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    v1.0.30
    OpenPayerPolicy UpdatesPodiatryUnitedHealthcare Foot Surgery Coverage | OpenPayer
    Ask Trek AI about this page
    ModifiedUnitedHealthcarePolicy CS342NM.E

    Surgery of the Foot (for New Mexico Only)

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    This policy governs coverage of specified foot surgeries and related procedures for UnitedHealthcare Community Plan members in New Mexico. It describes covered-with-criteria procedures, procedures considered unproven and not medically necessary, documentation requirements, definitions, and applicable procedure codes.

    Policy Summary
    PayerUnitedHealthcare
    PolicySurgery of the Foot (for New Mexico Only)
    Policy CodePolicy CS342NM.E
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionDocument persistent pain, radiographic severity, and failed conservative treatment before requesting covered hallux limitus or rigidus correction.
    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 because of insufficient evidence of efficacy.

    Medical-record documentation requirements were added for coverage reviews.

    The description of services, clinical evidence, definitions, and references were updated to reflect current information.

    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.

    NMApplicable state
    6InterQual references
    2Covered hallux rigidus pathways
    2Unproven foot procedures
    10Applicable procedure codes
    1st & 2ndAffected MTP joints

    Covered and Non-Covered Foot Surgery

    InterQual foot surgery procedures

    Surgery of the foot is proven and medically necessary in certain circumstances when the applicable InterQual CP Procedures criteria are met.

    ONE of the following applicable procedure criteria

    • Arthrodesis or arthroplasty of the interphalangeal joint of the second through fifth toes.
    • 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.
    • Plantar fascial release.

    Hallux limitus or rigidus correction without implant

    Covered when ALL of the following are met.

    ALL of the following

    • Diagnosis and imaging

      • The member has a 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.Mild to moderate pathology

    • Persistent symptoms despite conservative treatment

      • The member has persistent pain despite a reasonable trial of conservative treatment.

      • ONE or more of the following conservative measures

    Hallux rigidus correction with implant

    Covered when ALL of the following are met.

    ALL of the following

    • Diagnosis and imaging

      • The member has a 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.Moderate to severe pathology

    • Persistent symptoms despite conservative treatment

      • The member has persistent pain despite a reasonable trial of conservative treatment.

      • ONE or more of the following conservative measures

    Interposition/interpositional arthroplasty

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint is not medically necessary when used to treat limitations in motion or degenerative changes.

    Procedure and indication

    • The requested procedure is interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method.
    • The procedure is intended to treat limitations in motion or degenerative changes.

    Nonimplant correction of the first metatarsophalangeal joint using cheilectomy, debridement, and capsular release is not medically necessary for severe hallux rigidus because evidence of efficacy is insufficient. The nonimplant pathway may apply to mild to moderate radiographic disease when the member has persistent pain despite a reasonable trial of conservative treatment.

    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 because evidence of efficacy is insufficient.

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

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

    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.

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint is unproven and not medically necessary when used to treat limitations in motion or degenerative changes.

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

    Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is not medically necessary for treating limitations in motion or degenerative changes. The evidence for first-joint procedures is low quality and no quality evidence was identified for second-joint procedures.

    Applicable Procedure Codes

    Applicable CPT 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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    Documentation and Review Requirements

    Note

    Clinical Coverage Review

    Review the requested foot surgery against the applicable InterQual® CP Procedures criteria and the policy-specific medical-necessity requirements before determining coverage.

    • Applicable InterQual® procedures include arthrodesis or arthroplasty of the second-fifth interphalangeal joints, first MTP exostectomy or osteotomy, proximal phalanx osteotomy, and plantar fascial release.
    • Use the InterQual® criteria together with the requirements in this policy.
    Documentation Required

    Document Conservative Treatment Trial

    For covered hallux correction procedures, document that persistent pain continues despite a reasonable trial of conservative treatment.

    • Orthotics, shoe modification or shoe inserts
    • Medical therapy, including nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections

    Clinical Background

    Hallux limitus and hallux rigidus cause pain and progressive stiffness of the first metatarsophalangeal joint. Cheilectomy may preserve joint motion and is generally used for early or mild disease, while arthrodesis or arthroplasty may be used for more advanced disease. Coverage distinguishes implant and nonimplant correction according to the severity of radiographic pathology; interposition arthroplasty and osteochondral transplantation are considered insufficiently supported.

