ModifiedUnitedHealthcarePolicy CSNCT0555.04

Surgery of the Foot (for North Carolina Only)

Defines medical necessity and coverage stance for selected foot surgeries (e.g., hallux rigidus procedures, bunionectomy, plantar fascial release) for UnitedHealthcare members in North Carolina.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for North Carolina Only)

Policy CodePolicy CSNCT0555.04

Change TypeCoverage language revisedstate-specific version createddefinitions added

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization when required and document medical records to support InterQual-referenced clinical criteria for the applicable procedure codes.

SourceLink

POLICY UPDATE CHANGES

Replaced language to explicitly include hemi-implant and total implant arthroplasty as proven and medically necessary when listed criteria are met.

Created state-specific policy version for the state of North Carolina (no change to coverage guidelines).

Added definitions for Hemi-Implant Arthroplasty, Interposition Arthroplasty, and Total Implant Arthroplasty.

Added related policy link to Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds.

11procedure codes shown in policy

3definitions added

state-specificpolicy version

Guidance citations

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria — Foot Surgery

Hallux Limitus or Rigidus (Cheilectomy without implant) - Covered

Correction of the first metatarsophalangeal (MTP) joint with cheilectomy, debridement, and capsular release without implant is proven and medically necessary when ALL of the following criteria are met:

Coverage criteria: 1. Diagnosis of hallux limitus or hallux rigidus confirmed by radiographic imaging demonstrating mild-to-moderate pathology (e.g., a grading scale such as the Coughlin and Shurnas or Hattrup Johnson Classification). 2. Persistent pain despite a reasonable trial of conservative treatment including one or more of: orthotics or shoe modification (e.g., high and wide toe box, rocker bottom sole) and/or shoe inserts; medical therapy (NSAIDs, analgesics, or intra-articular injections); activity modification; debridement of hyperkeratotic lesions if present.

Hallux Rigidus (Cheilectomy with implant) - Covered

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 of the following criteria are met:

Coverage criteria: 1. Diagnosis of hallux rigidus confirmed by radiographic imaging demonstrating moderate-to-severe pathology (e.g., a grading scale such as the Coughlin and Shurnas or Hattrup Johnson Classification). 2. Persistent pain despite a reasonable trial of conservative treatment including one or more of: orthotics or shoe modification (e.g., high and wide toe box, rocker bottom sole) and/or shoe inserts; medical therapy (NSAIDs, analgesics, or intra-articular injections); activity modification; debridement of hyperkeratotic lesions if present.

Cheilectomy without implant - Not medically necessary for severe disease

Exclusion: Cheilectomy without implant is unproven and not medically necessary for severe hallux rigidus (e.g., as defined by grading scales such as Coughlin and Shurnas or Hattrup Johnson) due to insufficient evidence of efficacy.

Osteochondral Allograft or Autograft Transplantation - Not Medically Necessary

Stance: Osteochondral allograft or autograft transplantation for cartilage defects of the foot is unproven and not medically necessary due to insufficient evidence of efficacy; available studies are small, retrospective case series with heterogeneous techniques and limited long-term follow-up.

Hallux Rigidus (Correction With Implant)

Covered when ALL of the following are met (criteria details located elsewhere in the policy):

Implant arthroplasty coverage: Correction of the first metatarsophalangeal (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.

Full list of implant-specific criteria not included in this fragment; see other policy sections for complete criteria.

Cheilectomy — defined here as correction of the first metatarsophalangeal (MTP) joint with cheilectomy, debridement, and capsular release without implant — is considered proven and medically necessary when radiographic imaging confirms mild-to-moderate hallux limitus or hallux rigidus (for example, using Coughlin and Shurnas or Hattrup Johnson grading) and the member has persistent pain despite a reasonable trial of conservative measures such as orthotics or shoe modification, medical therapy (NSAIDs/analgesics or intra‑articular injections), activity modification, or debridement of hyperkeratotic lesions if present.

Note that FDA approval alone does not establish coverage. FDA clearance or approval of a device used during foot surgery is informational; coverage decisions depend on whether the service meets the plan’s clinical criteria and applicable federal, state, or contractual requirements.

Osteochondral allograft or autograft transplantation for cartilage defects of the foot is considered unproven and not medically necessary because the available evidence consists primarily of small, heterogeneous case series with limited follow-up and is insufficient to demonstrate clinically meaningful benefit compared with established treatments.

Procedures, devices, or techniques that do not meet the clinical criteria described in this policy — or lack sufficient evidence of efficacy — may not be covered. Coverage is determined by the plan’s medical necessity criteria and supporting documentation; FDA clearance of a device used during surgery does not by itself ensure coverage.

Applicable Procedure and Device Codes

Applicable CPT/Procedure 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.

1–10 of 11

1/2

Device/Regulatory notesneutral

No codes listed

evidence quality

Recommendation on trial qualityAdded guidance recommends future research include adequately powered randomized controlled trials to inform patient selection, disease stage, patient-reported outcomes (pain, mobility, quality of life), and long-term implant results.

Specific trial featuresTrials should be adequately powered to assess clinically meaningful differences in outcomes for implant procedures.

Outcomes to measurePatient-reported outcomes (pain, mobility, quality of life) and long-term implant performance should be included.

Population detailsResearch should inform details of patient selection and the stage of osteoarthritis appropriate for implant arthroplasty.

Provider Actions and Administrative Requirements

Prior Authorization

Prior Authorization and Clinical Criteria

Prior authorization may be required for some foot surgery procedures. Check the member’s benefit plan and the applicable federal, state, or contractual requirements before scheduling. UnitedHealthcare may use InterQual criteria to assist with medical necessity determinations for the CPTs and procedures listed in this policy.

Verify plan-specific prior authorization requirements before performing procedures referenced in this policy.
When requested, submit clinical documentation demonstrating the member meets InterQual (or equivalent) clinical criteria for the specific procedure.

Note

Contract and State Requirement Check

Benefit coverage is determined by the member’s federal, state, or contractual requirements and applicable laws. Before relying on this policy, confirm whether plan-specific or state-mandated provisions alter coverage decisions. In the event of a conflict, federal, state, or contractual requirements govern.

Check the member’s contract and applicable state mandates for any differences from this standard policy.

Clinical Background

Hallux rigidus (stiff great toe) is a degenerative condition of the first MTP joint characterized by pain, reduced dorsiflexion, and progressive osteophyte formation that can limit activities. In early or mild disease, cheilectomy can remove dorsal osteophytes and preserve motion, whereas arthrodesis or implant arthroplasty are options for more advanced disease. Cheilectomy without implant is not considered effective for severe hallux rigidus due to insufficient evidence of benefit.

Definitions

Hemi-Implant Arthroplasty definition

DefinitionA surgical procedure to replace one side of a joint with a prosthetic implant (partial joint replacement). Does not include Interposition Arthroplasty.

Also known asPartial joint replacement.

SourceAmerican Orthopaedic Foot & Ankle Society (AOFAS), 2025; added to policy definitions.

Interposition Arthroplasty definition

DefinitionA surgical procedure to remove some of the damaged bone and place a spacer (e.g., soft tissue graft) between two bones to minimize contact on either side of the joint (joint resurfacing).

Also known asJoint resurfacing.