DraftUnitedHealthcarePolicy CS342.K

Surgery of the Foot (Hallux Rigidus / Related Podiatric Procedures) — Coverage Criteria

Defines medical necessity and coverage considerations for surgical procedures of the foot (e.g., cheilectomy, arthrodesis, implant arthroplasty, osteotomies, plantar fascial release) for UnitedHealthcare Community Plan members; affects providers requesting authorization or documentation for these foot surgeries.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (Coverage Criteria) — Hallux rigidus/limitus management

Policy CodePolicy CS342.K

Change TypeRevised definitionsclarified implant coverage

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionFollow InterQual clinical coverage criteria and submit required documentation for prior authorization of listed foot surgeries.

SourceLink

POLICY UPDATE CHANGES

Coverage Rationale updated to state that 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.

Definitions were added for Hemi-Implant Arthroplasty, Interposition Arthroplasty, and Total Implant Arthroplasty.

Related policy link to Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds was added.

~20procedure codes included for reference

InterQualexternal clinical coverage criteria source

3definitions added

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.

1archived prior policy version

Coverage Criteria

InterQual referenced procedures

Covered when InterQual clinical coverage criteria for the listed procedures are met.

InterQual-based coverage: Coverage of listed foot surgeries (for example: exostectomy of the first MTP joint, arthrodesis or arthroplasty of interphalangeal joints, distal and proximal osteotomies of the first metatarsal/phalanx, and plantar fascial release) requires meeting InterQual Procedures clinical coverage criteria referenced in this policy.

See InterQual Procedures for procedure-specific medical necessity items and documentation requirements.

Cheilectomy without implant — Hallux limitus/rigidus (Covered)

Covered when ALL of the following are met:

Cheilectomy without implant criteria: Diagnosis of hallux limitus or hallux rigidus; use of an accepted severity classification (e.g., Shurnas or Hattrup and Johnson) as appropriate; persistent pain despite a reasonable trial of conservative treatment including orthotics or shoe modification (for example, high/wide toe box or rocker-bottom sole), activity modification, and medical therapy (NSAIDs, analgesics, or intra‑articular injections); debridement of hyperkeratotic lesions if present.

Cheilectomy without implant is proven and medically necessary when all criteria are met but is considered unproven and not medically necessary for severe hallux rigidus.

Cheilectomy with implant / Implant arthroplasty — Hallux rigidus (Covered)

Covered when ALL of the following are met:

Cheilectomy with implant criteria: Diagnosis of hallux rigidus; persistent pain despite a reasonable trial of conservative treatment including one or more of: orthotics/shoe modification (eg, high and wide toe box; rocker bottom sole) or shoe inserts, activity modification, and medical therapy (NSAIDs, analgesics, or intra‑articular injections); radiographic imaging confirming moderate to severe pathology (a grading scale such as Coughlin and Shurnas or Hattrup and Johnson may be used); debridement of hyperkeratotic lesions if present.

Implant arthroplasty (hemi‑implant or total implant) is proven and medically necessary when all criteria are met.

Osteochondral allograft/autograft transplantation (Not medically necessary)

Osteochondral grafts: Osteochondral allograft or autograft transplantation for cartilage defects of the foot is unproven and not medically necessary due to insufficient and low‑quality evidence (predominantly small case series, heterogeneous techniques, and limited long‑term follow‑up).

Further high‑level comparative studies with larger patient numbers and longer follow‑up are needed.

Hallux Rigidus (Correction With Implant)

Covered when ALL of the following are met

Coverage statement: 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 of the listed criteria are met.

See the policy sections for the full list of required criteria (diagnosis, conservative therapy trial, radiographic confirmation, and other items).

Osteochondral allograft or autograft transplantation for cartilage defects of the foot is considered unproven and not medically necessary. The available evidence consists primarily of small case series with heterogeneity and limited follow‑up, which is insufficient to demonstrate clinical efficacy for these indications. Further high‑quality comparative studies with adequate follow‑up are needed to support coverage.

FDA approval alone is not a basis for coverage. Surgeries of the foot are clinical procedures and are not regulated by the FDA; however, devices and instruments used during the surgery may require FDA approval. Device clearance or approval should be verified separately, but does not, by itself, establish medical necessity for the surgical procedure.

Cheilectomy with debridement and capsular release performed without an implant is considered unproven and not medically necessary for severe hallux rigidus. While cheilectomy may be appropriate for less severe hallux limitus/rigidus after a reasonable trial of conservative therapy (orthotics, shoe modification, activity modification, medical therapy, and debridement of hyperkeratotic lesions if present), the evidence does not support its efficacy in severe disease.

Coding / Procedure Codes

Applicable procedure CPTs (reference list)CPT

28285
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.

