ModifiedUnitedHealthcarePolicy CS342KY.11

Surgery of the Foot (for Kentucky Only)

This policy governs medical necessity and coverage considerations for surgical procedures of the foot for UnitedHealthcare members in Kentucky, including procedures for hallux rigidus and related interventions. It applies to providers performing foot surgery within Kentucky.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for Kentucky Only)

Policy CodePolicy CS342KY.11

Change TypeMaterial revisions and added definitions

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument radiographic confirmation of moderate to severe hallux rigidus and a trial of conservative therapies when requesting coverage for implant procedures.

SourceLink

POLICY UPDATE CHANGES

Added reference link to the Medical Policy titled Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds (for Kentucky Only).

Replaced language to specify 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.

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

Updated Clinical Evidence and References sections to reflect current information and archived previous policy version CS342KY.10.

Kentuckypolicy application state

InterQualInterQual referenced

Multiplecovered CPT codes listed

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.

multiplereferences updated/added

1policy versions archived

Coverage and Medical Necessity Criteria

Hallux rigidus — cheilectomy with implant (medical necessity)

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:

Hallux rigidus implant coverage criteria: Diagnosis of hallux rigidus.

Radiographic confirmation: Radiographic imaging confirming moderate to severe pathology (e.g., Coughlin and Shurnas or Hattrup and Johnson grading).radiographic moderate to severe

Conservative therapy failure: Persistent pain despite a reasonable trial of conservative treatment including: 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; and debridement of hyperkeratotic lesions if present.

Implant types: Intended procedure is cheilectomy, debridement, and capsular release with implant — either Hemi‑Implant Arthroplasty or Total Implant Arthroplasty.

Implant arthroplasty covered only when all required elements above are present

Hallux Rigidus (Correction With Implant)

Correction of the first metatarsophalangeal (MTP) joint with implant is considered proven and medically necessary when ALL listed criteria in the full policy are met.

Hallux Rigidus Implant 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 of the listed criteria are met in the policy.

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 and retrospective cohorts with heterogeneous techniques and limited long-term follow-up, which is insufficient to demonstrate effectiveness for improving health outcomes.

Note: FDA approval or clearance of a device is provided for informational purposes only. FDA approval alone is not a basis for coverage; surgeries of the foot are procedural and not regulated by the FDA, and device approval does not, by itself, establish that a procedure is medically necessary.

Restatement: Osteochondral allograft or autograft transplantation is not medically necessary for treating cartilage defects of the foot. The evidence base—small, mostly level IV studies and case series—does not support conclusions about clinical benefit compared with established treatments such as arthrodesis or arthroplasty.

Additional guidance: When evaluating coverage requests, do not rely solely on the FDA status of an implant or instrument. Device approval is insufficient by itself to determine coverage or medical necessity; clinical effectiveness and the body of evidence for the specific surgical indication must be considered.

Applicable Procedure Codes and Coding Notes

Applicable 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.

1–10 of 11

1/2

FDA informational (devices/instruments)mixed

No codes listed

Use of InterQual — guidance to apply InterQual medical/surgical criteria when available (compact)

GuidanceApply InterQual medical/surgical criteria when available for prior authorization and medical necessity determinations.

If InterQual not applicableUse UnitedHealthcare Medical Policies, Coverage Determination Guidelines, or Utilization Review Guidelines approved by the Kentucky Department for Medicaid Services.

AuthorityWhen federal, state, or contractual benefit plan requirements conflict with this policy, those requirements govern.

PurposeInterQual is used as the primary source for medical/surgical criteria; other referenced tools (e.g., ASAM) apply to their specialties.

Provider Requirements, Authorization, and Documentation

Prior Authorization

Prior Authorization / InterQual Requirement

Prior authorization may be required. UnitedHealthcare uses InterQual® as the primary source of medical/surgical criteria for authorization decisions. Providers should follow the applicable InterQual criteria for foot procedures (see list of InterQual CP: Procedures) when submitting requests.

InterQual® criteria apply to arthrodesis, arthroplasty, cheilectomy, exostectomy, osteotomy, plantar fascial release, and other listed foot procedures
Prior authorization decisions are based on InterQual® criteria and applicable benefit plan or contractual requirements

Prior Authorization

Authorization Requirement

Authorization decisions must meet InterQual® clinical coverage criteria and also comply with federal, state, or contractual benefit plan requirements. In the event of any conflict between this Medical Policy and federal, state, or contractual requirements, those requirements govern coverage decisions.

Check member-specific benefit plan, state, or federal requirements before requesting authorization

Clinical Background

Hallux rigidus is a degenerative arthritis of the first metatarsophalangeal (MTP) joint characterized by pain, dorsal osteophyte formation, and progressive loss of joint motion. Symptoms commonly include pain with dorsiflexion, stiffness of the great toe, and functional limitations. Surgical rationale varies by disease stage: cheilectomy (removal of dorsal osteophytes and debridement) can restore motion and relieve impingement in early disease, while more advanced pathology may require implant arthroplasty or arthrodesis to address pain and structural degeneration.

Definitions

Hemi-Implant Arthroplasty definition — partial joint replacement

DefinitionHemi-Implant Arthroplasty: Replacement of one side of a joint with a prosthetic implant (partial joint replacement).

ScopeDoes not include interposition arthroplasty.

