Surgery of the Foot (for Idaho Only)
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Medical policy governing indications, clinical rationale, and coding guidance for surgical procedures of the foot for UnitedHealthcare members in Idaho (including Idaho Medicaid Plus).
Revised language pertaining to medical necessity clinical coverage criteria; replaced prior phrasing to explicitly state that 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 listed criteria are met.
Added language clarifying medical records documentation requirements to support medical necessity reviews.
Added definitions for Hemi-Implant Arthroplasty, Interposition Arthroplasty, and Total Implant Arthroplasty.
Referenced use of InterQual ® criteria (Procedures, Osteotomy, Proximal Phalanx, First Toe +/- Bunionectomy Hallux Rigidus) to assist in adjudication.
Coverage and Medical Necessity Criteria
Hallux Limitus or Rigidus (Correction Without Implant)
Covered when ALL of the following are met
Persistent pain despite a reasonable trial of conservative treatment (one or more of orthotics/shoe modification, medical therapy such as NSAIDs/analgesics or intra-articular injections, activity modification, and debridement of hyperkeratotic lesions when present). Cheilectomy without implant is unproven and not medically necessary for severe hallux rigidus due to insufficient evidence of efficacy.
Hallux Rigidus (Correction With Implant)
Covered when ALL of the following are met
Persistent pain despite a reasonable trial of conservative treatment (one or more of orthotics/shoe modification, medical therapy such as NSAIDs/analgesics or intra-articular injections, activity modification, and debridement of hyperkeratotic lesions when present). Implant arthroplasty (Hemi-Implant or Total Implant) is indicated per criteria and referenced InterQual CP guidance.
Osteochondral Allograft or Autograft Transplantation
Not covered due to insufficient evidence
Considered unproven and not medically necessary due to small, low-quality studies, heterogeneity of techniques, limited long-term follow-up, and lack of comparative evidence; further larger, comparative studies are needed.
NICE-guided use and governance conditions
Coverage and use context summarized from policy excerpts and NICE guidance
NICE advises clinician and organizational responsibilities including notifying governance leads, providing patient information for shared decision-making, ensuring comprehension of safety/efficacy uncertainties, registering cases (e.g., BOFAS registry), and auditing outcomes; policy revisions also reference InterQual criteria for adjudication.
Correction of the first metatarsophalangeal (MTP) joint with cheilectomy, debridement, and capsular release without implant is proven and medically necessary when the listed criteria are met, including a diagnosis of hallux limitus or hallux rigidus with radiographic confirmation of mild to moderate pathology and persistent symptoms after a reasonable trial of conservative management (orthotics/shoe modification, medical therapy such as NSAIDs/analgesics or intra‑articular injections, activity modification, and debridement of hyperkeratotic lesions if present). However, cheilectomy without implant is considered unproven and not medically necessary for severe hallux rigidus due to insufficient evidence of efficacy.
This section is informational: FDA approval alone is not a basis for coverage. Note that surgical procedures themselves are not regulated by the FDA, although devices and instruments used during foot surgery may require FDA clearance or approval; providers can consult FDA databases for device-specific information.
Osteochondral allograft or autograft transplantation for cartilage defects of the foot is considered unproven and not medically necessary because the available evidence is insufficient to demonstrate efficacy. Similarly, cheilectomy without implant for severe hallux rigidus remains unsupported by adequate evidence and is therefore not medically necessary for that indication.
The evidence for synthetic cartilage implant insertion and other novel cartilage procedures is limited in quantity and quality. For individuals with advanced disease for whom arthrodesis would otherwise be indicated, NICE recommends use only with specific clinical governance, informed consent, auditing or research provisions. For other patients, NICE recommends use only in the research context, with systematic data collection, outcome reporting, and appropriately powered trials to define patient selection and long‑term effectiveness.
Applicable Procedure and Billing Codes
| 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 |
| 29893 | Endoscopic plantar fasciotomy |
Prior Authorization, Documentation, and Provider Requirements
InterQual-based Prior Authorization
Prior authorization may be required for these procedures. Coverage and medical necessity are determined using InterQual® CP criteria; documentation submitted must clearly support that the member meets those clinical criteria. Verify applicable federal, state, and contractual requirements before submitting a prior authorization request.
- Prior authorization may be required — check plan contract and applicable state/federal mandates.
- InterQual® CP criteria will be used to determine medical necessity for listed procedures.
- Complete medical records must be provided to support the InterQual review.
Required Medical Record Documentation
The provider must ensure the patient's medical record fully supports the medical necessity of the requested service. Required documentation includes, but is not limited to, relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Documentation must be legible, maintained in the medical record, and made available upon request. Providing records does not guarantee coverage.
- Relevant medical history and prior conservative treatments tried and dates.
- Detailed physical exam findings specific to the foot/toe condition.
- Pertinent diagnostic test results (e.g., imaging reports, nerve conduction studies) with dates.
- Operative reports and pathology when applicable.
- Documentation of functional impairment and impact on activities of daily living.
Documentation Insufficiency and Denial Risk
Insufficient or incomplete documentation may result in a request for additional information or denial of the request. Failure to provide complete medical records that demonstrate the member meets InterQual clinical criteria may lead to non-coverage.
- Lack of evidence that conservative management was attempted when required may result in denial.
- Missing or illegible test results, imaging, or exam findings may delay review or lead to adverse determination.
- Submit complete operative notes and prior treatment records to avoid delays.
Provider Actions
Providers should verify prior authorization requirements and submit all requested documentation at time of request. Use the InterQual® procedure-specific criteria referenced in this policy when preparing authorization requests.
- Confirm whether prior authorization is required for the member's plan before scheduling.
- Attach imaging, clinical notes, and prior treatment documentation to the authorization request.
- Respond promptly to requests for additional information to avoid denial or delays.
Key Procedure Definitions
Clinical Background and Rationale
Hallux rigidus is a degenerative disorder of the first metatarsophalangeal (MTP) joint that produces pain, stiffness, and reduced function. Surgical options aim either to preserve joint motion (for example, cheilectomy with debridement and capsular release in early to moderate disease) or to address end‑stage disease (for example, arthrodesis or implant arthroplasty when indicated). Procedures such as osteochondral grafting or synthetic cartilage implant insertion have limited and low‑quality evidence for efficacy in the foot, and their routine use is not supported without further research or governance mechanisms.
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