Loading...

    Explore
    • Policy Monitoring
    • Live Policy Feed
    • Billing Codes
    • Healthcare Providers
    • Health Insurance Payers
    • States
    • Service Lines
    • Taxonomy Codes
    Lookup tools
    • Billing Code Lookup
    • CPT Modifier Lookup
    • Provider Taxonomy Code Lookup
    • Healthcare Provider & Facility Lookup
    • Health Insurance Payer Lookup
    • Payer Contact Directory

    Policy & Benchmark Tools

    • Prior Authorization Lookup
    • Coverage Criteria Lookup
    • Timely Filing Lookup
    • Billing Code Reimbursement Rates
    • Payer Comparison Dashboard
    • Facility Comparison Dashboard
    • All tools

    Company

    • About OpenPayer
    • Data Sources
    • Trek Health
    OpenPayerby Trek Health
    LinkedInYouTube

    © 2026 Trek Health. All rights reserved.

    OpenPayer is built and maintained by Trek Health.

    v1.0.30
    OpenPayerPolicy UpdatesProsthetics & OrthoticsTexas Children's Orthoses Prior Auth | OpenPayer
    Ask Trek AI about this page
    CurrentTexas Children's Health PlanPolicy 10710

    Orthoses Guideline

    Customize your policy alerts

    Sign up for texaschildrenshealthplan Policy 10710 alerts

    Get alerted when Policy 10710 changes without checking for updates manually.

    Monitor payer policy activity

    Receive email alerts as soon as relevant payer policies are published or updated.

    This guideline governs prior authorization, medical necessity, provider qualifications, documentation, reimbursement, and exclusions for orthoses and related services for Texas Children's Health Plan members under Texas Medicaid requirements.

    Policy Summary
    PayerTexas Children's Health Plan
    PolicyOrthoses Guideline
    Policy CodePolicy 10710
    Change TypeNo material change
    Effective DateAug 31, 2023
    Next Review DateN/A
    Key ActionSubmit all prior authorization requests for orthoses and related services to the Utilization Management Department.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    90 daysInitial service window
    6 monthsAuthorization validity
    90 daysIncluded repair period
    4General indications
    3UCB insert conditions

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    Under 21Reviewer consideration

    Medical Necessity and Coverage Criteria

    General orthosis medical necessity

    Prior authorization requires documentation of medical necessity and at least one of the following indications:

    At least one indication

    • Reduce pain: The orthosis is needed to reduce pain by restricting mobility of the affected body part.
    • Healing after injury: The orthosis is needed to facilitate healing following an injury to the affected body part or related soft tissue.
    • Healing after surgery: The orthosis is needed to facilitate healing following a surgical procedure on the affected body part or related soft tissue.
    • Weak muscles or deformity: The orthosis is needed to support weak muscles or a deformity of the affected body part.

    Removable foot insert criteria

    A removable foot insert may be considered when documentation supports at least one of the following medical conditions:

    At least one foot condition

    • Diabetes mellitus.
    • History of amputation of the opposite foot or part of either foot.
    • Foot ulceration or pre-ulcerative calluses of either foot.
    • Deformity of either foot.
    • Poor circulation of either foot.

    UCB removable foot insert criteria

    A UCB removable foot insert may be considered when documentation shows that the insert is required to correct or treat at least one of the following conditions:

    At least one UCB insert condition

    • Valgus deformity and significant congenital pes planus with pain.
    • A structural problem that results in significant pes planus, such as Down Syndrome.
    • Acute plantar fasciitis.

    Pes planus medical-necessity exception

    Pes planus that is cosmetic in nature and lacks a coexisting medical condition is not medically necessary. Potential medical necessity requires both of the following:

    Coexisting medical condition

    • Function-limiting pain: Pain in the foot, leg, or knee results in a decrease of function.
    • Secondary condition: A secondary condition is present, such as valgus deformity or plantar fasciitis.