SourceAmerican Orthopaedic Foot & Ankle Society (AOFAS) definition cited in policy definitions.

Interposition Arthroplasty definition — spacer/joint resurfacing

DefinitionInterposition Arthroplasty: Removal of some damaged bone and placement of a spacer (eg, soft tissue graft) between two bones to minimize contact; also called joint resurfacing.

PurposeUsed to minimize contact on either side of the joint by placing a spacer.

Policy Revision History

2026-05-01policy_revisionLatest

Added reference link to the Kentucky-only ESWT medical policy; clarified implant types by specifying Hemi‑Implant and Total Implant Arthroplasty for hallux rigidus implant coverage; added definitions for Hemi‑Implant Arthroplasty, Interposition Arthroplasty, and Total Implant Arthroplasty; updated clinical evidence and references; archived prior version CS342KY.10.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for Kentucky Only)

Policy CodePolicy CS342KY.11

Change TypeMaterial revisions and added definitions

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionDocument radiographic confirmation of moderate to severe hallux rigidus and a trial of conservative therapies when requesting coverage for implant procedures.

SourceLink

On This Page

UnitedHealthcare reserves the right to modify policies; current InterQual criteria are used at the time of review

Denial Risk

InterQual Adherence Required

Procedures may be denied if the InterQual® clinical coverage criteria are not met. Providers should ensure documentation submitted with authorization requests demonstrates that InterQual criteria are satisfied for the specific procedure (for example, distinguishing arthrodesis versus implant eligibility).

Nonconformance with InterQual® criteria is a potential basis for denial
Clearly document the clinical rationale that aligns with the InterQual criteria for the requested procedure

Documentation Required

Decision and Documentation Guidance

When deciding coverage, reference and document any applicable federal, state, or contractual benefit plan requirements because those requirements govern in the event of a conflict with this Medical Policy. Provide complete clinical records and imaging to support medical necessity determinations.

Provide member-specific benefit verification and cite any state or contractual mandates affecting coverage
Submit clinical notes, operative reports (if applicable), and relevant imaging with the authorization request

Documentation Required

Conservative Therapy Requirements Before Implant

For hallux rigidus procedures involving implant (hemi-implant or total implant arthroplasty), document a trial of conservative therapy before implant placement. The record should show persistent symptoms despite these conservative measures.

Document radiographic confirmation of moderate to severe pathology (e.g., Coughlin and Shurnas or Hattrup/Johnson grading)
Conservative treatments documented as tried and failed: orthotics or shoe modification, medical therapy (NSAIDs/analgesics or injections), activity modification, and debridement of hyperkeratotic lesions when present

Step Therapy

No explicit step therapy procedures are specified in this section of the policy. Providers should not assume step therapy requirements beyond the conservative therapy documentation described for hallux rigidus implants; check member-specific plan documents for any plan-level step-therapy rules.

This policy does not define additional step therapy steps
Verify any plan-specific step therapy or prior authorization programs separately

Documentation Required

Required Clinical Documentation for Hallux Rigidus Procedures

Document diagnosis and radiographic imaging confirming moderate to severe disease when requesting authorization for hallux rigidus procedures. Use an accepted grading system (for example, Coughlin and Shurnas or Hattrup/Johnson) in the clinical documentation to support medical necessity for implant procedures.

Include imaging reports and classification/grading in the submission
Reference the applicable CPT code(s) corresponding to the requested procedure

Note

FDA Informational Note for Providers

FDA approval of a device is informational only and does not by itself determine coverage. Surgeries are procedures (not FDA-regulated), though devices used may have FDA considerations—search FDA resources as needed.

FDA approval alone is not a basis for coverage decisions
Devices used in surgery may have FDA clearance; this does not replace InterQual or benefit plan requirements

SourceAOFAS definition as recorded in the policy's Definitions section.

Total Implant Arthroplasty definition — total joint replacement

DefinitionTotal Implant Arthroplasty: Replacement of both sides of a joint with prosthetic implants (total joint replacement).

ScopeDoes not include interposition arthroplasty.

SourceAOFAS definition as recorded in the policy's Definitions section.

Hemi‑Implant Arthroplasty (added definition)

Policy updateAdds explicit definition wording for Hemi‑Implant Arthroplasty to the policy Definitions section: replacement of one side of a joint with a prosthetic implant (partial joint replacement).

ContextClarifies implant types (Hemi‑Implant and Total Implant Arthroplasty) in Coverage Rationale for hallux rigidus with implant.

Effective dateChange recorded in Policy History on 05/01/2026.

Interposition Arthroplasty (added definition)

Policy updateAdds explicit definition wording for Interposition Arthroplasty to the policy Definitions section: removal of damaged bone and placement of a spacer (eg, soft tissue graft) between two bones to minimize contact (joint resurfacing).

ContextIncluded in the revised Definitions and referenced in Coverage Rationale updates.

Effective dateChange recorded in Policy History on 05/01/2026.

Total Implant Arthroplasty (added definition)

Policy updateAdds explicit definition wording for Total Implant Arthroplasty to the policy Definitions section: replacement of both sides of a joint with prosthetic implants (total joint replacement).

ContextDefinition clarifies that Total Implant Arthroplasty is distinct from interposition arthroplasty in the policy.

Effective dateChange recorded in Policy History on 05/01/2026.