ModifiedUnitedHealthcarePolicy CS342KS.03

Surgery of the Foot (for Kansas Only)

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This policy governs coverage and medical necessity for selected foot surgeries and related procedures under the UnitedHealthcare Community Plan in Kansas. It applies to providers requesting these services for Kansas Medicaid managed care members.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for Kansas Only)

Policy CodePolicy CS342KS.03

Change TypeModified

Effective DateOct 1, 2026

Next Review DateN/A

Key ActionDocument hallux rigidus, moderate-to-severe radiographic pathology, persistent pain, and conservative treatments attempted for implant correction.

SourceLink

POLICY UPDATE CHANGES

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

The policy added requirements describing medical-record documentation used to assess medical necessity.

The description of services, clinical evidence, references, and the definition of interposition or interpositional arthroplasty were updated.

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ModifiedUnitedHealthcarePolicy CS342KS.03

Surgery of the Foot (for Kansas Only)

Customize your policy alerts

Sign up for UnitedHealthcare Policy CS342KS.03 alerts

Get alerted when Policy CS342KS.03 changes without checking for updates manually.

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Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for Kansas Only)

Policy CodePolicy CS342KS.03

Change TypeModified

Effective DateOct 1, 2026

Next Review DateN/A

Key ActionDocument hallux rigidus, moderate-to-severe radiographic pathology, persistent pain, and conservative treatments attempted for implant correction.

SourceLink

POLICY UPDATE CHANGES

The policy added requirements describing medical-record documentation used to assess medical necessity.

The description of services, clinical evidence, references, and the definition of interposition or interpositional arthroplasty were updated.

Medical Necessity and Coverage Criteria

InterQual procedure criteria

Surgery of the foot is proven and medically necessary in certain circumstances. The requested procedure must meet the applicable InterQual CP: Procedures clinical coverage criteria.

Applicable InterQual procedure criteria: The requested procedure must meet the applicable InterQual CP: Procedures clinical coverage criteria.

Referenced procedures include arthrodesis or arthroplasty of the interphalangeal joints of the second through fifth toes; cheilectomy of the first metatarsophalangeal joint; exostectomy of the first metatarsophalangeal joint (bunionectomy); distal transpositional or proximal osteotomy of the first metatarsal (bunionectomy); proximal phalanx osteotomy of the first toe with or without bunionectomy; and plantar fascial release.

Hallux rigidus correction with implant

Correction of the first metatarsophalangeal joint with cheilectomy, debridement, capsular release, and an implant is covered when ALL of the following are met.

Hallux rigidus with moderate-to-severe pathology: The patient has a diagnosis of hallux rigidus confirmed by radiographic imaging demonstrating moderate-to-severe pathology.Moderate to severe radiographic pathology

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

Persistent symptoms despite conservative treatment: The patient has persistent pain despite a reasonable trial of conservative treatment including orthotics, shoe modification and/or shoe inserts; medical therapy; activity modification; and debridement of hyperkeratotic lesions, if present.

Medical therapy may include nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections. Shoe modification may include a high and wide toe box or rocker bottom sole.

Interposition/interpositional arthroplasty

The following procedure is considered unproven and not medically necessary.

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

Applies to both the first and second metatarsophalangeal joints.

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

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

The policy identifies interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, as unproven and not medically necessary when used to treat limitations in motion or degenerative changes. This determination reflects insufficient evidence of efficacy.

Applicable Codes

Applicable CPT CodesCPT

28285	Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy).
28289	Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint; without implant.
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.

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Documentation and Submission Requirements

Documentation Required

Submit medical necessity documentation

Submit records that fully support medical necessity for the requested service. Include, at a minimum, relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures; records must be legible, maintained in the patient's medical record, and made available upon request.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Legible records maintained in the patient's medical record

Documentation Required

Document hallux rigidus criteria

For first metatarsophalangeal joint correction with cheilectomy, debridement, capsular release, and an implant, document hallux rigidus with radiographic confirmation of moderate-to-severe pathology and persistent pain despite a reasonable trial of conservative treatment.

Radiographic confirmation of moderate-to-severe pathology

Clinical Background

Hallux rigidus is a progressive condition affecting the first metatarsophalangeal joint and may cause pain, stiffness, swelling, and loss of motion. It may result from osteoarthritis, rheumatoid arthritis, or gout. Early or mild disease may be treated with cheilectomy, while moderate-to-severe disease may be treated with arthrodesis or arthroplasty. Surgery may be considered when conservative measures do not 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.

Does not includeInterposition arthroplasty.

Interposition/Interpositional Arthroplasty

DefinitionA surgical procedure to remove some of the damaged bone and place a spacer between two bones to minimize contact on either side of the joint.

Spacer materialThe spacer may come from the individual, a donor, or a graft made from animal or synthetic materials.

Joint replacement