JOHNS HOPKINS HEALTHCARE

of 8 ACTION: Effective Date: 06/01/2000 New Policy Review Dates: 10/22/2003, 10/22/2004, Revising : 10/21/2005, 10/19/2006, 06/25/2008, Superseding 06/04/2009, 04/02/2010, 04/06/2011, 05/29/2012, 03/06/2015 Archiving : Retiring Johns Hopkins HealthCare (JHHC) provides a full spectrum of health care products and services for Employer Health Programs, Priority Partners, and US Family Health Plan. Each line of business possesses its own unique contract and guidelines which, for benefit and payment purposes, should be consulted to know what benefits are available for reimbursement. Specific contract benefits, guidelines or policies supersede the information outlined in this policy. ACTIVE AND ARCHIVED This document has been archived as of 03/06/2015 and is no longer scheduled for review for either one or more of the following reasons: 1. This document is either primarily administrative in nature and/or 2. It addresses operational issues only and/or 3. It is mandated by statute or regulation and/or 4. It is unlikely that further published literature would change the determination. ARCHIVED POLICIES REMAIN ACTIVE FOR THE PURPOSE OF MEDICAL NECESSITY DETERMINATION POLICY: For US Family Health Plan see TRICARE Policy Manual 6010.57-M, February 1, 2008, Orthotics: Chapter 8, Section 3.1. I. When benefits are provided under the member s contract, JHHC considers custom foot orthotics medically necessary when one of the following criteria is met: A. The individual could not be fitted with a prefabricated ankle foot orthosis (AFO), or B. The condition necessitating the orthosis is expected to be permanent or of longstanding duration, (more than 6 months), OR C. There is a need to control the knee, ankle, or foot in more than one place, or D. The individual has a documented neurological, circulatory, or orthopedic problem that requires custom fabrication in order to prevent tissue injury. II. When benefits are provided under the member s contract, JHHC considers custom foot

of 8 orthotics medically necessary when one of the following diagnoses is documented: A. Proximal Lower Extremity Pathology including: 1. Shin Splint Syndrome (Periosteal Myositis) 2. Stress fractures 3. Periositis 4. Tendonitis (Tenosynovitis) 5. Posterior Tibial Dysfunction B. Arthritis 1. Inflammatory Arthritis (The degree of deformity or abnormal motion that is manifested precludes the use of an over-the-counter device or attempts to use such a device have failed.) 2. Osteoarthritis (for management of lower extremity deformities and dysfunctions) C. Mechanically Induced Pain and Deformities 1. Pes Cavus 2. Haglund s Deformity 3. Functional Hallux Limitus, Hallux Rigidus, Hallux Valgus 4. Plantar Fasciitis (also known as Heel Spur Syndrome) 5. Sinus Tarsi Syndrome 6. Metatarsalgia 7. Excessive pronation with resultant skeletal pain 8. Morton s Neuroma (also known as Intermetatarsal Neuroma) 9. Sesamoiditis D. Pediatric Conditions 1. Tarsal Coalition 2. Metatarsus Adductus 3. Pes planus with foot pain (flat feet) E. Sensory Neuropathies 1. Peripheral Neuropathy (also includes neuropathic ulcers) 2. Charcot Neuroarthropathy (also known as Charcot Foot) F. Congenital or Traumatic Painful and Disabling Deformities G. Partial Amputation of foot H. Some Complications of Peripheral Vascular Disease III. Replacement of custom foot orthotics is considered medically necessary when there is growth or a documented change in the patient s condition. Unless specific contract language applies, custom foot orthotics may be replaced every 2 years due to documented wear and tear. BACKGROUND Foot orthotics are devices used to support, align, balance and improve function of the foot. In

of 8 addition to correcting compensatory joint motions, foot orthotics may also delay or prevent deformity. They may also eliminate the need for surgery or in some cases prevent the recurrence of deformities after surgery. CODING INFORMATION: CPT Copyright 2015 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Note: The following CPT/HCPCS codes are included below for informational purposes. Inclusion or exclusion of a CPT/HCPCS code(s) below does not signify or imply member coverage or provider reimbursement. The member's specific benefit plan determines coverage and referral requirements. All inpatient admissions require preauthorization. PRE-AUTHORIZATION REQUIRED Compliance with the provision in this policy may be monitored and addressed through post-payment data analysis and/or medical review audits Employer Health Programs (EHP) **See Specific Summary Plan Description (SPD) Priority Partners (PPMCO) refer to COMAR guidelines and PPMCO SPD then apply policy criteria US Family Health Plan (USFHP), TRICARE Medical Policy supersedes JHHC Medical Policy. If there is no Policy in TRICARE, apply the Medical Policy Criteria HCPCS CODE A5500 A5501 A5503 A5504 A5505 A5506 A5507 DESCRIPTION For diabetics, fitting (including follow-up), custom preparation and supply of offthe-shelf depth-inlay shoe manufactured to accommodate multidensity insert(s), per shoe For diabetics, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient s foot (custom molded shoe), per shoe For diabetics, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe For diabetics, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe For diabetics, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe For diabetics, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe For diabetics, not otherwise specified modification (including fitting) off off-the-

