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    v1.0.30
    OpenPayerPolicy UpdatesPodiatryUnitedHealthcare Foot Surgery Coverage | OpenPayer
    Ask Trek AI about this page
    ModifiedUnitedHealthcarePolicy CSNCT0555.05

    Surgery of the Foot (for North Carolina Only)

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    UnitedHealthcare Community Plan coverage of selected foot surgeries and related procedures for members in North Carolina, including medically necessary procedures, noncovered procedures, documentation expectations, and applicable procedure codes.

    Policy Summary
    PayerUnitedHealthcare
    PolicySurgery of the Foot (for North Carolina Only)
    Policy CodePolicy CSNCT0555.05
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionProvide legible medical records supporting medical necessity, including relevant history, examination findings, and pertinent diagnostic or procedure results, upon request.
    SourceLink
    POLICY UPDATE CHANGES

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

    The policy added documentation requirements that the medical record fully support medical necessity for requested services.

    CPT code 28899 was noted as not being on the North Carolina Medicaid Fee Schedule and therefore potentially not covered by the North Carolina Medicaid Program.

    The definition of interposition or interpositional arthroplasty and the supporting clinical evidence and references were updated.

    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.

    11Procedure codes listed
    3Unproven or not medically necessary categories
    1Code absent from NC Medicaid fee schedule
    1st and 2nd MTPJoints affected by interposition arthroplasty noncoverage

    Covered and Non-Covered Foot Surgery

    InterQual®-Referenced Foot Surgery Criteria

    For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures criteria.

    Applicable InterQual® CP procedure-specific criteria

    • Arthrodesis or Arthroplasty, Interphalangeal Joint, Second-Fifth Toes
    • Exostectomy, First Metatarsophalangeal (MTP) Joint (Bunionectomy)
    • Osteotomy, Distal Transpositional, First Metatarsal (MT) (Bunionectomy)
    • Osteotomy, Proximal, First Metatarsal (MT) (Bunionectomy)
    • Osteotomy, Proximal Phalanx, First Toe +/- Bunionectomy
    • Plantar Fascial Release

    Hallux Limitus or Rigidus Correction Without Implant

    Covered when ALL of the following criteria are met:

    ALL of the following

    • Diagnosis of hallux limitus or hallux rigidus.
    • Radiographic imaging confirms mild to moderate pathology; a grading scale such as the Coughlin and Shurnas or Hattrup and Johnson Classification may be used.

      • ONE or more

        • Orthotics, shoe modification (e.g., high and wide toe box, rocker bottom sole), and/or shoe inserts.
        • Medical therapy, including nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections.

    Hallux Rigidus Correction With Implant

    Covered when ALL of the following criteria are met:

    ALL of the following

    • Diagnosis of hallux rigidus.
    • Radiographic imaging confirms moderate to severe pathology; a grading scale such as the Coughlin and Shurnas or Hattrup and Johnson Classification may be used.

      • ONE or more

        • Orthotics, shoe modification (e.g., high and wide toe box, rocker bottom sole), and/or shoe inserts.
        • Medical therapy, including nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections.

    Severe Hallux Rigidus Correction Without Implant

    The following correction is unproven and not medically necessary due to insufficient evidence of efficacy when hallux rigidus is severe.

    ALL of the following

    • Severe hallux rigidus is present; a grading scale such as the Coughlin and Shurnas or Hattrup and Johnson Classification may be used.
    • Correction of the first metatarsophalangeal joint with cheilectomy, debridement, and capsular release without implant is requested.

    Interposition Arthroplasty and Osteochondral Transplantation

    The following treatments are unproven and not medically necessary due to insufficient evidence of efficacy.

    ONE or more

    • Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, for treating limitations in motion or degenerative changes.
    • Osteochondral allograft or autograft transplantation for treating cartilage defects of the foot.

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

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

    Correction of the first metatarsophalangeal joint with cheilectomy, debridement, and capsular release without implant is unproven and not medically necessary for severe hallux rigidus due to insufficient evidence of efficacy.

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

    Osteochondral allograft or autograft transplantation is excluded from covered medically necessary treatment when used to treat cartilage defects of the foot.

    Correction of the first metatarsophalangeal joint with cheilectomy, debridement, and capsular release without implant is excluded from covered medically necessary treatment when hallux rigidus is severe.

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

    Applicable Procedure Codes

    Applicable 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
    1/2
    Applicable CodesCPT
    28899

    Documentation, Billing, and Denial Risks

    Documentation Required

    Provide supporting medical records

    Upon request, provide legible medical records that fully support medical necessity, including relevant medical history, physical examination findings, and results of pertinent diagnostic tests or procedures. Records must be maintained in the patient's medical record and made available for review.

    Documentation Required

    Document medical necessity

    The patient's medical record must contain legible documentation that fully supports medical necessity for the requested services. Documentation must include relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures, and must be maintained in the medical record and made available upon request.

    Clinical Background

    Hallux rigidus causes pain and stiffness at the first metatarsophalangeal joint and may progress from hallux limitus to end-stage rigidity. Cheilectomy may preserve motion in early or mild disease, while arthrodesis or arthroplasty may be used for more advanced disease. The policy describes interposition arthroplasty and osteochondral transplantation but considers them unproven and not medically necessary.

    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 materialMay come from the individual, a donor, or a graft made from animal or synthetic materials.
    Joint replacement
    Policy Summary
    PayerUnitedHealthcare
    PolicySurgery of the Foot (for North Carolina Only)
    Policy CodePolicy CSNCT0555.05
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionProvide legible medical records supporting medical necessity, including relevant history, examination findings, and pertinent diagnostic or procedure results, upon request.
    SourceLink
    On This Page
    Covered and Non-Covered Foot SurgeryApplicable Procedure CodesDocumentation, Billing, and Denial RisksClinical BackgroundProcedure Definitions
    Activity modification.
  1. Debridement of hyperkeratotic lesions, if present.
    2. Activity modification.
  2. Debridement of hyperkeratotic lesions, if present.
    3. Denial Risk

    Severe hallux rigidus without implant may be denied

    Correction of the first metatarsophalangeal joint with cheilectomy, debridement, and capsular release without an implant is unproven and not medically necessary for severe hallux rigidus because of insufficient evidence of efficacy.

    Denial Risk

    Interposition arthroplasty is not medically necessary

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

    Denial Risk

    Osteochondral transplantation may be denied

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

    Billing Rule

    Check fee-schedule status for CPT 28899

    The unlisted foot or toe procedure code 28899 is marked with an asterisk and is not on the North Carolina Medicaid Fee Schedule. It therefore may not be covered by the North Carolina Medicaid Program.

    Denial Risk

    Interposition arthroplasty may be denied

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

    Billing Rule

    CPT 28899 may not be covered

    CPT 28899 is not on the North Carolina Medicaid Fee Schedule and therefore may not be covered by the North Carolina Medicaid Program.

    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.