is considered medically necessary:

  1. For treatment of contractures.
  2. To immobilize a limb to promote healing.
  3. To provide support and stability during ambulation.

Upper extremity orthotics

An upper extremity orthotic is considered medically necessary:

  1. To immobilize an extremity to promote healing.
  2. For treatment of contractures.
  3. To provide support and stability during activities of daily living.

Therapeutic Shoes, Modifications and Inserts for Persons with Diabetes

Therapeutic footwear is used to prevent diabetic ulcers.

Custom-made or stock therapeutic shoes and modifications to therapeutic shoes are covered for members with diagnosed diabetes and one or more of the following conditions:

  1. Previous amputation of the other foot, or part of either foot
  2. History of foot ulceration of either foot
  3. History of pre-ulcerative calluses of either foot
  4. Peripheral neuropathy of either foot
  5. Foot deformity of either foot
  6. Poor circulation of either foot

Inserts for therapeutic shoes, whether custom-made or stock, are covered only when the member has covered therapeutic shoes.

2 pair of therapeutic shoes, modifications and inserts are covered in a calendar year. They can be dispensed at the same time, or at different times.

Orthopedic Shoes and Inserts

Orthopedic footwear is used by individuals with structural conditions of the foot.

Custom-made orthopedic shoes, modifications and inserts will be covered when the shoe is an integral part of a leg brace, or for members with one or more of the following medical conditions:

  1. Foot deformity accompanied by pain.
  2. Plantar fasciitis.
  3. Calcaneal bursitis (acute or chronic).
  4. Calcaneal spurs.
  5. Inflammatory conditions such as submetatarsal bursitis, synovial cyst or plantar fascial fibromatosis.
  6. Medial osteoarthritis of the knee.
  7. Musculoskeletal / arthropathic deformities.
  8. Neurologically impaired feet.
  9. Vascular conditions.
  10. Hallus valgus deformities in children.

Stock orthopedic shoes are covered only if the shoes are an integral part of a covered leg brace and if they are medically necessary for the proper functioning of the leg brace.

Stock inserts are covered only for use in covered orthopedic shoes.

One pair of orthopedic shoes and 2 pair of inserts are covered in a calendar year.

Orthopedic and therapeutic shoes, modifications and inserts must be prescribed by a podiatrist or physician knowledgeable in the fitting of orthopedic shoes and inserts.

All shoes, modifications and inserts must be fitted and furnished by a qualified individual such as a podiatrist, pedorthist, orthotist or prosthetist.

Foot Pressure Off-Loading Device

A foot pressure off-loading device is covered for pressure reduction for existing pressure ulcers on the foot.

Indications that are not covered

  1. Medical supplies or equipment supplied or prescribed by a chiropractor are not covered.
  2. A device whose primary purpose is to serve as a convenience to a person caring for the member.
  3. A device that serves to address social and environmental factors and that does not directly address the member’s physical or mental health.
  4. A device that is supplied to the member by the physician who prescribed the device or by a provider who is an affiliate of the physician who prescribed the device.
  5. Repair costs for a prosthetic or orthotic device that is under warranty.
  6. Repair costs for any rented equipment.
  7. Orthotics when used to prevent injury in a previously uninjured limb.
  8. Orthotics that are to be used only during sports or other leisure activities.
  9. A custom fabricated orthotic when the member’s needs can be met with a prefabricated orthotic.
  10. Stance control orthotics (L2005).
  11. Externally powered upper extremity orthotics (L3904).
  12. Electronic /microprocessor-controlled orthotics, including the Sensor Walk, E-MAG.
  13. Deluxe features of therapeutic shoes.

Definitions

Affiliate: A person that directly or indirectly, through one or more intermediaries, controls or is controlled by, or is under common control with, the referring physician or consultant.

Custom-made/ custom-fabricated: Made for a specific patient from his or her individual measurements and/or pattern, starting with basic materials such as plastic, metal, leather.

Inserts: Artificial devices which are placed in a shoe to assist in restoring or maintaining normal alignment of the foot

Orthotic: A rigid or semi-rigid device that is used for the purpose of supporting a weak or deformed body member or for restricting or eliminating motion in a disease or injured part of the body. Elastic support garments do not meet the definition of an orthotic because they are not rigid or semi-rigid devices. Devices that are not rigid or semi-rigid should be coded A4466.

Prosthetic: An artificial device, as defined by Medicare, to replace a missing or nonfunctional body part

Stock/off-the-shelf/prefabricated: Orthotic items that are not fabricated to an individual’s specifications. They may be adjusted or altered to meet the member’s needs, but are not made specifically for the member. An orthotic that is assembled solely from prefabricated components is considered prefabricated.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Codes

Description

A5500-A5501

Therapeutic shoes

A5503-A5507

Modifications to therapeutic shoes

A5510-A5513

Inserts for therapeutic shoes

A9283

Foot Pressure Off-Loading Device

L0112-L1499

Spinal Orthotics

L1600-L1755, L2040-L2090

Orthotics for the hip

L1810-L2035, L2106-L2999, L4350-L4631

Lower limb orthotics

L3650-L3999

Upper extremity orthotics

L2005

Stance control orthotics

L3000-L3031

Custom inserts

L3040-L3060

Pre-molded, removable arch supports

L3070-L3100

Non-removable arch supports

L3140-L3150

Abduction and rotation bars

L3224-L3253

Orthopedic footwear

L3300-L3595

Additions and modifications to orthopedic shoes

L3600-L3640

Transfer of orthotic

L3649

Orthopedic shoe, modification, addition or transfer, not otherwise specified

L3904

Externally powered upper extremity orthotic

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, Minnesota Health Care Programs plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

References

  1. Minnesota Health Care Programs (MHCP) Provider Manual: Equipment and Supplies: Orthotics. Revised 09-13-2012.
  2. Minnesota Health Care Programs (MHCP) Provider Manual: Equipment and Supplies: Orthopedic and Therapeutic Footwear. Revised 06-08-2012.
  3. Minnesota Health Care Programs (MHCP) Provider Manual: Chiropractic Services. Revised 06-09-2016.

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Policy activity

  • 06/24/2016 - Date of origin
  • 07/01/2017 - Effective date
Review date
  • 06/2017
Revision date
  • 06/22/2017

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