?; ] ROUTINE FOOT CARE UnitedHealthcare Oxford Clinical Policy Policy Number: OUTPATIENT 023.22 T1 Effective Date: October 1, 2017 Table of Contents Page INSTRUCTIONS FOR USE... 1 CONDITIONS OF COVERAGE... 1 BENEFIT CONSIDERATIONS... 1 COVERAGE RATIONALE... 2 APPLICABLE CODES... 2 REFERENCES... 6 POLICY HISTORY/REVISION INFORMATION... 6 Related Policy Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies, and Repairs/ Replacements INSTRUCTIONS FOR USE This Clinical Policy provides assistance in interpreting Oxford benefit plans. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify its policies as necessary. This Clinical Policy is provided for informational purposes. It does not constitute medical advice. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. When deciding coverage, the member specific benefit plan document must be referenced. The terms of the member specific benefit plan document [e.g., Certificate of Coverage (COC), Schedule of Benefits (SOB), and/or Summary Plan (SPD)] may differ greatly from the standard benefit plan upon which this Clinical Policy is based. In the event of a conflict, the member specific benefit plan document supersedes this Clinical Policy. All reviewers must first identify member eligibility, any federal or state regulatory requirements, and the member specific benefit plan coverage prior to use of this Clinical Policy. Other Policies may apply. UnitedHealthcare may also use tools developed by third parties, such as the MCG Care Guidelines, to assist us in administering health benefits. The MCG Care Guidelines are intended to be used in connection with the independent professional medical judgment of a qualified health care provider and do not constitute the practice of medicine or medical advice. CONDITIONS OF COVERAGE Applicable Lines of Business/ Products Benefit Type Referral Required (Does not apply to non-gatekeeper products) Authorization Required (Precertification always required for inpatient admission) Precertification with Medical Director Review Required Applicable Site(s) of Service (If site of service is not listed, Medical Director review is required) Special Considerations This policy applies to Oxford Commercial plan membership. General benefits package Yes - Office No - Home, Outpatient Yes - Home, Outpatient No - Office No Home, Outpatient, Office Routine foot care is excluded from coverage for all Commercial plans except as outlined in the Coverage Rationale section of this policy. BENEFIT CONSIDERATIONS Before using this policy, please check the member specific benefit plan document and any federal or state mandates, if applicable. Page 1 of 6
Essential Health Benefits for Individual and Small Group For plan years beginning on or after January 1, 2014, the Affordable Care Act of 2010 (ACA) requires fully insured non-grandfathered individual and small group plans (inside and outside of Exchanges) to provide coverage for ten categories of Essential Health Benefits ( EHBs ). Large group plans (both self-funded and fully insured), and small group ASO plans, are not subject to the requirement to offer coverage for EHBs. However, if such plans choose to provide coverage for benefits which are deemed EHBs, the ACA requires all dollar limits on those benefits to be removed on all Grandfathered and Non-Grandfathered plans. The determination of which benefits constitute EHBs is made on a state by state basis. As such, when using this policy, it is important to refer to the member specific benefit plan document to determine benefit coverage. Benefit Interpretation Routine foot care for members with diabetes or who are at risk for neurological or vascular disease arising from diseases such as diabetes is a covered health service. A shoe that is an integral part of a covered brace may be a covered health service. Please refer to the policy titled Durable Medical Equipment, Orthotics, Ostomy Supplies, Medical Supplies, and Repairs/Replacements for details. Shoe, Shoe Orthotic/Inserts, Arch Supports: When an Oxford Member Certificate of Coverage indicates orthotics are excluded from coverage, this refers to shoe inserts (including diabetic shoe inserts) unless there is language within the exclusion clause to indicate otherwise. The following codes will not be covered unless the members plan includes coverage for foot orthotics. Please refer to the member specific benefit plan document for additional information. COVERAGE RATIONALE Routine foot care for members with diabetes or who are at risk for neurological or vascular disease arising from diseases such as diabetes