Does Anthem Blue Cross Pay for Shoe Inserts

Clinical UM Guideline

Subject: Orthopedic Footwear
Guideline #: CG-DME-20	Publish Date: 07/07/2021
Status: Reviewed	Last Review Date: 05/13/2021

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:

• CG-DME-19 Therapeutic Shoes, Inserts or Modifications for Individuals with Diabetes

Medically Necessary:

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

1. Shoes are considered medically necessary if they are an integral part of a leg brace that is medically necessary.
2. Heel replacements, sole replacements and shoe transfers involving shoes on a medically necessary leg brace are also considered medically necessary.
3. Inserts and other shoe modifications (such as lifts, wedges, arch supports and other additions) are considered medically necessary if they are on a shoe that is an integral part of a medically necessary leg brace, if they are medically necessary for the proper functioning of the brace.
4. Prosthetic shoes are considered medically necessary if they are an integral part of a prosthesis for individuals with a partial foot amputation.

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.

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.

When services may be Medically Necessary when criteria are met:

HCPCS
L3000-L3031	Foot insert, removable, molded to patient model [includes codes L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031]
L3040-L3060	Foot, arch supports, removable, premolded [includes codes L3040, L3050, L3060]
L3070-L3090	Foot, arch supports, non-removable, attached to shoe [includes codes L3070, L3080, L3090]
L3160	Foot, adjustable shoe-styled positioning device
L3170	Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each
L3224-L3225	Orthopedic footwear, used as an integral part of a brace (orthosis)
L3230	Orthopedic footwear, custom shoe, depth inlay, each
L3250	Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
L3251	Foot, shoe molded to patient model; silicone shoe, each
L3252	Foot, shoe molded to patient model; Plastazote (or similar), custom fabricated, each
L3253	Foot, molded shoe Plastazote (or similar) custom fitted, each
L3254	Non-standard size or width
L3255	Non-standard size or length
L3257	Orthopedic footwear, additional charge for split size
L3265	Plastazote sandal, each
L3300-L3334	Lifts [includes codes L3300, L3310, L3320, L3330, L3332, L3334]
L3340-L3350	Heel wedges [includes codes L3340, L3350]
L3360-L3370	Sole wedges [includes codes L3360, L3370]
L3390	Outflare wedge
L3400-L3410	Metatarsal bar wedges [includes codes L3400, L3410]
L3420	Full sole and heel wedge, between sole
L3430-L3485	Heels [includes codes L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485]
L3500-L3595	Orthopedic shoe additions [includes codes L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595]
L3600-L3630	Transfer of an orthosis from one shoe to another [includes codes L3600, L3610, L3620, L3630]
ICD-10 Diagnosis
	All diagnoses

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met or for situations designated in the Clinical Indications section as not medically necessary.

Discussion/General Information

Orthopedic footwear including shoes, inserts and modifications to shoes are utilized for the alignment, support, prevention or correction of deformities or to improve the function of movable parts of the body. Orthotics includes braces which are used to support a weak joint or joints.

The medical necessity of orthopedic footwear including shoes, inserts and modification to shoes for individuals who do not have diabetes is based on the evaluation of the individual's needs and capabilities in relation to the following definition of medical necessity (CGS, 2020).

• The orthopedic footwear is reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.

This document is based on peer-reviewed published literature and Medicare criteria.

Peer Reviewed Publications:

1. McDermott P, Wolfe E, Lowry C, et al. Evaluating the immediate effects of wearing foot orthotics in children with joint hypermobility syndrome (JHS) by analysis of tempero-spatial parameters of gait and dynamic balance: A preliminary study. Gait Posture. 2018; 60:61-64.
2. Rasenberg N, Riel H, Rathleff MS, et al. Efficacy of foot orthoses for the treatment of plantar heel pain: A systematic review and meta-analysis. Br J Sports Med. 2018; 52(16):1040-1046.
3. Whittaker GA, Munteanu SE, Menz HB, et al. Foot orthoses for plantar heel pain: A systematic review and meta-analysis. Br J Sports Med. 2018; 52(5):322-328.

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. Effective May 5, 2005. Available at: https://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx?list_type=ncd. Accessed on April 12, 2021.
2. CGS Administrators, LLC. Jurisdictions B and C. Local Coverage Determination for Orthopedic Footwear (L33641). Revised 01/01/2020. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on April 12, 2021.
3. Noridian Administrative Services. Jurisdictions A and D. Local Coverage Determination for Orthopedic Footwear (L33641). Revised 01/01/2020. Available at: http://www.cms.hhs.gov/mcd/index_local_alpha.asp?from2=index_local_alpha.asp&from=alphalmrp&letter=A&. Accessed on April 12, 2021.

Orthopedic Footwear

Status	Date	Action
Reviewed	05/13/2021	Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section.
Reviewed	11/05/2020	MPTAC review. Updated References section. Reformatted Coding section.
Reviewed	11/07/2019	MPTAC review. Updated Discussion/General Information and References sections.
Reviewed	01/24/2019	MPTAC review. Updated References section.
Reviewed	02/27/2018	MPTAC review. The document header wording updated from "Current Effective Date" to "Publish Date." Updated References section.
Reviewed	02/02/2017	MPTAC review. Updated formatting in Clinical Indications section. Updated Coding, Discussion and Reference sections.
Reviewed	11/03/2016	MPTAC review. Updated Reference section.
Reviewed	11/05/2015	MPTAC review. Updated References. Removed ICD-9 codes from Coding section.
Reviewed	11/13/2014	MPTAC review. Updated References.
Reviewed	11/14/2013	MPTAC review. Description, References and Websites updated. Updated Coding section with 01/01/2014 HCPCS descriptor change for L3170.
Reviewed	11/08/2012	MPTAC review. Updated references and websites.
Reviewed	11/17/2011	MPTAC review. Updated references and websites.
Reviewed	11/18/2010	MPTAC review. References and Websites updated.
Reviewed	11/19/2009	MPTAC review. Place of service removed and references updated
Reviewed	11/20/2008	MPTAC review. References updated.
Reviewed	11/29/2007	MPTAC review. References and coding updated. Minor wording changes.
Reviewed	12/07/2006	MPTAC review. References updated.
New	12/01/2005	MPTAC initial document development.

Pre-Merger Organizations	Last Review Date	Document Number	Title
Anthem, Inc.			No document
Anthem CO/NV	10/29/2004	DME.709	Orthopedic Footwear
Anthem CT		Benefit Detail	Foot Orthotics
WellPoint Health Networks, Inc.			No document

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Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. We reserve the right to review and update Clinical UM Guidelines periodically. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card.

Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plan's or line of business's members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner.

No part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from the health plan.

© CPT Only - American Medical Association

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Source: https://www.anthem.com/dam/medpolicies/abc/active/guidelines/gl_pw_a053656.html#:~:text=Inserts%20and%20other%20shoe%20modifications,proper%20functioning%20of%20the%20brace.

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