DraftUnitedHealthcarePolicy CS342NM.D

Surgery of the Foot (for New Mexico Only)

Governs medical necessity and coverage for foot surgical procedures for UnitedHealthcare members in New Mexico, including hallux limitus/rigidus procedures, implant arthroplasty, and osteochondral grafting; applies to providers and claims in New Mexico.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for New Mexico Only)

Policy CodePolicy CS342NM.D

Change TypeCoverage language reviseddefinitions added

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization using InterQual CP criteria and document radiographic grading, trial of conservative therapy, and registry/governance details when implants or synthetic cartilage are used.

SourceLink

POLICY UPDATE CHANGES

Replaced language to explicitly state correction of the first MTP joint with cheilectomy, debridement, and capsular release with implant now includes 'Hemi-Implant or Total Implant Arthroplasty' as proven and medically necessary when criteria are met.

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

Updated Supporting Information to reflect current clinical evidence and references.

New MexicoState-specific

InterQualInterQual referenced

Codes listedCPT list present

NICE

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Coverage and Medical Necessity Criteria

Cheilectomy (without implant)

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

Cheilectomy without implant coverage: 1) Diagnosis of hallux limitus or hallux rigidus with radiographic imaging confirming mild to moderate pathology (a grading scale such as Coughlin and Shurnas or Hattrup and Johnson may be used). 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 is unproven and not medically necessary for severe hallux rigidus.

Cheilectomy (with implant)

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 are met:

Cheilectomy with implant coverage: 1) Diagnosis of hallux rigidus with radiographic imaging confirming moderate to severe pathology (a grading scale such as Coughlin and Shurnas or Hattrup and Johnson may be used). 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.

Policy History clarifies 'Hemi-Implant or Total Implant Arthroplasty' terminology.

Osteochondral Allograft/Autograft Transplantation

Osteochondral allograft or autograft transplantation for cartilage defects of the foot:

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

Available evidence consists mainly of small case series and level IV studies; larger comparative studies with longer follow-up are needed.

Synthetic Cartilage Implant — governance and research-linked coverage

Use and coverage of synthetic cartilage implants and implant arthroplasty:

NICE stance on synthetic cartilage implant: For individuals with advanced disease for whom arthrodesis is indicated, synthetic cartilage implant insertion shows no major short-term safety concerns but evidence of effectiveness is limited in quantity and quality; the procedure should only be used with clinical governance, informed consent, and audit or research provisions.

NICE IPG727

NICE stance for non-advanced disease: For individuals with less advanced hallux rigidus, safety evidence shows no major short-term safety concerns but effectiveness evidence is insufficient; the procedure should be used only in the research context.

NICE IPG727

Clinician obligations for advanced-disease synthetic cartilage implant: When performing synthetic cartilage implant insertion for advanced disease, clinicians must: notify clinical governance leaders; provide explicit printed decision-support materials and ensure patient/family understanding of safety and efficacy uncertainties; register cases (e.g., BOFAS Registry) and evaluate local results; and consider results with the patient during annual assessment.

Hemi-Implant and Total Implant Arthroplasty — covered when criteria met

Implant arthroplasty (hemi or total) coverage statement:

Implant arthroplasty coverage: 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 listed criteria in the Coverage Rationale are met.

Policy History revision effective 10/01/2025 clarified implant types included.

Correction of the first metatarsophalangeal (MTP) joint with cheilectomy, debridement, and capsular release without implant is considered proven and medically necessary when all listed criteria are met. Key requirements include: a diagnosis of hallux limitus or hallux rigidus with radiographic confirmation of mild to moderate pathology (grading scales such as Coughlin and Shurnas or Hattrup and Johnson may be used), and persistent pain despite a reasonable trial of conservative treatment such as orthotics/shoe modification/shoe inserts, medical therapy (NSAIDs, analgesics, or intra-articular injections), activity modification, or debridement of hyperkeratotic lesions if present.

Use of synthetic cartilage implants outside of research or without required governance and registry reporting is restricted. For individuals with advanced disease, NICE advises that insertion should occur only with unique clinical governance, explicit consent, audit or research provisions, including case registration and local outcome evaluation. Routine use for non-advanced cases is recommended only in a research context until stronger evidence of effectiveness is available.

Cheilectomy without implant is appropriate primarily for mild to moderate hallux rigidus where conservative measures have failed; it is not supported for severe disease due to insufficient evidence of benefit. By contrast, osteochondral allograft or autograft transplantation for foot cartilage defects is considered unproven and not medically necessary because the evidence base is limited to small case series and low-quality studies.

Available evidence for synthetic cartilage implant insertion demonstrates no major short-term safety concerns but has limited quantity and quality regarding effectiveness. Consequently, these implants are insufficiently supported for routine clinical use; their use should be confined to research settings or to carefully governed clinical programs with consent, audit, and registry reporting as outlined by NICE.