of 8 A5510 A5512 A5513 L1900 L1920 L1940 L1945 L1950 L1951 L1960 L1970 L1980 L1990 L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3040 L3050 L3060 L3070 shelf depth-inlay shoe or custom molded shoe, per shoe For diabetics, direct formed, compression molded to patient s foot without external heat source, multiple-density insert(s) prefabricated, per shoe For diabetics, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient s foot, including arch, base layer minimum of ¼ inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each For diabetics, multiple density insert, custom molded from model of patient s foot, total contact with patient s foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping material custom fabricated, each Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf, band custom fabricated Ankle-foot orthotic (AFO), single upright with static or adjustable stop (Phelps or Perstein type), custom fabricated Ankle-foot orthotic (AFO), plastic or other material, custom fabricated Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated Ankle-foot orthotic (AFO), spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated Ankle-foot orthotic (AFO), spiral, (Institute of rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated Ankle-foot orthotic (AFO), plastic with ankle joint, custom fabricated Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'BK' orthotic), custom fabricated Ankle-foot orthotic (AFO), double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'BK' orthotic), custom fabricated Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each Foot insert, removable, molded to patient model, Spenco, each Foot insert, removable, molded to patient model, Plastazote or equal, each Foot insert, removable, molded to patient model, silicone gel, each Foot insert, removable, molded to patient model, longitudinal arch support, each Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each Foot insert, removable, formed to patient foot, each Foot, arch support, removable, premolded, longitudinal, each Foot, arch support, removable, premolded, metatarsal, each Foot, arch support, removable, premolded, longitudinal/metatarsal, each Foot, arch support, nonremovable, attached to shoe, longitudinal, each

of 8 L3080 L3090 L3100 L3140 L3150 L3160 L3170 L3201 L3202 L3203 L3204 L3206 L3207 L3208 L3209 L3211 L3212 L3213 L3214 L3215 L3216 L3217 L3219 L3221 L3222 L3224 L3225 L3230 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3300 L3310 Foot, arch support, nonremovable, attached to shoe, metatarsal, each Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each Hallus-valgus night dynamic splint Foot, abduction rotation bar, including shoes Foot, abduction rotation bar, without shoes Foot, adjustable shoe-styled positioning device Foot, plastic, silicone or equal, heel stabilizer, each Orthopedic shoe, Oxford with supinator or pronator, infant Orthopedic shoe, Oxford with supinator or pronator, child Orthopedic shoe, Oxford with supinator or pronator, junior Orthopedic shoe, high-top with supinator or pronator, infant Orthopedic shoe, high-top with supinator or pronator, child Orthopedic shoe, high-top with supinator or pronator, junior Surgical boot, each, infant Surgical boot, each, child Surgical boot, each, junior Benesch boot, pair, infant Benesch boot, pair, child Benesch boot, pair, junior Orthopedic footwear, ladies shoe, oxford, each Orthopedic footwear, ladies shoe, depth inlay, each Orthopedic footwear, ladies shoe, high-top, depth inlay, each Orthopedic footwear, men s shoe, depth inlay, each Orthopedic footwear, men s shoe, depth inlay, each Orthopedic footwear, men s shoe, high-top, depth inlay, each Orthopedic footwear, woman s shoe, oxford, used as an integral part of a brace (orthotic) Orthopedic footwear, man s shoe, oxford, used as an integral part of a brace (orthotic) Orthopedic footwear, custom shoe, depth inlay, each Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each Foot, shoe molded to patient model, silicone shoe, each Foot, shoe molded to patient model, silicone shoe, each Foot, molded shoe, Plastazote (or similar), custom fitted, each Nonstandard size or width Nonstandard size or length Orthopedic footwear, additional charge for split size Lift, elevation, heel, tapered to metatarsals, per in Lift, elevation, heel and sole, neoprene, per in