is covered. Benefit Limitations and Exclusions Routine care of the foot is an exclusion except when rendered to members with diabetes or members who are at risk of neurological or vascular disease arising from diseases such as diabetes. Examples of routine foot care include but are not limited to: o Cutting or removal of corns and calluses; nail trimming, cutting, or debriding o Hygienic and preventive maintenance foot care such as cleaning and soaking the feet, applying skin creams to maintain skin integrity and other services that are performed when there is not a localized illness, injury, or symptom involving the feet. This can take place in the physician office, outpatient setting, or member s home. The following foot care services are excluded from coverage. These are examples, not an all-inclusive list: o Treatment of flat feet o Treatment of subluxation of the foot The following items are excluded from coverage, regardless of diagnosis. However, state mandates may apply. Refer to member specific benefit plan document and state mandates. o Arch supports o Shoe inserts o Shoe orthotics o Shoes (standard or custom) APPLICABLE CODES The following list(s) of procedure and/or diagnosis codes is provided for reference purposes only and may not be all inclusive. Listing of a code in this policy does not imply that the service described by the code is a covered or noncovered health service. Benefit coverage for health services is determined by the member specific benefit plan document and applicable laws that may require coverage for a specific service. The inclusion of a code does not imply any right to reimbursement or guarantee claim payment. Other Policies may apply. Coding Clarification: There are no specific codes for Hygienic and Preventive Maintenance Foot Care and Treatment of Subluxation of the Foot. CPT Code CPT codes 11055, 11056, and 11057 will also be covered when billed with one of the diabetes, neurological or vascular disease diagnosis codes listed below any one of the following routine foot care diagnosis codes: B35.3, L60.1-L60.5, L60.8, L62, L84, M21.6X1, M21.6X2 or M21.6X9. 11055 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); single lesion Page 2 of 6
CPT Code CPT codes 11055, 11056, and 11057 will also be covered when billed with one of the diabetes, neurological or vascular disease diagnosis codes listed below any one of the following routine foot care diagnosis codes: B35.3, L60.1-L60.5, L60.8, L62, L84, M21.6X1, M21.6X2 or M21.6X9. 11056 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); 2 to 4 lesions 11057 Paring or cutting of benign hyperkeratotic lesion (e.g., corn or callus); more than 4 lesions Nail Trimming Cutting or Debriding CPT codes 11719, 11720, and 11721 are covered when billed with a diabetes and neurological or vascular disease diagnosis code below. 11719 Trimming of nondystrophic nails, any number 11720 Debridement of nail(s) by any method(s); 1 to 5 11721 Debridement of nail(s) by any method(s); 6 or more Treatment for Flat Feet The following is excluded regardless of diagnosis code used. 28735 Arthrodesis, midtarsal or tarsometatarsal, multiple or transverse; with osteotomy (e.g., flatfoot correction) CPT is a registered trademark of the American Medical Association HCPCS Code HCPCS code S0390 will also be covered when billed with one of the diabetes and neurological or vascular disease diagnosis codes listed below and any one of the following routine foot care diagnosis codes: B35.3, L60.1-L60.5, L60.8, L62, L84, M21.6X1, M21.6X2 or M21.6X9. S0390 Routine foot care; removal and/or trimming of corns, calluses and/or nails and preventive maintenance in specific medical conditions (e.g., diabetes), per visit Nail Trimming Cutting or Debriding HCPCS code G0127 is covered when billed with a diabetes and neurological or vascular disease diagnosis code below. G0127 Trimming of dystrophic nails, any number Diabetic Shoes A5500 A5501 A5503 A5504 A5505 A5506 A5507 A5508 All Other Shoes L3201 L3202 L3203 For diabetics only, fitting (including follow-up) custom preparation and supply of offthe-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe For diabetics only, fitting (including follow-up) custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe custom molded shoe with roller or rigid rocker bottom, per shoe custom molded shoe with wedge(s), per shoe custom molded shoe with metatarsal bar, per shoe custom molded shoe with off-set heel(s), per shoe For diabetics only, not otherwise specified modification (including fitting) of off-theshelf depth-inlay shoe or custom molded shoe, per shoe For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe Orthopedic shoe, oxford with supinator or pronator, infant Orthopedic shoe, oxford with supinator or pronator, child Orthopedic shoe, oxford with supinator or pronator, junior Page 3 of 6
