Colorado Rocky Mountain Health Plans foot surgery Coverage

Coverage Criteria

Cheilectomy without implant (Hallux limitus/rigidus)

Correction of the first MTP joint with cheilectomy, debridement, and capsular release without implant is proven and medically necessary when ALL of the following are met:

Cheilectomy without implant — required conditions: 1) Diagnosis of hallux limitus or hallux rigidus confirmed by clinical evaluation and radiographic imaging showing mild-to-moderate pathology (grading scales such as Coughlin and Shurnas or Hattrup and Johnson may be used). 2) Persistent pain despite a reasonable trial of conservative treatment including one or more of: orthotics or shoe modification (e.g., high and wide toe box, rocker bottom sole) and/or shoe inserts; medical therapy (NSAIDs, analgesics, or intra-articular injections); activity modification; debridement of hyperkeratotic lesions if present.radiographic mild-to-moderate

Cheilectomy without implant is considered unproven and not medically necessary for severe hallux rigidus due to insufficient evidence of efficacy.

Cheilectomy with implant (Hallux rigidus)

Correction of the first MTP joint with cheilectomy, debridement, and capsular release with implant (Hemi-Implant or Total Implant Arthroplasty) is proven and medically necessary when ALL of the following are met:

Cheilectomy with implant — required conditions: 1) Diagnosis of hallux rigidus confirmed by clinical evaluation and radiographic imaging showing moderate-to-severe pathology (grading scales such as Coughlin and Shurnas or Hattrup and Johnson may be used). 2) Persistent pain despite a reasonable trial of conservative treatment including one or more of: orthotics or shoe modification (e.g., high and wide toe box, rocker bottom sole) and/or shoe inserts; medical therapy (NSAIDs, analgesics, or intra-articular injections); activity modification; debridement of hyperkeratotic lesions if present.radiographic moderate-to-severe

Implant arthroplasty (hemi-implant or total implant arthroplasty) is indicated for moderate-to-severe hallux rigidus when the above criteria are met; policy language was updated to explicitly include hemi-implant and total implant arthroplasty.

Osteochondral allograft/autograft transplantation

Osteochondral allograft or autograft transplantation is considered unproven and not medically necessary for treating cartilage defects of the foot due to insufficient evidence of efficacy.

Osteochondral grafts — not medically necessary: Available studies are small, heterogeneous case series or cohort studies with limited long-term follow-up; evidence is insufficient to demonstrate improved health outcomes compared with established treatments.insufficient evidence

Policy classifies osteochondral allograft and autograft transplantation in the foot as unproven and not medically necessary; further larger comparative studies with longer follow-up are needed.

Evidence and Guidance-Based Coverage Considerations

Evidence summary and guidance-based recommendations relevant to coverage decisions:

Osteochondral grafts evidence summary: The body of evidence for osteochondral grafting in the foot is limited to small case series and retrospective cohort studies with heterogeneity in techniques and outcome measures; this evidence is insufficient to draw conclusions about effects on health outcomes and does not support routine coverage.

Further high-quality comparative studies with larger samples and longer follow-up are required.

NICE guidance on synthetic cartilage implants: NICE (2022) recommends that synthetic cartilage implant insertion for first MTPJ OA have restricted use: for individuals with advanced disease where arthrodesis would otherwise be specified, use only with clinical governance, consent, and audit or research provisions; for others, use only in a research context. Clinicians must notify governance leaders, provide explicit patient information, and ensure informed consent and understanding of limitations of evidence.

Documentation, registry reporting and local governance are expected per NICE recommendations.

Policy-level implant statement: Policy history notes that correction of the first MTP joint with cheilectomy, debridement, and capsular release with implant (hemi-implant or total implant arthroplasty) is stated as proven and medically necessary when all listed criteria are met; refer to the policy criteria sections for the specific required elements.

Correction of the first metatarsophalangeal (MTP) joint with cheilectomy, debridement, and capsular release without implant is considered proven and medically necessary when the member has a diagnosis of hallux limitus or hallux rigidus with radiographic confirmation of mild-to-moderate disease (for example, using Coughlin & Shurnas or Hattrup-Johnson grading) and persistent pain despite a reasonable trial of conservative measures such as orthotics or shoe modification, medical therapy (NSAIDs/analgesics or intra-articular injections), activity modification, or debridement of hyperkeratotic lesions if present.

