ModifiedUnitedHealthcarePolicy CS342ID.B

Surgery Foot Id Cs

Defines medical necessity criteria and coverage rationale for foot surgeries (including cheilectomy, arthroplasty, arthrodesis, bunion procedures, plantar fascial release, and osteochondral grafting) for UnitedHealthcare members in Idaho (including Idaho Medicaid Plus). References InterQual CP: Procedures for specific operative criteria.

Policy Summary

PayerUnitedHealthcare

PolicySurgery Foot Id Cs

Policy CodePolicy CS342ID.B

Change TypeRevised coverage rationaleclarified implant languageadded InterQual reference

Effective DateMay 1, 2026

Next Review Date

Key ActionEnsure the patient medical record contains legible documentation supporting medical necessity (history, exam, diagnostic tests) and make records available upon request.

SourceLink

POLICY UPDATE CHANGES

Revised language in Coverage Rationale to reference InterQual CP: Procedures and added Osteotomy, Proximal Phalanx, First Toe +/- Bunionectomy to the InterQual references.

Clarified Hallux Rigidus (Correction With Implant) language to explicitly name Hemi-Implant or Total Implant Arthroplasty.

Added Medical Records Documentation Used for Reviews language specifying documentation expectations for medical necessity reviews.

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

Updated Clinical Evidence and References sections to reflect most current information; archived previous version CS342ID.A.

ConditionalCheilectomy without implant - covered for mild-moderate disease

ConditionalCheilectomy with implant - covered for moderate-severe disease

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 Summary

This policy (Idaho-only, Policy Number CS342ID.B, effective May 1, 2026) defines medical necessity criteria for surgery of the foot for UnitedHealthcare members in Idaho (including Idaho Medicaid Plus). It references InterQual CP: Procedures for detailed operative criteria and lists specific procedures covered under those criteria.

Cheilectomy without implant (cheilectomy, debridement, and capsular release of the first MTP joint) is considered medically necessary for mild-to-moderate hallux limitus/rigidus when radiographic grading (e.g., Coughlin & Shurnas or Hattrup & Johnson) confirms mild–moderate disease and conservative treatments have failed. Cheilectomy with implant (Hemi-Implant or Total Implant Arthroplasty) is considered medically necessary for moderate-to-severe hallux rigidus when radiographic confirmation of moderate–severe disease and failed conservative therapy are documented.

Arthrodesis or arthroplasty for advanced disease are included as accepted treatments per the policy and InterQual references; specific InterQual procedure criteria should be consulted for arthrodesis/arthroplasty of interphalangeal joints, bunion procedures, proximal phalanx osteotomy, and plantar fascial release. In contrast, osteochondral allograft or autograft transplantation is described as unproven and not medically necessary due to limited evidence.

For detailed medical necessity clinical coverage criteria for the listed procedures, the policy directs reviewers to InterQual CP: Procedures. Medical record documentation supporting necessity (history, exam, diagnostic tests) must be available upon request.

Key thresholds and quick facts

Radiographic severity gradingMild, Moderate, Severe per Coughlin and Shurnas or Hattrup and Johnson scales (used to determine eligibility: cheilectomy without implant for mild-moderate vs with implant for moderate-severe)

Effective dateMay 1, 2026

Last reviewMay 1, 2026

StatusMODIFIED

Stat: Cheilectomy without implantCovered (conditional) for mild–moderate disease

Stat: Cheilectomy with implantCovered (conditional) for moderate–severe disease

Stat: Osteochondral graftingNot medically necessary — evidence limited to small case series

Medical-Necessity Criteria

Coding

Referenced Procedure CPT 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

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Provider Actions

Documentation Required

Medical record documentation required

Patient medical record must contain documentation supporting medical necessity including relevant history, physical exam, and pertinent diagnostic test results; documentation must be legible, maintained in record, and available upon request.

Relevant medical history
Physical examination findings
Results of pertinent diagnostic tests or procedures
Records must be legible, maintained in the patient's medical record, and made available upon request

Prior Authorization

InterQual criteria reference / Prior Authorization

For detailed medical necessity clinical coverage criteria for listed procedures, refer to InterQual CP: Procedures; use of InterQual may be used by UnitedHealthcare to assist in administering benefits.

Background and Evidence

Evidence summarized in the policy indicates cheilectomy can preserve motion and is appropriate in early/mild hallux limitus/rigidus, while arthrodesis or arthroplasty are treatment options for advanced (moderate–severe) disease. A 2022 systematic review/meta-analysis (de Bot et al.) found comparable outcomes between arthrodesis and metallic hemiarthroplasty, with arthrodesis associated with lower pain scores. Systematic review-level evidence (McNeil et al., 2013) supports arthrodesis (grade B) but found poor evidence (grade C) for many other approaches, including cheilectomy and implant arthroplasty, highlighting the need for higher-quality comparative trials.

The evidence base for osteochondral grafting in the foot is limited: available studies are small case series or case reports with short follow-up and heterogeneous techniques and outcomes. Systematic reviews of these small studies report some improvements in clinical scores but conclude the data are insufficient to demonstrate efficacy or to compare grafting with established treatments.

Evidence Type	Summary
Systematic review/meta-analysis	de Bot et al. (2022) — compared arthrodesis vs metallic hemiarthroplasty; outcomes and complication rates comparable; arthrodesis associated with lower pain; limited RCTs and mostly short- to mid-term follow-up.
Systematic review (level III)	McNeil et al. (2013) — reviewed 135 studies; fair evidence (grade B) supporting arthrodesis; poor evidence (grade C) for cheilectomy, osteotomy, implant arthroplasty, resection and interpositional arthroplasty; insufficient high-quality comparative data.
NICE guidance (IPG727, 2022)	Recommends synthetic cartilage implant insertion only with governance/audit or in research; safety data limited and effectiveness evidence restricted in quantity and quality.
Systematic review of case series / case reports	Evidence for osteochondral grafts limited to small case series and case reports (e.g., Artioli et al., 2023; Diniz et al., 2019); improvements reported in some outcomes but numbers small and long-term data lacking; insufficient evidence for efficacy.

Hemi-Implant Arthroplasty: A surgical procedure to replace one side of a joint with a prosthetic implant (partial joint replacement). Does not include Interposition Arthroplasty (AOFAS, 2025).

Interposition Arthroplasty: A surgical procedure removing damaged bone and placing a spacer (e.g., soft tissue graft) between two bones to minimize contact; also known as joint resurfacing (AOFAS, 2025).

Total Implant Arthroplasty: A surgical procedure to replace both sides of a joint with prosthetic implants (total joint replacement). Does not include Interposition Arthroplasty (AOFAS, 2025).

Revision History

Policy History 05/01/2026revisedLatest

Revised language in Coverage Rationale to reference InterQual CP: Procedures and added Osteotomy, Proximal Phalanx, First Toe +/- Bunionectomy to the InterQual references; replaced phrasing to explicitly name implant types (Hemi-Implant or Total Implant Arthroplasty) in Hallux Rigidus (Correction With Implant) section.

Policy History 05/01/2026added

Added Medical Records Documentation Used for Reviews language specifying documentation expectations for medical necessity reviews (medical history, physical exam, pertinent diagnostic test results; legible, maintained, and available upon request).