    Orthoses whose sole purpose is restraint are not medically necessary and are not a Texas Medicaid benefit.

    Orthoses provided solely for sports-related activities are not medically necessary or a Texas Medicaid benefit when there is no acute injury or other indicated medical condition.

    An orthotic device prescribed by a chiropractor is not medically necessary and is not a Texas Medicaid benefit.

    Orthopedic shoes with deluxe features, including special colors, special leathers, or special styles, are not medically necessary when those features do not contribute to the shoe’s accommodative or therapeutic function.

    A foot-drop splint, recumbent positioning device, or replacement interface is not medically necessary for a member with foot drop who is non-ambulatory, because other treatment modalities are more appropriate.

    A pneumatic thoracic-lumbar-sacral orthosis is considered experimental and investigational and is not a benefit.

    A static ankle-foot orthosis (AFO) is not medically necessary when the contracture is fixed, when the member has foot drop without an ankle flexion contracture, or when the AFO is used to address knee or hip positioning.

    Tired feet, fatigued feet, and nonsevere bowlegs are not considered medically necessary diagnoses.

    Valgus deformity of the foot is not considered medically necessary except as outlined in the orthotic section of the Texas Medicaid Provider Procedures Manual.

    Cosmetic pes planus (flat feet) without a coexisting medical condition is not medically necessary. Coexisting conditions may include foot, leg, or knee pain that results in a decrease of function, together with a secondary condition such as valgus deformity or plantar fasciitis.

    Authorization, Documentation, and Limitations

    Prior Authorization

    Submit Prior Authorization Request

    Submit all orthoses and related-service prior authorization requests to the Utilization Management Department through online submission, fax, phone, or mail. Requests are processed during normal business hours.

    • Include the required clinical and supporting documentation with the request.
    Billing Rule

    Use Qualified Dispensing and Fabrication Providers

    To qualify for reimbursement, an orthosis must be dispensed, fabricated, or modified by a licensed orthotist or licensed prosthetist/orthotist enrolled with Medicaid and the Comprehensive Care Program (CCP).

    • Upper-extremity customized splints made with low-temperature materials and inhibitive casting may be provided by occupational or physical therapists.

    Policy Background

    Orthoses are custom-fabricated or custom-fitted medical devices used to support, align, prevent, or correct conditions involving the neuromuscular or musculoskeletal system. This guideline addresses orthoses used for pain reduction, healing after injury or surgery, muscle weakness, deformity, and selected foot conditions; coverage depends on documented medical necessity and Texas Medicaid requirements.

    Key Definitions

    Orthosis
    DefinitionA custom-fabricated or custom-fitted medical device designed to provide support, alignment, prevention, or correction of neuromuscular or musculoskeletal disease, injury, or deformity.
    Does not includeFabric or elastic supports, corsets, arch supports, low-temperature plastic splints, trusses, elastic hose, canes, crutches, soft cervical collars, diagnostic or evaluation orthoses, dental appliances, or similar devices carried in stock and sold by a retail store.
    Primary purposeSupport, alignment, prevention, or correction of a neuromuscular or musculoskeletal disease, injury, or deformity.
    Brace
    DefinitionAn orthosis or orthopedic appliance that supports or holds any movable part of the body in the correct position while allowing motion of that part.
    Construction
    Policy Summary
    PayerTexas Children's Health Plan
    PolicyOrthoses Guideline
    Policy CodePolicy 10710
    Change TypeNo material change
    Effective DateAug 31, 2023
    Next Review DateN/A
    Key ActionSubmit all prior authorization requests for orthoses and related services to the Utilization Management Department.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaAuthorization, Documentation, and LimitationsPolicy BackgroundKey Definitions
  1. Other orthopedic devices listed in the orthotic section of the Texas Medicaid Provider Procedures Manual may be provided by a Medicaid-enrolled DME vendor.
  2. Orthopedic shoes must be provided by a shoe vendor enrolled as a DME provider.
    3. Prior Authorization

    Authorization Validity and Renewal

    Prior authorization is valid for a maximum of six months from the prescription signature date. A new prescription is required to authorize additional services after the six-month period.

