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    v1.0.30
    OpenPayerPolicy UpdatesPodiatryUnitedHealthcare Foot Surgery Coverage | OpenPayer
    Ask Trek AI about this page
    ModifiedUnitedHealthcare Community PlanPolicy CS342ID.C

    Surgery of the Foot (for Idaho Only)

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    This policy governs medical necessity and coverage considerations for foot surgery under UnitedHealthcare Community Plan Medical Policy. It applies only to Idaho, including Idaho Medicaid Plus plans, and affects providers requesting covered foot surgery services.

    Policy Summary
    PayerUnitedHealthcare Community Plan
    PolicySurgery of the Foot (for Idaho Only)
    Policy CodePolicy CS342ID.C
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionDocument the diagnosis, radiographic severity, persistent pain, and trial of conservative treatment for hallux limitus or rigidus correction.
    SourceLink
    POLICY UPDATE CHANGES

    The policy added language stating that interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is unproven and not medically necessary for limitations in motion or degenerative changes because of insufficient evidence of efficacy.

    The definition of interposition or interpositional arthroplasty was updated.

    The policy added instructions to consult the Idaho Medicaid Provider Handbook for additional information about non-covered and excluded services.

    The Description of Services, Clinical Evidence, and References sections were updated to reflect current information.

    The previous policy version CS342ID.B was archived.

    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.

    Idaho onlyGeographic scope
    6InterQual criteria referenced
    2Hallux rigidus pathways
    2Procedures designated unproven
    10Procedure codes listed

    Medical Necessity and Coverage Criteria

    Referenced InterQual foot surgery criteria

    Covered according to the referenced InterQual clinical criteria.

    Referenced covered foot surgery procedures

    • Arthrodesis or arthroplasty, interphalangeal joint, second-fifth toes: Apply the applicable InterQual criteria.
    • Exostectomy, first metatarsophalangeal joint (bunionectomy): Apply the applicable InterQual criteria.
    • Osteotomy, distal transpositional, first metatarsal (bunionectomy): Apply the applicable InterQual criteria.
    • Osteotomy, proximal, first metatarsal (bunionectomy): Apply the applicable InterQual criteria.
    • Osteotomy, proximal phalanx, first toe with or without bunionectomy: Apply the applicable InterQual criteria.
    • Plantar fascial release: Apply the applicable InterQual criteria.

    Hallux limitus or rigidus correction without implant

    Covered when all of the following are met.

    • Diagnosis and imaging: The patient has hallux limitus or hallux rigidus, with radiographic imaging confirming mild to moderate pathology.Mild to moderate pathology

      A grading scale such as Coughlin and Shurnas or Hattrup and Johnson may be used.

    • Persistent pain after conservative treatment

      • Conservative treatment measures: At least one of the following has been tried: orthotics, shoe modification or shoe inserts; medical therapy such as nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections; activity modification; or debridement of hyperkeratotic lesions when present.At least 1 measure

        Examples of shoe modification include a high and wide toe box or rocker-bottom sole.

    Hallux rigidus correction with implant

    Covered when all of the following are met.

    • Diagnosis and imaging: The patient has hallux rigidus, with radiographic imaging confirming moderate to severe pathology.Moderate to severe pathology

      A grading scale such as Coughlin and Shurnas or Hattrup and Johnson may be used.

    • Persistent pain after conservative treatment

      • Conservative treatment measures: At least one of the following has been tried: orthotics, shoe modification or shoe inserts; medical therapy such as nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections; activity modification; or debridement of hyperkeratotic lesions when present.At least 1 measure

        Examples of shoe modification include a high and wide toe box or rocker-bottom sole.

    Interposition or interpositional arthroplasty

    The following service is classified as unproven and not medically necessary.

    Interposition/interpositional arthroplasty exclusion: Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is unproven and not medically necessary when performed to treat limitations in motion or degenerative changes.

    The determination is based on insufficient evidence of efficacy.

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is unproven and not medically necessary when performed to treat limitations in motion or degenerative changes, due to insufficient evidence of efficacy.

    Osteochondral allograft or autograft transplant is unproven and not medically necessary for treating cartilage defects of the foot because evidence of efficacy is insufficient.

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is excluded from medically necessary coverage when used to treat limitations in motion or degenerative changes.

    Cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint without an implant is proven and medically necessary for mild to moderate hallux limitus or hallux rigidus when the applicable diagnostic, imaging, pain, and conservative-treatment criteria are met. For severe hallux rigidus, this treatment is unproven and not medically necessary because evidence of efficacy is insufficient.

    The policy determines that interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is unproven and not medically necessary for limitations in motion or degenerative changes because of insufficient evidence of efficacy.

    The policy determines that osteochondral allograft or autograft transplant is unproven and not medically necessary for treating cartilage defects of the foot because evidence of efficacy is insufficient.

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is not medically necessary for treating limitations in motion or degenerative changes because evidence of efficacy is insufficient.

