Foot reconstruction procedures: bunionectomy and hallux valgus correction — Medical Necessity Guideline
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This medical necessity guideline governs prior authorization requirements and coverage criteria for foot reconstruction procedures (fifth metatarsal osteotomy, proximal phalanx osteotomy of the first toe, and first MTP joint arthrodesis) for Harvard Pilgrim and affiliated Tufts commercial/public products.
New Medical Necessity Guideline requiring prior authorization for specified foot reconstruction procedures effective June 1, 2026.
Coverage Criteria
Authorization contingent on InterQual criteria
Covered when the applicable InterQual SmartSheet criteria are met and prior authorization is obtained.
This policy references InterQual criteria rather than embedding detailed clinical inclusion/exclusion criteria.
Coverage under this guideline is determined in conjunction with the Member's benefit document. For self‑insured plans, applicable benefits in the employer’s plan may supersede this guideline and will govern coverage decisions. For members of Tufts Health Together (Medicaid), the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit may allow coverage beyond the guideline for pediatric members under age 21 when prior authorization is obtained.
This guideline does not enumerate a fixed list of procedures that are automatically considered not medically necessary. Instead, determinations of medical necessity — including whether a requested foot reconstruction procedure is not medically necessary — are made by applying the specified InterQual SmartSheet criteria and the Member’s benefit document. Services that do not meet the applicable InterQual criteria or are excluded by the member’s benefit document may be denied.
Coding
| 28308 | Osteotomy, with or without lengthening, shortening or angular correction, metatarsal; other than first metatarsal, each |
| 28750 | Arthrodesis, great toe; metatarsophalangeal joint |
Provider Actions & Authorization
Prior authorization required for listed procedural codes
Prior authorization is required for the listed CPT procedures and must be obtained using the appropriate InterQual SmartSheet(s); completed SmartSheets must be sent to the applicable fax number or submitted via HPHConnect as part of the prior authorization request.
InterQual SmartSheet requirement and access
This policy uses Harvard Pilgrim–customized InterQual criteria; providers must select the appropriate InterQual SmartSheet subset for the specific foot reconstruction procedure when requesting authorization.
- InterQual SmartSheets are the required clinical criteria/tool for authorization
- Providers may view the medical necessity criteria and questionnaire via HPHConnect
Required documentation and submission methods
Submit supporting clinical documentation and clinical notes as part of the prior authorization request via HPHConnect Clinical Upload or secure fax (800-232-0816).
- If required, include all pertinent clinical documentation when submitting the authorization request
- HPHConnect provides access to the authorization questionnaire and medical necessity criteria
Coverage denial risk if authorization not obtained
Failure to obtain the required prior authorization using the appropriate InterQual SmartSheet(s) and to submit supporting clinical documentation via the listed channels may result in denial of coverage.
- Ensure completed SmartSheets are sent to the applicable fax number or submitted through HPHConnect to avoid denial risk
Background
Foot reconstruction procedures are surgical interventions intended to correct deformity, relieve pain, and restore function. Examples addressed in this guideline include a fifth metatarsal osteotomy to treat a bunionette, a proximal phalanx osteotomy to correct hallux valgus of the great toe, and first metatarsophalangeal (MTP) arthrodesis to address severe hallux valgus or degenerative disease. The guideline references objective criteria from InterQual to assess medical necessity and is used alongside the Member’s benefit document to inform prior authorization and coverage decisions.
Definitions
Revision History
Policy created and reviewed by the Medical Policy Approval Committee (MPAC) as a new Medical Necessity Guideline requiring prior authorization.
New guideline establishing prior authorization requirement for specified foot reconstruction procedures became effective.
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