ModifiedUnitedHealthcarePolicy CS343KS.02

Surgery of the Foot (for Kansas Only)

Clinical coverage guidance for surgical procedures of the foot (including hallux rigidus treatments and osteochondral grafting) applicable to UnitedHealthcare Community Plan members in Kansas.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for Kansas Only)

Policy CodePolicy CS343KS.02

Change TypeMaterial revision — clarifies implant arthroplasty and aligns with InterQual

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization using InterQual procedural criteria and document trials of conservative therapy before implant arthroplasty.

SourceLink

POLICY UPDATE CHANGES

Replaced language to explicitly 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.

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

Added a related policy link to Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Wounds (for Kansas Only).

InterQualInterQual referenced

NMNOsteochondral grafts NMN

3New definitions 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.

Procedure codes listed

Coverage Criteria

Hallux rigidus (implant arthroplasty) coverage

Covered when ALL of the following are met:

Hallux rigidus implant criteria: Diagnosis of hallux rigidus with severity classified (e.g., Shurnas or Hattrup/Johnson/Coughlin and Shurnas classifications).

Severity classification as referenced in policy.

Conservative management: Documented trial and failure of conservative measures including orthotics and shoe modification (for example, high/wide toe box or rocker sole) and/or shoe inserts; activity modification; and a reasonable trial of medical therapy (NSAIDs, analgesics, or intra‑articular injections).

Conservative measures must be tried and documented prior to implant arthroplasty.

Local measures: Debridement of hyperkeratotic lesions when present has been performed if applicable.

Included as part of required conservative care when indicated.

Procedure selection: Planned surgical correction of the first metatarsophalangeal (MTP) joint with cheilectomy, debridement, and capsular release with implant (Hemi‑Implant or Total Implant Arthroplasty).

Implant type must be Hemi‑Implant or Total Implant Arthroplasty as specified in policy.

InterQual-guided procedures

Covered when InterQual CP procedural criteria are met:

InterQual-referenced procedures: Procedures such as cheilectomy (first MTP joint), arthrodesis or arthroplasty of interphalangeal joints (toes 2–5), exostectomy (bunionectomy), proximal and distal first metatarsal osteotomies, and related listed foot surgeries are subject to the InterQual CP: Procedures criteria for determination of medical necessity.per InterQual

Providers must follow and document InterQual procedural criteria when seeking coverage.

Osteochondral allograft/autograft — Not medically necessary

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

Policy cites limited, low‑quality evidence and small case series as the basis for noncoverage.

Implant arthroplasty (Hemi-Implant or Total Implant) - Medical Necessity

Correction of the first MTP joint with cheilectomy, debridement, capsular release with implant (Hemi‑Implant or Total Implant Arthroplasty) is proven and medically necessary when ALL listed criteria are met:

Primary coverage condition: Patient meets applicable InterQual CP procedural criteria for first MTP joint correction and the clinical criteria below are satisfied.per InterQual

Policy language was revised to explicitly include Hemi‑Implant and Total Implant Arthroplasty and to align with InterQual pathways.

Severity classification: Documentation of hallux rigidus severity using an accepted classification (for example, Shurnas or Hattrup/Johnson/Coughlin and Shurnas).

Severity should be recorded in the clinical documentation.

Failure of nonoperative care: Documented failure of conservative management including orthotics/shoe modification/shoe inserts, activity modification, and a reasonable trial of medical therapy (NSAIDs, analgesics, or intra‑articular injections).

Osteochondral allograft or autograft transplantation for treating cartilage defects of the foot is considered unproven and not medically necessary. The policy cites insufficient and low-quality evidence—predominantly small case series and retrospective reports with heterogeneous techniques and limited follow-up—so these procedures do not meet the plan’s standards for coverage.

This information is provided for reference only: FDA approval alone is not a basis for coverage. Foot surgeries themselves are not regulated by the FDA, although devices and instruments used during surgery may require FDA approval. Coverage decisions are based on the policy’s clinical criteria and evidence, not solely on regulatory status.

The available clinical evidence is insufficient to support the use of osteochondral grafting (allograft or autograft) for cartilage defects of the foot. Published studies are small and mostly level IV case series, with inconsistent outcomes and limited long-term data, so the treatment effect on meaningful health outcomes remains unproven and the procedure is therefore not medically necessary.

Policy language has been revised to clarify covered implant procedures. Prior wording that implied cheilectomy, debridement, and capsular release with implant were proven and medically necessary has been replaced to explicitly specify implant types: correction of the first MTP joint with cheilectomy, debridement, and capsular release with implant is now described as Hemi-Implant or Total Implant Arthroplasty and is considered proven and medically necessary only when all listed clinical criteria are met.

Coding

Applicable Procedure CodesCPT

28285	Correction, hammertoe 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 resection of proximal phalanx base, any method
28295	Correction, hallux valgus with bunionectomy; with proximal metatarsal osteotomy, any method
28296	Correction, hallux valgus with bunionectomy; with distal metatarsal osteotomy, any method
28297	Correction, hallux valgus with bunionectomy; with first metatarsal and medial cuneiform joint arthrodesis, any method
28298	Correction, hallux valgus with bunionectomy; with proximal phalanx osteotomy, any method
28299	Correction, hallux valgus with bunionectomy; with double osteotomy, any method
28899	Unlisted procedure, foot or toes

1–10 of 11

1/2

FDA note (devices/instruments)mixed

No codes listed

Provider Actions / Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests for procedures referenced to InterQual (see Coverage Rationale) must be submitted for review and will be evaluated against the applicable InterQual procedural criteria for medical necessity.

All requests for first MTP joint correction with implant (hemi-implant or total implant arthroplasty) require prior authorization and review against InterQual procedural criteria.
Include specific InterQual chapter/line items used in the review when available.