    Applicable Codes

    Applicable CPT CodesCPT
    28285Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy).
    28289Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant.
    28291Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; with implant.
    28292Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with resection of proximal phalanx base, when performed, any method.
    28295Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal metatarsal osteotomy, any method.
    28296Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with distal metatarsal osteotomy, any method.
    28297Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with first metatarsal and medial cuneiform joint arthrodesis, any method.
    28298Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with proximal phalanx osteotomy, any method.
    28299Correction, hallux valgus with bunionectomy, with sesamoidectomy when performed; with double osteotomy, any method.
    28899Unlisted procedure, foot or toes.
    1–10 of 11
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    Documentation and Provider Guidance

    Documentation Required

    Medical Necessity Records Required

    Provide legible medical-record documentation that fully supports the medical necessity of the requested service. Records may be required for clinical review, but documentation does not guarantee coverage; maintain the records and make them available upon request.

    • Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.
    • Coverage remains subject to federal, state, or contractual requirements and applicable law.
    Documentation Required

    Document Hallux Rigidus Criteria

    Document the diagnosis, radiographic severity, persistent pain, and conservative treatment history supporting the requested first metatarsophalangeal-joint correction.

    • For cheilectomy, debridement, and capsular release without an implant: document hallux limitus or hallux rigidus and radiographic confirmation of mild to moderate pathology; a Coughlin and Shurnas or Hattrup and Johnson classification may be used.
    • For correction with an implant—hemi-implant or total implant arthroplasty—document hallux rigidus and radiographic confirmation of moderate to severe pathology; a Coughlin and Shurnas or Hattrup and Johnson classification may be used.

    Clinical Background

    Hallux limitus and hallux rigidus cause progressive pain, stiffness, and loss of motion at the first metatarsophalangeal joint. Cheilectomy may preserve motion in early disease, while arthrodesis or arthroplasty may be used in more advanced disease. Surgery may be considered when conservative measures fail to provide sufficient relief.

    Procedure Definitions

    Hemi-Implant Arthroplasty
    DefinitionA surgical procedure to replace one side of a joint with a prosthetic implant.
    Also known asPartial joint replacement.
    ExcludesInterposition arthroplasty.
    Interposition/Interpositional Arthroplasty
    DefinitionA surgical procedure to remove some damaged bone and place a spacer between two bones to minimize contact on either side of the joint.
    Spacer materialsThe spacer may come from the individual, a donor, or a graft made from animal or synthetic materials.
    Joint replacement
    Policy Summary
    PayerUnitedHealthcare Community Plan
    PolicySurgery of the Foot (for Idaho Only)
    Policy CodePolicy CS342ID.C
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionDocument the diagnosis, radiographic severity, persistent pain, and trial of conservative treatment for hallux limitus or rigidus correction.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaApplicable CodesDocumentation and Provider GuidanceClinical BackgroundProcedure Definitions
  1. Document persistent pain despite a reasonable trial of conservative treatment, including one or more of: orthotics, shoe modification such as a high and wide toe box or rocker-bottom sole, shoe inserts, medical therapy such as NSAIDs, analgesics, or intra-articular injections, activity modification, or debridement of hyperkeratotic lesions when present.
    2. Denial Risk

    Severe Hallux Rigidus Without Implant

    Correction of the first metatarsophalangeal joint with cheilectomy, debridement, and capsular release without an implant is unproven and not medically necessary when the patient has severe hallux rigidus. Document the applicable severity classification because the non-implant procedure is supported only for mild to moderate pathology.

    • A grading scale such as the Coughlin and Shurnas or Hattrup and Johnson Classification may be used to establish severity.
    Denial Risk

    Interposition Arthroplasty Denial Risk

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is unproven and not medically necessary due to insufficient evidence of efficacy. Claims for these procedures may be denied when treating limitations in motion or degenerative changes.

    • Applies to first- or second-metatarsophalangeal-joint interposition arthroplasty.
    Denial Risk

    Osteochondral Transplant

    Osteochondral allograft or autograft transplant is unproven and not medically necessary for treating cartilage defects of the foot because evidence of efficacy is insufficient.

    • Expect denial risk when submitting osteochondral transplant procedures for foot cartilage defects.
    Billing Rule

    Code Listing Does Not Guarantee Payment

    The policy's procedure and diagnosis code lists are provided for reference only and may not be all inclusive. Code inclusion does not establish that a service is covered or non-covered, create a right to reimbursement, or guarantee claim payment.

    • Benefit coverage is determined by federal, state, or contractual requirements and applicable laws.
    • Other policies and guidelines may apply.
    Denial Risk

    MTP Interposition Arthroplasty Is Unproven

    MTP interposition arthroplasty is unproven and not medically necessary. Avoid assuming coverage for first- or second-metatarsophalangeal-joint interposition procedures, regardless of the method used, when treating motion limitations or degenerative changes.

    • Insufficient evidence of efficacy creates denial risk for these procedures.
    This procedure does not replace the joint itself.
    Related terminologyAlso called interpositional arthroplasty.
    Total Implant Arthroplasty
    DefinitionA surgical procedure to replace both sides of a joint with prosthetic implants.
    Also known asTotal joint replacement.
    ExcludesInterposition arthroplasty.