Surgery of the Foot (for Kentucky Only)
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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.
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.
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:
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.
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
| 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. |
| No codes listed |
Provider Requirements, Authorization, and Documentation
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
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
- UnitedHealthcare reserves the right to modify policies; current InterQual criteria are used at the time of review
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
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
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
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
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
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
Policy Revision History
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.
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