Documentation Required

InterQual Criteria Required

Documentation demonstrating how the patient meets InterQual medical necessity criteria must be provided with the authorization request. Failure to meet InterQual procedural criteria may result in denial of coverage.

State which InterQual criteria (name and version) the request is being evaluated against.

Background

Hallux rigidus (the stiff great toe) is a degenerative joint disease of the first metatarsophalangeal (MTP) joint characterized by pain, swelling, osteophyte formation, and limited range of motion. Early disease may be treated with cheilectomy to remove osteophytes and preserve motion, while more advanced disease can require arthrodesis or implant arthroplasty. Clinical severity should be documented (for example using Shurnas or Hattrup/Johnson classifications) and conservative measures tried before considering implant procedures.

Definitions

Hemi-Implant Arthroplasty — definition

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

ScopeAlso known as partial joint replacement; does not include interposition arthroplasty per AOFAS (2025).

Policy insertionNewly added to the policy definitions to describe partial implant replacement of the first metatarsophalangeal (MTP) joint when criteria are met.

Interposition Arthroplasty — definition

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

ScopeUsed as an alternative resurfacing technique; distinguished from implant arthroplasty in AOFAS (2025).

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for Kansas Only)

Policy CodePolicy CS343KS.02

Change TypeMaterial revision — clarifies implant arthroplasty and aligns with InterQual

Effective DateOct 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization using InterQual procedural criteria and document trials of conservative therapy before implant arthroplasty.

SourceLink

On This Page

Nonoperative care must be attempted and documented prior to implant arthroplasty.

Local debridement when indicated: Debridement of hyperkeratotic lesions has been performed when present and appropriate.

Included among required prior treatments when clinically indicated.

Surgical plan: Planned correction includes cheilectomy, debridement, and capsular release with implant — specifically a Hemi‑Implant or Total Implant Arthroplasty of the first MTP joint.

Procedure and implant type must match policy definitions and InterQual criteria.

If InterQual lacks applicable criteria, reference applicable UnitedHealthcare Medical Policy language and state/federal/contractual requirements.

Billing Rule

Benefit Contract Compliance

Coverage determinations must comply with the member's federal, state, and contractual benefit requirements. In the event of conflict between this medical policy and a benefit contract or law, the federal, state, or contractual requirements govern.

Verify benefit plan terms, state mandates, and any applicable federal requirements prior to authorization decision.
Document any contract-specific limitations or exclusions in the request.

Documentation Required

Clinical Documentation to Support Medical Necessity

Provide complete clinical documentation to support medical necessity. Include diagnosis, severity/classification, prior treatments, and objective findings.

Diagnosis and severity using accepted classifications (e.g., Shurnas, Hattrup-Johnson, Coughlin-Shurnas) when applicable.
Relevant imaging reports (e.g., radiographs) and physical exam findings documenting pain, range of motion, and functional limitation.
Operative reports for prior foot procedures, if applicable.

Documentation Required

Clinical Criteria Documentation

When requesting coverage, explicitly document how the patient meets each InterQual criterion being used for the review (clinical criteria documentation).

Map each required InterQual element to the patient's chart (e.g., duration of symptoms, prior conservative measures tried, imaging findings).
If conservative therapy elements are not met, provide rationale and supporting clinical evidence.

Step Therapy

Conservative Therapy Required Before Implant

Conservative therapy is required prior to implant procedures for hallux rigidus unless contraindicated. Submit documentation of a reasonable trial of nonoperative management.

Orthotics and shoe modification (e.g., high/wide toe box, rocker sole) and/or shoe inserts.
Medical therapy: NSAIDs, analgesics, and/or intra-articular injections.
Activity modification and debridement of hyperkeratotic lesions when present.
Duration and response to each conservative measure tried.

Policy insertionAdded in policy definitions as an alternative surgical technique for first MTP joint reconstruction.

Total Implant Arthroplasty — definition

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

ScopeAlso known as total joint replacement; does not include interposition arthroplasty per AOFAS (2025).

Policy insertionAdded to policy definitions to describe total implant replacement of the first MTP joint when criteria are met.

Hemi-Implant Arthroplasty (policy)

Policy definitionHemi-Implant Arthroplasty for first MTP joint: partial implant replacement of one side of the first metatarsophalangeal joint used as a treatment option when the policy's medical necessity criteria are satisfied.

ContextInserted to clarify that correction of the first MTP joint with implant may be performed as a hemi-implant procedure, and is covered when all listed criteria (including InterQual procedural criteria) are met.

Relation to other techniquesDistinguished from interposition arthroplasty (joint resurfacing) in policy definitions.

Total Implant Arthroplasty (policy)

Policy definitionTotal Implant Arthroplasty for first MTP joint: replacement of both articular surfaces of the first metatarsophalangeal joint with prosthetic implants, considered a covered surgical option when all policy medical necessity criteria and InterQual procedural criteria are met.

ContextAdded to explicitly name total implant arthroplasty as a covered implant option in the revised coverage rationale.

DistinctionSpecified separately from hemi-implant and interposition techniques in the policy definitions.

Interposition Arthroplasty (policy)

Policy definitionInterposition Arthroplasty for first MTP joint: surgical removal of damaged bone surfaces with placement of a spacer (e.g., soft tissue graft) between bones to resurface the joint; identified in the policy as an alternative reconstructive technique.

ContextAdded to policy definitions to clarify alternative to hemi- and total implant arthroplasty for first MTP joint reconstruction.

Clinical noteTerm used to denote joint resurfacing procedures and explicitly distinguished from implant arthroplasty in the policy text and AOFAS definition.