    Procedure Definitions

    Hemi-Implant Arthroplasty
    DefinitionA surgical procedure to replace one side of a joint with a prosthetic implant.
    Also known asPartial joint replacement.
    Scope exclusionDoes not include interposition arthroplasty.
    Interposition/Interpositional Arthroplasty
    DefinitionA surgical procedure that removes some damaged bone and places 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.
    Procedure concept
    Policy Summary
    PayerUnitedHealthcare
    PolicySurgery of the Foot (for New Mexico Only)
    Policy CodePolicy CS342NM.E
    Change TypeModified
    Effective DateOctober 1, 2026
    Next Review DateN/A
    Key ActionDocument persistent pain, radiographic severity, and failed conservative treatment before requesting covered hallux limitus or rigidus correction.
    SourceLink
    On This Page
    Covered and Non-Covered Foot SurgeryApplicable Procedure CodesDocumentation and Review RequirementsClinical BackgroundProcedure Definitions
  1. Orthotics, shoe modification (for example, a high and wide toe box or rocker-bottom sole), and/or shoe inserts.
  2. Medical therapy, including nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections.
  3. Activity modification.
  4. Debridement of hyperkeratotic lesions, if present.
  5. Orthotics, shoe modification (for example, a high and wide toe box or rocker-bottom sole), and/or shoe inserts.
  6. Medical therapy, including nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections.
  7. Activity modification.
  8. Debridement of hyperkeratotic lesions, if present.
  9. Activity modification
  10. Debridement of hyperkeratotic lesions, if present
    11. Documentation Required

    Medical Necessity Records Required

    The medical record must fully support medical necessity for the requested service with relevant history, examination findings, and pertinent diagnostic or procedural results.

    • Include relevant medical history and physical examination findings.
    • Include results of pertinent diagnostic tests or procedures.
    • Ensure documentation is legible, maintained in the medical record, and available upon request.
    Documentation Required

    Support Hallux Rigidus Diagnosis

    For hallux rigidus correction, document the diagnosis, qualifying radiographic severity, and persistent symptoms despite conservative treatment.

    • Without an implant: radiographic imaging must confirm mild to moderate pathology.
    • With a hemi-implant or total implant arthroplasty: radiographic imaging must confirm moderate to severe pathology.
    • A grading scale such as Coughlin and Shurnas or Hattrup and Johnson may be used.
    Documentation Required

    Maintain Medical-Record Support

    Medical-record documentation must fully support the requested service and must be made available for review. Documentation may be required to assess clinical criteria and does not guarantee coverage.

    • Maintain complete, legible supporting records in the patient's medical record.
    • Provide records upon request for medical-necessity review.
    Denial Risk

    Severe Hallux Rigidus Without Implant

    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.

    • Do not submit this procedure as medically necessary for severe hallux rigidus without an implant.
    Denial Risk

    Interposition Arthroplasty

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

    • Applies to the first and second metatarsophalangeal joints.
    • Insufficient evidence of efficacy supports the unproven designation.
    Denial Risk

    Osteochondral Transplantation

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

    • The unproven designation applies to both allograft and autograft transplantation.
    Denial Risk

    Interposition Arthroplasty Not Medically Necessary

    Interposition or interpositional arthroplasty is unproven and not medically necessary for the first or second metatarsophalangeal joint, regardless of the method used.

    • Apply this limitation to procedures intended to treat limitations in motion or degenerative changes.
    • Ensure the requested procedure and supporting documentation do not conflict with this coverage position.
    Billing Rule

    Benefit-Plan Requirements Govern

    Federal, state, or contractual benefit-plan requirements govern coverage when they conflict with this policy. Check the applicable benefit requirements before using this policy to make a coverage determination.

    • Policy language assists in interpreting standard UnitedHealthcare benefit plans.
    • UnitedHealthcare may use InterQual® criteria and other tools to assist in administering benefits.
    • The policy does not replace the qualified health care provider's independent professional medical judgment.
    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.
    Scope exclusionDoes not include interposition arthroplasty.