Priority Health orthotics coverage update: Prior Auth

Coverage Criteria

Diabetic shoe/insert coverage

Covered when ALL of the following are met:

Diabetic therapeutic shoes/inserts coverage: Priority Health may consider therapeutic shoes and inserts to be medically necessary for persons with diabetes when applicable InterQual® criteria are met. When criteria are met with a diagnosis of diabetes mellitus, coverage is limited to the A5500-A5514 code range and appropriate modifiers (e.g., KX) as applicable.

From policy Section I.A; see HCPCS A5500-A5514 for diabetic-specific codes.

Non-diabetic therapeutic shoe/insert exceptions

Priority Health generally considers therapeutic shoes and inserts for persons without diabetes not medically necessary except when ALL of the following apply:

Non-diabetic sensory-loss exception: 1) The insert is custom-made; 2) The insert must be worn for all activities of daily living; 3) Three inserts (or pairs) are covered per contract year; 4) The orthotic is pre-authorized.Three inserts per contract year

Therapeutic shoes/inserts for persons without diabetes are requested/billed using 'L' codes; pre-authorization required.

Pediatric leg length discrepancy

Priority Health may consider therapeutic/orthopedic shoes or inserts or lifts, or modifications to such, medically necessary if EITHER of the following criteria are met:

Leg length discrepancy criteria: C1: Leg-length discrepancy of 1 inch or greater in members <18 years of age with no other congenital or neurologic abnormalities; OR C2: Leg-length discrepancy greater than 1/2 inch in members <18 years of age with developmental dysplasia of the hip (DDH) or other hip problems, scoliosis, limb differences due to congenital, traumatic, or septic shortening, amputations, or neurologic abnormalities (e.g., cerebral palsy, myelomeningocele).1 in; >1/2 in

Members meeting C1 or C2 and for whom coverage applies are eligible for one pair of shoes, or one pair of inserts, or 2 shoe lifts or 2 shoe modifications per contract year.

Pediatric deformity prevention

For members age 18 or less, orthopedic shoes and/or inserts may be considered medically necessary for prevention of progression of deformity when ANY of the following conditions are exhibited:

Pediatric deformity prevention indications: talipes calcaneovalgus; cerebral palsy; myelomeningocele; talipes equinovarus (clubfoot); congenital vertical talipes (rocker-bottom foot); insensate feet due to spinal cord lesions; muscular dystrophy; traumatic amputation.

When medical necessity and benefit coverage apply, benefit is limited to one pair of shoes or one pair of inserts per contract year.

Coverage notes and limitations

Coverage notes and limitations as stated in the document

Not Covered Commercial: Codes marked with an asterisk are not covered for Commercial products.

See coding section for asterisked items and product-specific limitations.

Not Covered Medicaid: Some codes are noted as not covered for Medicaid; providers should consult the current Medicaid fee schedule for up-to-date coverage guidance.

See Medicaid-specific list in coding section.

Diabetic-specific codes: Certain HCPCS (e.g., A5508, A5510) are designated 'for diabetics only' or have diabetic-specific descriptions and may have product- or payor-specific coverage notes.

Refer to diabetic footwear rules and relevant LCDs.

No prior authorization items:

Priority Health generally considers therapeutic shoes and inserts for persons without diabetes to be not medically necessary except for a limited set of documented exceptions. These exceptions apply when the member has sensory loss in the feet and/or legs from other systemic or neurologic/neuromuscular conditions and ALL of the following criteria are met: the insert is custom-made, the insert must be worn for all activities of daily living, three inserts (or pairs) per contract year is the maximum when criteria are met, and the orthotic has been pre-authorized.

Specific HCPCS codes identified in the coding sections that are annotated with an asterisk or labeled in the policy as *Not Covered for Commercial Products or *Not Covered for Medicaid are excluded from coverage for those respective populations. Providers should consult the code list and applicable fee schedules for the current product-specific restrictions before billing.

Reiterating the policy stance: therapeutic shoes and inserts for persons without diabetes are generally considered not medically necessary except where the policy explicitly lists qualifying exceptions and the specified criteria (custom-made insert, wear for all activities of daily living, quantity limit of three inserts (or pairs) per contract year, and pre-authorization) are satisfied.

