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    v1.0.30
    OpenPayerPolicy UpdatesPodiatryUnitedHealthcare Foot Surgery Coverage | OpenPayer
    Ask Trek AI about this page
    ModifiedUnitedHealthcare Community PlanPolicy CS342KY.12

    Surgery of the Foot (for Kentucky Only)

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    This policy governs coverage of foot surgery services for UnitedHealthcare Community Plan members in Kentucky, including medically necessary procedures, hallux rigidus implant correction criteria, procedures considered unproven and not medically necessary, documentation requirements, and applicable procedure codes.

    Policy Summary
    PayerUnitedHealthcare Community Plan
    PolicySurgery of the Foot (for Kentucky Only)
    Policy CodePolicy CS342KY.12
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionSubmit legible medical records documenting medical history, examination findings, and pertinent diagnostic results to support medical necessity.
    SourceLink
    POLICY UPDATE CHANGES

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

    The policy adds medical-record documentation requirements for coverage reviews.

    The policy clarifies that documentation supporting medical necessity does not guarantee coverage.

    The definitions, description of services, clinical evidence, and references were updated, and the prior policy version CS342KY.11 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.

    KYApplicable state
    7InterQual criteria referenced
    2Categories unproven and not medically necessary
    11Applicable procedure codes
    All criteriaImplant correction logic

    Medical Necessity and Coverage Criteria

    InterQual-covered foot surgery criteria

    For medical necessity clinical coverage criteria, refer to the applicable InterQual criteria.

    Applicable InterQual foot surgery criteria: Coverage criteria are referenced for arthrodesis or arthroplasty of the interphalangeal joint of the second-fifth toes; cheilectomy of the first metatarsophalangeal joint; exostectomy of the first metatarsophalangeal joint (bunionectomy); distal transpositional osteotomy of the first metatarsal (bunionectomy); proximal osteotomy of the first metatarsal (bunionectomy); proximal phalanx osteotomy of the first toe with or without bunionectomy; and plantar fascial release.

    The applicable InterQual clinical coverage criteria establish the medical necessity requirements for these procedures.

    Hallux rigidus correction with implant

    Correction of the first metatarsophalangeal joint with cheilectomy, debridement, capsular release, and an implant is proven and medically necessary when all of the following criteria are met.

    Hallux rigidus implant correction

    • Diagnosis and imaging: Diagnosis of hallux rigidus with radiographic imaging confirming 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.

    • Failed conservative treatment: Persistent pain despite a reasonable trial of conservative treatment including orthotics, shoe modification such as a high and wide toe box or rocker bottom sole, and/or shoe inserts; medical therapy including nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections; activity modification; and debridement of hyperkeratotic lesions, if present.All listed conservative measures, as applicable

    MTP interposition arthroplasty

    Not medically necessary and unproven.

    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 used to treat limitations in motion or degenerative changes.

    This determination is based on insufficient evidence of efficacy.

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is excluded from medically necessary coverage because it is considered unproven due to insufficient evidence of efficacy.

    Osteochondral allograft or autograft transplantation for cartilage defects of the foot is excluded from medically necessary coverage because it is considered unproven due to insufficient evidence of efficacy.

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is restricted when the requested treatment is intended to address limitations in motion or degenerative changes.

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint is not medically necessary for limitations in motion or degenerative changes because the policy identifies insufficient evidence of efficacy.

    Osteochondral allograft or autograft transplantation is 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 considered unproven and not medically necessary when used to treat limitations in motion or degenerative changes.

    Applicable Codes and Coding Details

    Applicable Procedure 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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    Hallux Rigidus Radiographic Severity
    Required severityModerate to severe hallux rigidus pathology
    Confirmation methodRadiographic imaging must confirm the pathology
    Applicable grading scalesCoughlin and Shurnas or Hattrup Johnson Classification may be used

    Documentation and Provider Action Requirements

    Documentation Required

    Submit complete medical necessity documentation

    Submit records that fully support the medical necessity of the requested service. Include relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures.

    • Ensure documentation is legible, maintained in the patient's medical record, and available upon request.
    Documentation Required

    Document implant correction criteria

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

    • Document conservative treatment including orthotics, shoe modification and/or shoe inserts; medical therapy; activity modification; and debridement of hyperkeratotic lesions, if present.
    • A grading scale such as the Coughlin and Shurnas or Hattrup Johnson Classification may be used to confirm radiographic severity.

    Clinical Background

    Hallux rigidus is a progressive condition involving the first metatarsophalangeal joint. Patients may experience pain, stiffness, swelling, and reduced joint motion. Causes may include osteoarthritis, rheumatoid arthritis, or gout. Cheilectomy may be used in earlier or milder disease, while arthrodesis or arthroplasty may be considered for moderate to severe joint damage after conservative treatment has failed.

    Procedure Definitions

    Hemi-Implant Arthroplasty
    DefinitionA surgical procedure to replace one side of a joint with a prosthetic implant
    Also known asPartial joint replacement
    ExclusionDoes not include interposition 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 distinction
    Policy Summary
    PayerUnitedHealthcare Community Plan
    PolicySurgery of the Foot (for Kentucky Only)
    Policy CodePolicy CS342KY.12
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionSubmit legible medical records documenting medical history, examination findings, and pertinent diagnostic results to support medical necessity.
    SourceLink
    On This Page
    Medical Necessity and Coverage CriteriaApplicable Codes and Coding DetailsDocumentation and Provider Action RequirementsClinical BackgroundProcedure Definitions
    Documentation Required

    Maintain complete, legible medical records

    The patient's medical record must contain legible documentation that fully supports medical necessity for the requested services, including relevant medical history, physical examination, and pertinent diagnostic test or procedure results. Maintain the records and make them available upon request; documentation may be required to assess clinical criteria but does not guarantee coverage.

    Denial Risk

    Interposition arthroplasty is unproven

    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.

    • Expect a coverage denial risk for this procedure under the policy.
    Denial Risk

    Osteochondral transplantation is unproven

    Osteochondral allograft or autograft transplantation for cartilage defects of the foot is considered unproven and not medically necessary because of insufficient evidence of efficacy. This determination creates a risk of denial for the requested service.

    Denial Risk

    Meet applicable medical necessity criteria

    Foot surgery is covered as proven and medically necessary only in certain circumstances. Refer to the applicable InterQual clinical coverage criteria for the listed procedures, and ensure that first metatarsophalangeal joint correction with an implant meets all stated hallux rigidus criteria.

    • For implant correction, all criteria must be met, including hallux rigidus with radiographic moderate to severe pathology and persistent pain despite a reasonable conservative treatment trial.
    Denial Risk

    Avoid unproven MTP interposition arthroplasty

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, may be denied when used for limitations in motion or degenerative changes because the policy considers it unproven and not medically necessary due to insufficient evidence of efficacy.

    This procedure does not replace the joint itself
    Total Implant Arthroplasty
    DefinitionA surgical procedure to replace both sides of a joint with prosthetic implants
    Also known asTotal joint replacement
    ExclusionDoes not include interposition arthroplasty