The policy specifies that cheilectomy without implant is unproven and not medically necessary for severe hallux rigidus because evidence of efficacy in advanced disease is insufficient; for severe radiographic disease, alternative procedures such as arthrodesis or implant arthroplasty may be more appropriate.

Insertion of a synthetic cartilage implant for first MTPJ osteoarthritis (hallux rigidus) is not supported for routine use without additional safeguards. Per NICE guidance, for individuals with advanced disease where arthrodesis would otherwise be specified the procedure should only be performed with explicit clinical governance, informed consent, and audit or research provisions; for other patients the technique should only be used in a research context.

Providers intending to use synthetic cartilage implants must follow documented governance steps including notification of clinical governance leaders, provision of printed decision-support materials to patients and families, and registration/reporting of cases to an outcomes registry (for example, the BOFAS registry) as described in the NICE recommendations.

Osteochondral allograft or autograft transplantation for cartilage defects of the foot is considered unproven and not medically necessary due to insufficient evidence of efficacy. Available studies are small and heterogeneous, and do not establish improved long-term health outcomes compared with established treatments.

Systematic reviews and available series report limited patient numbers, varying techniques (autograft, allograft, interpositional procedures), and short follow-up; although some improvement in functional scores has been reported, these data are inadequate to support routine coverage of osteochondral grafting in the foot.

The evidence base for osteochondral procedures in the foot is limited to small case series and retrospective cohorts with heterogeneity in technique and outcome measurement. A systematic review of focal osteochondral lesions of the first metatarsal head included 11 studies (n = 90), and reviews of allografts identified only three small studies (n = 24) for hallux rigidus—most were level IV evidence—supporting only low-level conclusions.

Because available studies are small, non-comparative, and of low methodological quality with limited long-term follow-up, the policy classifies osteochondral grafting procedures as supported by low-level evidence and therefore not adequate to justify broad medical necessity.

Applicable Codes

Applicable procedure CPT/HCPCS codesCPT

28285	Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy).
28289	Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant.
28291	Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant.
28292	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method.
28295	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method.
28296	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method.
28297	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method.
28298	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method.
28299	Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with double osteotomy, any method.
28899	Unlisted procedure, foot or toes.

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Provider Actions & Authorization

Prior Authorization

InterQual-based medical necessity (Prior Authorization Guidance)

InterQual Procedures criteria are referenced and will be used to determine medical necessity for prior authorization decisions. Providers should submit a prior authorization request when indicated; coverage determinations will reference the InterQual CP: Procedures criteria listed in this policy.

InterQual-based medical necessity criteria will guide prior authorization determinations
Prior authorization required when plan benefits or provider portal indicates

Prior Authorization

Device / Procedure Authorization Considerations

Confirm device approval status and benefit applicability before scheduling procedures. Some implants or synthetic cartilage devices have limited evidence and may be subject to plan-specific benefit exclusions or special handling. Providers should verify member benefits and obtain any required prior authorization for devices/devices with special coverage rules.

Verify FDA status for devices/instruments used in surgery (informational only)
Check member’s benefit plan for device-specific coverage limits or exclusions

Background

Hallux rigidus (the stiff or painful great toe) is a degenerative arthritis of the first metatarsophalangeal (MTP) joint characterized by pain, osteophyte formation, and reduced dorsiflexion of the hallux. In early or mild-to-moderate disease, cheilectomy (removal of dorsal osteophytes with debridement and capsular release) can relieve impingement and restore motion.

For advanced disease where motion is severely limited or pain persists despite conservative therapy, treatment options include arthrodesis or implant arthroplasty; osteochondral grafting and synthetic cartilage implants currently lack sufficient high-quality evidence to be considered routine treatments and are subject to the policy's restrictive stance.

Definitions

Hemi-Implant Arthroplasty — definition entry

TermHemi-Implant Arthroplasty

DefinitionA surgical procedure to replace one side of a joint with a prosthetic implant (partial joint replacement).

Exclusion noteDoes not include Interposition Arthroplasty.

Interposition Arthroplasty — definition entry

TermInterposition Arthroplasty

DefinitionA surgical procedure that removes damaged bone and places a spacer (e.g., soft tissue graft) between bones to minimize contact; also known as joint resurfacing.

Context

Revision History

2026-04-01template_update

Template update removing content/language pertaining to the state of Louisiana.

2025-11-01application_note

Added language indicating this Medical Policy does not apply to the state of North Carolina (refer to state-specific policy version).

2025-10-01material_revisionLatest

OpenPayer

Surgery of the Foot (podiatric procedures) — Coverage Criteria