Coding

Covered HCPCS Codes (selected list as shown)HCPCSCovered

A5500	For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe
A5501	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
A5503	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe
A5504	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe
A5505	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe
A5506	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe
A5507	For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-
A5510	For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe
A5512	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
A5513	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

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ICD-10 Codes that may applyICD-10

E08.00 - E13.9	Diabetes mellitus (ICD-10 range)
G60.0 - G60.9	Hereditary motor and sensory neuropathy (ICD-10 range)
G80.0 - G80.9	Cerebral palsy (ICD-10 range)
I70.201 - I70.299	Other peripheral vascular diseases (ICD-10 range)
L89.500 - L89.629	Pressure ulcer of foot and ankle (ICD-10 range)
M21.751 - M21.769	Unequal limb length (acquired) (ICD-10 range)
Q66.0	Congenital talipes equinovarus (clubfoot)
Q05.0 - Q05.9	Spina bifida (ICD-10 range)

Orthotics and Shoe-related HCPCS CodesHCPCS

L3170	Foot, plastic, silicone or equal, heel stabilizer, each.
L3201	Orthopedic shoe, Oxford with supinator or pronator, infant.
L3202	Orthopedic shoe, Oxford with supinator or pronator, child.
L3203	Orthopedic shoe, Oxford with supinator or pronator, junior.
L3204	Orthopedic shoe, hightop with supinator or pronator, infant.
L3206	Orthopedic shoe, hightop with supinator or pronator, child.
L3207	Orthopedic shoe, hightop with supinator or pronator, junior.
L3215	Orthopedic footwear, ladies shoe, oxford, each.
L3216	Orthopedic footwear, ladies shoe, depth inlay, each.
L3217	Orthopedic footwear, ladies shoe, hightop, depth inlay, each.

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Leg length discrepancy threshold (pediatric) — inv-12

Threshold (general)1 inch (1') or greater in members < 18 years with no other congenital or neurologic abnormalities

Threshold (with hip/neurologic conditions)> 1/2 inch (> 1/2') in members < 18 years with DDH, other hip problems, scoliosis, limb differences due to congenital/traumatic/septic shortening, amputations, or neurologic abnormalities (e.g., cerebral palsy, myelomeningocele)

Benefit limit when criteria metEligible for one pair of shoes, or one pair of inserts, or 2 shoe lifts or 2 shoe modifications per contract year

Annual quantity limit (non-diabetic sensory-loss exceptions) — inv-13

Annual quantity limitThree inserts (or pairs) per contract year

Provider Actions and Billing Notes

Prior Authorization

Prior Authorization Required

Prior authorization required when indicated — When prior authorization is required, providers must submit a prior authorization request demonstrating that the item or service is medically necessary. Requests must document InterQual® criteria where applicable and include all supporting clinical documentation per the Priority Health Provider Manual.

When prior authorization is required, include InterQual® documentation and relevant clinical records.
Refer to the Priority Health Provider Manual for submission instructions and documentation expectations.

Billing Rule

No Prior Authorization Required for Listed Items

No prior authorization required for listed items — Certain transfer and orthosis transfer codes do not require prior authorization. Providers may bill these items without a prior authorization when the code is listed as 'No auth required'.

Definitions

Therapeutic shoes/inserts (diabetic) — inv-24

DefinitionTherapeutic shoes and inserts for persons with diabetes: footwear and multi-density inserts provided to persons with diabetes when InterQual® criteria are met; coverage is limited to the A5500–A5514 code range when criteria are met

Identifiers / codesDiabetic-specific HCPCS range A5500–A5514 (examples include A5500, A5510, A5512, A5513, A5514); certain codes (e.g., A5508, A5510) noted in coding section for diabetics

Clinical intentProvided to reduce risk of diabetic foot complications (ulcers, amputations) as part of diabetic foot care and prevention

Orthopedic shoes/inserts (pediatric leg length/deformity) — inv-25

DefinitionOrthopedic shoes, inserts, lifts, or modifications used in pediatric patients to correct or accommodate leg length discrepancy or to prevent progression of deformity (e.g., clubfoot, cerebral palsy, myelomeningocele)

Background

Foot care and prevention are central to reducing the risk of serious complications in patients with diabetes. Risk factors that increase the need for careful foot management include loss of protective sensation (neuropathy), peripheral vascular disease, prior foot ulcer or amputation, poor glycemic control, nephropathy, smoking, structural foot abnormalities, and visual impairment. For persons with diabetes who meet InterQual® criteria, Priority Health limits footwear coverage to defined diabetic codes and requires appropriate documentation and modifier use to indicate medical necessity; routine therapeutic footwear is not supported for persons without diabetes except as noted in the exceptions above.

Coding and Coverage Highlights

Orthotics and Shoe-related HCPCS Codes (quick access)HCPCS

L3170	Foot, plastic, silicone or equal, heel stabilizer, each.
L3201	Orthopedic shoe, Oxford with supinator or pronator, infant.
L3202	Orthopedic shoe, Oxford with supinator or pronator, child.
L3203	Orthopedic shoe, Oxford with supinator or pronator, junior.
L3204	Orthopedic shoe, hightop with supinator or pronator, infant.
L3206	Orthopedic shoe, hightop with supinator or pronator, child.
L3207	Orthopedic shoe, hightop with supinator or pronator, junior.
L3215	Orthopedic footwear, ladies shoe, oxford, each.
L3216	Orthopedic footwear, ladies shoe, depth inlay, each.
L3217	Orthopedic footwear, ladies shoe, hightop, depth inlay, each.