Procedure Codes, Radiographic Grading, and Regulatory Notes

Applicable Procedure CPT Codes (part 1)CPT

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

Applicable Procedure CPT Codes (part 2)CPT

28899	Unlisted procedure, foot or toes
29893	Endoscopic plantar fasciotomy

Regulatory/Citation — FDA notemixed

No codes listed

Radiographic grading (examples listed)

Examples of grading scalesCoughlin and Shurnas; Hattrup and Johnson classifications are referenced for radiographic grading of hallux limitus/rigidus (used to define mild, moderate, or severe disease).

Use in without-implant criteriaRadiographic imaging confirming mild to moderate pathology may be documented using Coughlin and Shurnas or Hattrup and Johnson grading (supports cheilectomy without implant).

Use in with-implant criteriaRadiographic imaging confirming moderate to severe pathology may be documented using Coughlin and Shurnas or Hattrup and Johnson grading (supports cheilectomy with implant).

Grade examples (policy mapping)Coughlin and Shurnas: 0 (no OA) through 3–4 (severe); Hattrup and Johnson: I (mild) through III (severe) as detailed in the policy.

N/A

Prior Authorization, Documentation, and Research/Registry Requirements

Prior Authorization

Prior Authorization Required — InterQual-Based

Prior authorization is required and is based on InterQual® CP clinical criteria for the listed foot and toe procedures. Providers must obtain prior authorization and document how the patient meets the InterQual medical necessity criteria for the requested CPT/Codes.

Affected procedures include (but are not limited to) arthrodesis or arthroplasty of interphalangeal joints, exostectomy (MTP bunionectomy), distal and proximal metatarsal osteotomies, proximal phalanx osteotomy, plantar fascial release, cheilectomy (with or without implant), and other listed CPTs (see Applicable Codes).
Providers should follow the InterQual clinical coverage criteria linked in the policy when submitting prior authorization requests: https://www.uhcprovider.com/content/provider/en/policies-protocols/sec_interqual-clinical-criteria.html

Prior Authorization

Prior Authorization — Demonstrate Criteria Met

When requesting prior authorization for implant arthroplasty (hemi or total) or other covered procedures, the request must explicitly show that all applicable clinical criteria are met. This includes diagnosis, radiographic findings, prior conservative treatment, and treatment rationale.

Clinical Background and Context

Hallux rigidus (stiff great toe) is a degenerative joint condition of the first MTP joint characterized by pain, swelling, osteophyte formation and progressive stiffness. Clinical management depends on disease stage: cheilectomy (debridement and capsular release) can relieve symptoms in early to moderate disease after failure of conservative therapy, while more advanced disease may require arthrodesis or implant arthroplasty. Evidence for osteochondral grafting in the foot is limited, and newer interventions such as synthetic cartilage implants currently require research or governance frameworks to evaluate effectiveness and safety.

Definitions of Arthroplasty and Related Procedures

Hemi-Implant Arthroplasty definition

DefinitionHemi-Implant Arthroplasty: A surgical procedure to replace one side of a joint with a prosthetic implant (partial joint replacement).

ScopeDoes not include Interposition Arthroplasty per the policy definitions (AOFAS, 2025).

SynonymAlso known as partial joint replacement.

Interposition Arthroplasty definition

DefinitionInterposition Arthroplasty: A surgical procedure to remove some damaged bone and place a spacer (e.g., soft tissue graft) between bones to minimize contact — also known as joint resurfacing.

PurposeIntended to preserve motion by placing tissue or material between joint surfaces.

Policy Updates and Material Changes

2025-11-01related_policy_updateLatest

Updated related policy reference link for Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications (for New Mexico Only).

2025-10-01coverage_rationale_modification

Clarified Coverage Rationale to explicitly state that correction of the first MTP joint with cheilectomy, debridement, and capsular release with implant includes 'Hemi-Implant or Total Implant Arthroplasty' as proven and medically necessary when criteria are met.

2025-10-01

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for New Mexico Only)

Policy CodePolicy CS342NM.D

Change TypeCoverage language reviseddefinitions added

Effective DateOct 1, 2025

Next Review DateN/A

SourceLink

On This Page

NICE IPG727 actions required

N/A placeholderNo threshold specified in this section; policy notes use of grading scales elsewhere and references NICE guidance for implants and research governance.

ContextThis field is reserved and not applicable for additional numeric thresholds in the policy's coding thresholds table.

Documentation noteRadiographic grading details are provided elsewhere (see Coughlin and Shurnas or Hattrup and Johnson references).

Document the specific diagnosis (e.g., hallux rigidus or hallux limitus) and side (left/right).
Include radiographic imaging evidence demonstrating disease stage/severity (e.g., Coughlin and Shurnas or Hattrup-Johnson classification when used).
State which InterQual criteria are met and reference the applicable InterQual indications in the prior authorization submission.

Denial Risk

Denial Risk — Insufficient Criteria or Authorization

Lack of documentation that the patient meets InterQual clinical coverage criteria or failure to obtain prior authorization may result in denial of coverage.

