Notification



Notification Issue Date:



Medicare Advantage Policy

Title:Orthopedic Footwear
Policy #:MA05.012a

This policy is applicable to the Company’s Medicare Advantage products only. Policies that are applicable to the Company’s commercial products are accessible via a separate commercial policy database.


The Company makes decisions on coverage based on the Centers for Medicare and Medicaid Services (CMS) regulations and guidance, benefit plan documents and contracts, and the member’s medical history and condition. If CMS does not have a position addressing a service, the Company makes decisions based on Company Policy Bulletins. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable. Although the Medicare Advantage Policy Bulletin is consistent with Medicare’s regulations and guidance, the Company’s payment methodology may differ from Medicare.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.


This Policy Bulletin document describes the status of CMS coverage, medical terminology, and/or benefit plan documents and contracts at the time the document was developed. This Policy Bulletin will be reviewed regularly and be updated as Medicare changes their regulations and guidance, scientific and medical literature becomes available, and/or the benefit plan documents and/or contracts are changed.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's Evidence of Coverage.

MEDICALLY NECESSARY

PROSTHETIC SHOES
Prosthetic shoes (L3250) are considered medically necessary and, therefore, covered, when they are considered an integral part of a prosthesis for an individual with a partial foot amputation, and both of the following indications are met:
  • The shoe is custom fabricated from a model of the individual
  • The shoe has a removable custom fabricated insert designed for a toe or distal partial foot amputation.

OTHER SHOES AND FOOTWEAR
Other types of shoes (e.g., oxford shoes, high top, depth inlay or custom for non-diabetics) are considered medically necessary and, therefore, covered if they are an integral part of a covered leg brace as described by codes L1900, L1920, L1980-L2030, L2050, L2060, L2080, L2090, L3224, L3225, and L3649, and medically necessary for the proper functioning of the brace.

Heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600-L3640) involving shoes on a covered brace are considered medically necessary and, therefore, covered.

Inserts and other shoe modifications (L3000-L3170, L3300-L3450, L3465-L3520, L3550-L3595) are considered medically necessary and, therefore, covered if they are on a shoe that is an integral part of a covered brace, and if they are medically necessary, for the proper functioning of the brace.

NOT COVERED

A matching shoe which is not attached to a brace, including items related to that shoe are not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

Shoes which are incorporated into a brace must be billed by the same supplier billing for the brace. Shoes which are billed separately (i.e., not as part of a brace) are not covered by the Company because it is an item not covered by Medicare. Therefore, it is not eligible for reimbursement consideration.

Shoes are that are put on over a partial foot prosthesis or other lower extremity prosthesis (L5010-L5600), which is attached to the residual limb by other mechanisms, (not part of a covered brace), are not covered by the Company because these are items not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

A foot pressure off-loading/supportive device (A9283) is not covered by the Company, and, therefore, not eligible for reimbursement consideration, because it is an item not covered by Medicare as it does not meet the definition of:
  • A therapeutic shoe for diabetics or related insert or modification
  • An orthopedic shoe or modification
  • A walking boot

The following orthopedic footwear L3215, L3216, L3217, L3219, L3221, L3222 are not covered by the Company because these items are not covered by Medicare. Therefore, they are not eligible for reimbursement consideration.

REQUIRED DOCUMENTATION

The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.

CONSUMABLE SUPPLIES
The supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately seven days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the supplier may be required to reimburse the Company for overpayments.
Policy Guidelines

This policy is consistent with Medicare’s coverage determination. The Company’s payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, orthopedic footwear are covered under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this medical policy are met.

However, services that are identified in this policy as not covered are not eligible for coverage or reimbursement by the Company.

Description

A prosthetic shoe (a device used when all or a substantial portion of the front part of the foot is missing) can be covered as a terminal device; i.e., a structural supplement replacing a totally or substantially absent hand or foot. The function of the prosthetic shoe is quite distinct from that of excluded orthopedic shoe and supportive foot devices which are used by individuals whose feet, although impaired, are essentially intact.
References

Centers for Medicare and Medicaid Services (CMS). Medicare Benefit Policy Manual. Chapter 15: Covered medical and other health Services. 120: Prosthetic Devices [CMS Web site]. 03/01/2019. Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf. Accessed April 1, 2019

Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD). 280.10: Prosthetic shoe. [CMS Web site.] Available at:
http://www.cms.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=208&ncdver=1&bc=AgAAQAAAAAAAAA%3D%3D&. Accessed April 1, 2019.

Noridian. Local Coverage Determination (LCD): Orthopedic Footwear (L33641). (Original Date 10/01/2015). Revised 01/01/2019. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Orthopedic+Footwear+LCD+and+PA/4405657c-dfe0-4d5c-98d7-6c1865cea4be. Accessed April 1, 2019.

Noridian. Local Coverage Article for Orthopedic Footwear- Policy Article (A52481). (Original Date 01/01/2017). Revised 01/01/2019. Available at: https://med.noridianmedicare.com/documents/2230703/7218263/Orthopedic+Footwear+LCD+and+PA/4405657c-dfe0-4d5c-98d7-6c1865cea4be. Accessed April 1, 2019.

Noridian.Noncovered Items. Last Updated October 26, 2018. Available at:
https://med.noridianmedicare.com/web/jadme/topics/noncovered-items. Accessed April 1, 2019.



Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD -10 Diagnosis Code Number(s)

See Attachment B


HCPCS Level II Code Number(s)

See Attachment A


Revenue Code Number(s)

N/A

Coding and Billing Requirements


Cross References

Attachment A: Orthopedic Footwear
Description: ICD-10 Codes

Attachment B: Orthopedic Footwear
Description: HCPCS Code In Conjuction with ICD-10 Diagnosis Codes







Policy History

MA05.012a
02/12/2020This policy has been reissued in accordance with the Company's annual review process.
06/05/2019The policy has been reviewed and reissued to communicate the Company’s continuing position on Orthopedic Footwear.
10/24/2018This policy has been reissued in accordance with the Company's annual review process.
06/21/2017The policy has been reviewed and reissued to communicate the Company’s continuing position on Orthopedic Footwear.
08/31/2016The policy has been reviewed and reissued to communicate the Company’s continuing position on Orthopedic Footwear.
11/06/2015This version of the policy will become effective 11/06/2015.

The policy statement has been revised to include the following criteria:

Prosthetic shoes (L3250) are considered medically necessary when an integral part of a prosthesis for an individual with a partial foot amputation.

Existing durable medical equipment documentation requirements, in accordance with Medicare, are now included with examples.

MA05.012
01/01/2015This is a new policy.






Version Effective Date: 11/06/2015
Version Issued Date: 11/06/2015
Version Reissued Date: 02/14/2020