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Provider Actions & Authorization

Prior Authorization

Prior Authorization / Medical Necessity Review

InterQual-based prior authorization — Certain foot surgeries listed (see InterQual Procedures referenced) and the CPTs enumerated are subject to medical necessity review.

See InterQual Procedures referenced in Coverage Rationale for specific procedures
Prior authorization may be required for listed foot surgeries

Documentation Required

Conservative Therapy Requirements

Conservative therapy prerequisite — Conservative therapy requirements (e.g., orthotics, shoe modification, activity modification, medical therapy such as NSAIDs/analgesics or other listed measures) should be documented and met where specified in the medical necessity criteria.

Orthotics and shoe modification (high/wide toe box, rocker bottom sole) when indicated
Medical therapy: NSAIDs, analgesics, intra-articular injections as appropriate

Background

Hallux rigidus (stiff great toe) is degenerative arthritis of the first metatarsophalangeal (MTP) joint that produces pain, stiffness, and progressive functional limitation. Clinical features frequently include reduced range of motion and dorsal osteophyte formation. Management ranges from conservative measures (orthotics, shoe modification, activity modification, analgesics or intra‑articular injections) for early disease to surgical options — such as cheilectomy to preserve motion in milder cases and arthrodesis or implant arthroplasty for more advanced disease. Evidence comparing procedures is limited and higher‑quality randomized studies with longer follow‑up are needed.

Definitions

Hemi-Implant Arthroplasty — definition (policy)

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 (AOFAS, 2025)

Policy noteAdded to policy definitions on 10/01/2025 to clarify implant inclusion in coverage rationale.

Interposition Arthroplasty — definition (policy)

DefinitionA surgical procedure to remove damaged bone and place a spacer (e.g., soft tissue graft) between two bones to minimize contact; also called joint resurfacing.

PurposeTo reduce bone-on-bone contact and preserve joint motion by interposing a spacer between joint surfaces (AOFAS, 2025).

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (Coverage Criteria) — Hallux rigidus/limitus management

Policy CodePolicy CS342.K

Change TypeRevised definitionsclarified implant coverage

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionFollow InterQual clinical coverage criteria and submit required documentation for prior authorization of listed foot surgeries.

SourceLink

On This Page

Activity modification and debridement of hyperkeratotic lesions if present

Documentation Required

Medical Records & Documentation

Medical records documentation — Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage. Lack of required documentation may lead to denial because benefit coverage is determined by federal, state, or contractual rules.

Refer to the 'Medical Records Documentation Used for Reviews' guideline
Documentation should support diagnosis, conservative therapy trials, imaging, and functional impact

Note

FDA Approval Information

FDA approval note — FDA approval alone is not a basis for coverage. Surgeries of the foot are procedures and therefore not regulated by the FDA; however, devices and instruments used during surgery may require FDA approval.

FDA approval of a device does not guarantee coverage of the procedure using that device
Verify device regulatory status when applicable

Note

Policy Use & Verification

Policy applicability and verification — Use this Medical Policy to assist in interpreting standard benefit plan coverage; verify federal, state, or contractual benefit requirements which may differ and govern in the event of a conflict.

Before using this policy, check the applicable federal, state, or contractual benefit requirements
UnitedHealthcare may use third-party tools (e.g., InterQual) to assist in administering benefits

Note

(Provider-action) Check federal/state/contractual benefit requirements before using this policy.

Policy noteDefinition added to the policy on 10/01/2025.

Total Implant Arthroplasty — definition (policy)

DefinitionA surgical procedure to replace both sides of a joint with prosthetic implants (total joint replacement). Does not include interposition arthroplasty.

Also known asTotal joint replacement (AOFAS, 2025)

Policy noteDefinition added to the policy on 10/01/2025 to support coverage language clarifying hemi and total implants.

Hemi-Implant Arthroplasty — definition added in policy (update)

What changedThe policy explicitly added definitions for Hemi-Implant Arthroplasty, clarifying inclusion of hemi-implant in coverage rationale.

Effective date10/01/2025

ReasonTo clarify that hemi-implant arthroplasty is explicitly included in the proven and medically necessary coverage statement for correction of the first MTP joint with implant when criteria are met.

Interposition Arthroplasty — definition added in policy (update)

What changedInterposition Arthroplasty definition was added to the policy definitions list.

Effective date10/01/2025

PurposeProvide explicit definition for interposition (joint resurfacing) to support interpretation of coverage criteria and procedural distinctions.

Total Implant Arthroplasty — definition added in policy (update)

What changedTotal Implant Arthroplasty definition was added to the policy definitions list.

Effective date10/01/2025

ReasonTo clarify that total implant arthroplasty (total joint replacement) is explicitly referenced in the coverage rationale alongside hemi-implant procedures.