of 8 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 L3520 L3530 L3540 L3550 L3570 L3580 L3590 L3595 L3600 L3610 L3620 L3630 L3640 L3649 Lift, elevation, heel and sole, cork, per in Lift, elevation, metal extension (skate) Lift, elevation, inside shoe, tapered, up to one-half in Lift, elevation, heel, per in Heel wedge, SACH Heel wedge Sole wedge, outside sole Sole wedge, between sole Clubfoot wedge Out flare wedge Metatarsal bar wedge, rocker Metatarsal bar wedge, between sole Full sole and heel wedge, between sole Heel, counter, plastic reinforced Heel, counter, leather reinforced Heel, SACH cushion type Heel, new leather, standard Heel, new rubber, standard Heel, Thomas with wedge Heel, Thomas extended to ball Heel, pad and depression for spur Heel, pad, removable for spur Orthopedic shoe addition, insole, leather Orthopedic shoe addition, insole, rubber Orthopedic shoe addition, insole, felt covered with leather Orthopedic shoe addition, sole, half Orthopedic shoe addition, sole, full Orthopedic shoe addition, toe tap, standard Orthopedic shoe addition, special extension to instep (leather with eyelets) Orthopedic shoe addition, convert instep to Velcro closure Orthopedic shoe addition, convert firm shoe counter to soft counter Orthopedic shoe addition, March bar Transfer of an orthotic from one shoe to another, caliper plate, existing Transfer of an orthotic from one shoe to another, caliper plate, new Transfer of an orthotic from one shoe to another, solid stirrup, existing Transfer of an orthotic from one shoe to another, solid stirrup, existing Transfer of an orthotic from one shoe to another, Dennis Browne splint (Riveton), both shoes Orthopedic shoe, modification, addition or transfer, NOS

of 8 REFERENCES STATEMENT: Analyses of the scientific and clinical references cited below were conducted and utilized by the JHHC Medical Policy Team during the development and implementation of this medical policy. Per NCQA standards, the Medical Policy Team will continue to monitor and review any newly published clinical evidence and adjust the references below accordingly if deemed necessary. CLINICAL: 1. Richie DH Jr. Effects of Foot Orthoses on Patients with Chronic Ankle Instability [Abstract]. Journal of the American Podiatric Medical Association, 97(1): 19-30, (2007). Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/17218622 2. Guldemond N A, Leffers P, Sanders AP, et al. Casting Methods and Plantar Pressure: Effects of Custom-made Foot Orthoses on Dynamic Plantar Pressure Distribution [Abstract]. Journal American Podiatric Medical Association, 96(1), 9-18, (2006). Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/16415278 3. Hayes, Inc. Subtalar Arthroereisis for the Treatment of Flatfoot. Review November 13, 2014. Retrieved from: http://www.hayesinc.com/hayes/ 4. Clugston JR, Hatch RL, (updated 2015, January 20). Stress Fractures of the Metatarsal Shaft. Retrieved from: http://www.uptodate.com/contents/stress-fractures-of-themetatarsalshaft?source=search_result&search=stress+fractures+of+the+metatarsal+shaft&select edtitle=1%7e95 5. Hordon LD, (2014, February 19). Diabetic Neuropathic Arthropathy. Retrieved from: http://www.uptodate.com/contents/diabetic-neuropathicarthropathy?source=search_result&search=neuropathic+arthropathy&selectedtitle=1 %7E22 HEALTH PLAN: 6. Aetna, Clinical Policy Bulletin: (2014, September 12). Ankle Orthoses, Ankle-Foot Orthoses (AFOs) and Knee-ankle-Foot Orthoses (KAFOs). : 0565. Retrieved from: http://www.aetna.com/cpb/medical/data/500_599/0565.html 7. Aetna, Clinical Policy Bulletin: (2014, July 28). Foot Orthotics. : 0451. Retrieved from: http://www.aetna.com/cpb/medical/data/400_499/0451.html 8. CIGNA Medical Coverage Policy: (2014, August 15). Lower Limb Orthoses and Shoes. Policy No: 0150. https://cignaforhcp.cigna.com/public/content/pdf/coveragepolicies/medical/mm_0150_ coveragepositioncriteria_foot_ankle_knee_orthotics.pdf

of 8 REGULATORY 9. TRICARE Policy Manual. Orthotics; Chapter 8, Section 3.1. Retrieved from: http://manuals.tricare.osd.mil/ 10. Centers for Medicare & Medicaid Services (CMS). Date Modified: November 8, 2010. Retrieved from: http://www.cms.gov/dmeposfeesched/