    • The authorization period begins on the prescription signature date.
    • Additional services after six months require a new prescription and prior authorization.
    Documentation Required

    Document Medical Necessity

    Submit clinical and diagnostic documentation supporting the medical necessity of the requested orthosis. Documentation must show that the device is needed to reduce pain by restricting mobility, facilitate healing after injury or surgery, or support weak muscles or a deformity.

    • Include accurate diagnostic information and relevant medical history.
    • Document the applicable medical indication for the requested device.

    Unsupported block type: documentation

    Prior Authorization

    Verify Prescription Dates

    The prescription must be dated on or before the initial requested date of service. The initial requested dates of service may be no more than 90 days from the prescription signature date.

    • Verify the prescription date and requested service dates before submitting the authorization request.
    Documentation Required

    Document Foot Insert Eligibility

    For removable foot inserts, submit documentation of a qualifying medical condition affecting either foot or the required history. Inserts may be covered separately from orthopedic shoes when the member has appropriate footwear into which the insert can be placed.

    • Diabetes mellitus.
    • History of amputation of the opposite foot or part of either foot.
    • Foot ulceration or pre-ulcerative calluses.
    • Deformity or poor circulation of either foot.
    Documentation Required

    Support UCB Insert Medical Need

    For a removable University of California at Berkeley (UCB) foot insert, document that the insert is required to correct or treat at least one qualifying condition.

    • Valgus deformity with significant congenital pes planus and pain.
    • A structural problem causing significant pes planus, such as Down Syndrome.
    • Acute plantar fasciitis.
    Denial Risk

    Avoid Excluded Devices and Uses

    Do not request coverage for orthoses that are excluded or not medically necessary under the guideline. These include restraint-only devices, sports-only use without an acute injury or other indicated condition, and devices or features that do not provide an accommodative or therapeutic function.

    • Deluxe orthopedic shoe features, including special colors, leathers, or styles, are not covered when they do not contribute to therapeutic function.
    • Foot-drop splints, recumbent positioning devices, and replacement interfaces are not medically necessary for nonambulatory members with foot drop.
    • A pneumatic thoracic-lumbar-sacral orthosis is experimental and investigational and is not a benefit.
    • A static AFO is not medically necessary when the contracture is fixed, when foot drop occurs without an ankle flexion contracture, or when it is used for knee or hip positioning.
    Denial Risk

    Screen for Noncovered Diagnoses

    Do not submit requests based solely on diagnoses that are not considered medically necessary under the guideline. Cosmetic pes planus may be considered only when a coexisting medical condition supports medical necessity.

    • Tired feet.
    • Fatigued feet.
    • Nonsevere bowlegs.
    • Valgus deformity of the foot, except as allowed by the orthotic section of the Texas Medicaid Provider Procedures Manual.
    • Cosmetic pes planus without a coexisting condition; qualifying conditions may include function-limiting foot, leg, or knee pain with a secondary valgus deformity or plantar fasciitis.
    Denial Risk

    Apply Criteria and Benefit Limitations

    Coverage is based on the guideline's medical-necessity criteria and remains subject to benefit limitations, exclusions, and eligibility. Members under age 21 who need services beyond the guideline limits may be considered by a TCHP Medical Director or Physician Reviewer; requests that do not meet the criteria are reviewed under the Denial Policy.

    • Preauthorization is not a guarantee of benefits or eligibility.
    • Authorization applies only to the medical necessity of the approved treatment or service.
    • Providers must comply with state and federal requirements; noncompliance may result in retrospective audit and financial recoupment.
    A brace must be a rigid or semi-rigid device.
    UsesSupports a weak or deformed body part, or restricts or eliminates motion in a diseased or injured body part.