HCPCS Code All Other Shoes L3204 L3206 L3207 L3215 L3216 L3217 L3219 L3221 L3222 L3230 L3250 L3251 L3252 L3253 L3254 L3255 L3257 L3265 L3300 L3310 L3320 L3330 L3332 L3334 L3340 L3350 L3360 L3370 L3380 L3390 L3400 L3410 L3420 L3430 L3440 L3450 L3455 L3460 L3465 L3470 L3480 L3485 L3500 L3510 Orthopedic shoe, hightop with supinator or pronator, infant Orthopedic shoe, hightop with supinator or pronator, child Orthopedic shoe, hightop with supinator or pronator, junior Orthopedic footwear, ladies shoe, oxford, each Orthopedic footwear, ladies shoe, depth inlay, each Orthopedic footwear, ladies shoe, hightop, depth inlay, each Orthopedic footwear, mens shoe, oxford, each Orthopedic footwear, mens shoe, depth inlay, each Orthopedic footwear, mens shoe, hightop, depth inlay, each 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, plastazote (or similar), custom fabricated, 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 Plastazote sandal, each Lift, elevation, heel, tapered to metatarsals, per inch Lift, elevation, heel and sole, neoprene, per inch Lift, elevation, heel and sole, cork, per inch Lift, elevation, metal extension (skate) Lift, elevation, inside shoe, tapered, up to one-half inch Lift, elevation, heel, per inch Heel wedge, sach Heel wedge Sole wedge, outside sole Sole wedge, between sole Clubfoot wedge Outflare 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 Page 4 of 6
HCPCS Code All Other Shoes L3520 L3530 L3540 L3550 L3560 L3570 L3580 L3590 L3595 L3649 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, toe tap, horseshoe 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 Diabetic Shoe Orthotics/Shoe Inserts A5510 A5512 A5513 All Other Shoe Orthotics/Shoe Inserts L3000 L3001 L3002 L3003 L3010 L3020 L3030 L3031 S0395 Orthopedic shoe, modification, addition or transfer, not otherwise specified For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe For diabetics only, 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 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each For diabetics only, 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 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 Arch Supports L3040 L3050 L3060 L3070 L3080 L3090 Foot, insert/plate, removable, addition to lower extremity orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, each Impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic Foot, arch support, removable, premolded, longitudinal, each Foot, arch support, removable, premolded, metatarsal, each Miscellaneous Foot Care A9285 Foot, arch support, removable, premolded, longitudinal/metatarsal, each Foot, arch support, nonremovable, attached to shoe, longitudinal, each Foot, arch support, nonremovable, attached to shoe, metatarsal, each Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each Inversion/eversion correction device Page 5 of 6
HCPCS Code Miscellaneous Foot Care L3140 L3150 L3160 L3170 L3600 L3610 L3620 L3630 L3640 ICD-10 Diagnosis Codes 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, prefabricated, off-the-shelf, each Transfer of an orthosis from one shoe to another, caliper plate, existing Transfer of an orthosis from one shoe to another, caliper plate, new Transfer of an orthosis from one shoe to another, solid stirrup, existing Transfer of an orthosis from one shoe to another, solid stirrup, new Transfer of an orthosis from one shoe to another, Dennis Browne splint (Riveton), both shoes ICD10 Diagnosis REFERENCES The foregoing Oxford policy has been adapted from an existing UnitedHealthcare national policy that was researched, developed and approved by UnitedHealthcare Medical Technology Assessment Committee. [BI-020.04] American Medical Association. Current Procedural Terminology: CPT Professional Edition. American Medical Association. ICD-9-CM Code Book. Ingenix. Healthcare Common Procedure Coding System: HCPCS Level II Expert. Oxford Certificates of Coverage. POLICY HISTORY/REVISION INFORMATION Date 10/01/2017 Action/ Updated list of applicable ICD-10 codes to reflect annual code edits: o Added E11.10, E11.11, L97.405, L97.406, L97.408, L97.415, L97.416, L97.418, L97.425, L97.426, L97.428, L97.505, L97.506, L97.508, L97.515, L97.516, L97.518, L97.525, L97.526, and L97.528 Archived previous policy version OUTPATIENT 023.21 T1 Page 6 of 6