If InterQual criteria are not met, the request is at risk for denial.
Failure to provide required imaging, documentation of conservative therapy, or details tying the patient’s presentation to the InterQual criteria may lead to noncoverage.

Step Therapy

Require Prior Reasonable Trial of Conservative Treatment

Prior to surgical correction (with or without implant), a reasonable trial of conservative treatment must be documented. Conservative measures should be tried and documented unless clinically contraindicated or clearly ineffective.

Examples of conservative treatments: orthotics or shoe modification (e.g., high/wide toe box, rocker sole), shoe inserts, NSAIDs or other analgesic therapy, intra-articular injections, activity modification, and debridement of hyperkeratotic lesions when present.
Documentation should include duration and response to each conservative measure and reasons for escalation to surgery.

Documentation Required

Documentation Requirements

Documentation submitted with authorization and claims should include the diagnosis, supporting radiographic imaging and reports, history of symptoms, prior conservative treatments and outcomes, and the specific clinical rationale linking the patient’s condition to the requested procedure.

Include diagnosis code, imaging dates and findings, clinical classification or grading when applicable, and notes describing failed conservative management.
Include operative plan (procedure and implant details if applicable) and any consultation notes supporting the indication.

Note

Research / Registry and Governance Requirements

Use of synthetic cartilage implants or other newer implants may have research, registry, and clinical governance requirements. Procedures recommended by guidance bodies for use only in research or with special governance must follow those requirements; failure to do so may affect coverage determination.

For synthetic cartilage implant insertion for first MTPJ OA (hallux rigidus), follow local clinical governance and registry reporting requirements when used for advanced disease and use in research settings for other patients.
Notify organizational clinical governance leaders and follow any required institutional reporting or registry submission processes (e.g., BOFAS Registry where applicable).
Document rationale for use of the implant, informed consent discussing uncertain efficacy/long-term outcomes, and participation in research or registry when indicated.

Documentation Required

Informed Consent, Patient Education, and Registry Reporting

Providers must obtain and document informed consent and patient education specific to the procedure and implant. When guidance or policy requires registry reporting or use within a research context, document that the patient was informed and that registry or research enrollment steps were taken.

Provide and document printed or electronic educational materials discussed with the patient and family regarding risks, benefits, alternatives, and uncertainties of new implant technologies.
Document that informed consent included discussion of limited evidence, potential risks, and alternative treatments (including arthrodesis).
Record registry enrollment or reporting actions (e.g., BOFAS Registry entry) when applicable, or document why registry participation was not possible.

Note

Research-Preferred Use and Consideration of Alternatives

When considering synthetic cartilage implants or other technologies where evidence is limited, providers should prefer use within research or registry contexts and consider alternative established treatments. Additional high-quality research is recommended to define patient selection and long-term outcomes.

For patients with advanced disease for whom arthrodesis is indicated, synthetic cartilage implant use should follow unique clinical governance, consent, and audit/research provisions.
For other patients, consider use only in approved research protocols or registries until stronger evidence of efficacy and long-term safety is available.

DistinctionConsidered distinct from implant arthroplasty in the policy definitions (AOFAS, 2025).

Total Implant Arthroplasty definition

DefinitionTotal Implant Arthroplasty: A surgical procedure to replace both sides of a joint with prosthetic implants (total joint replacement).

ScopeDoes not include Interposition Arthroplasty per the policy definitions (AOFAS, 2025).

SynonymAlso known as total joint replacement.

Hemi-Implant Arthroplasty (policy addition)

Added definition (policy revision)Hemi-Implant Arthroplasty: An implant procedure replacing part of the first metatarsophalangeal (MTP) joint surface (explicitly added to policy definitions).

Coverage contextPolicy history clarifies that Hemi-Implant Arthroplasty is included in the revised coverage language for cheilectomy with implant (effective 10/01/2025).

ReferenceSee Policy History/Revision Information noting addition of hemi-implant term to definitions and coverage rationale updates.

Total Implant Arthroplasty (policy addition)

Added definition (policy revision)Total Implant Arthroplasty: An implant procedure replacing both articular surfaces of the first MTP joint (explicitly added to policy definitions).

Coverage contextPolicy history indicates Total Implant Arthroplasty is specifically named in the revised coverage rationale for cheilectomy with implant (effective 10/01/2025).

ReferenceSee Policy History/Revision Information for the definition addition and coverage rationale change.

Interposition Arthroplasty (policy addition)

Added definition (policy revision)Interposition Arthroplasty: Surgical procedure placing tissue or material between joint surfaces to preserve motion (added to policy definitions).

DistinctionPolicy notes interposition arthroplasty is separate from hemi- and total implant arthroplasty; definitions section clarifies the distinction.

ReferencePolicy History/Revision Information documents the addition of interposition arthroplasty to definitions (10/01/2025).

Added definitions for Hemi-Implant Arthroplasty, Interposition Arthroplasty, and Total Implant Arthroplasty to the policy definitions section.

2025-10-01supporting_information_updated

Updated Supporting Information section to reflect current clinical evidence and references.