ModifiedUnitedHealthcarePolicy CS342.L

Surgery of the Foot

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This UnitedHealthcare Community Plan medical policy governs coverage of selected surgical procedures for conditions of the foot, including hallux limitus or rigidus, bunions, hammertoes, and plantar fasciitis. It describes medical-necessity requirements, procedures considered unproven or not medically necessary, documentation expectations, and applicable procedure codes.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot

Policy CodePolicy CS342.L

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionBefore covered hallux limitus or rigidus correction, document persistent pain despite a reasonable trial of conservative treatment.

SourceLink

POLICY UPDATE CHANGES

Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is identified as unproven and not medically necessary for limitations in motion or degenerative changes.

The policy's definition of interposition or interpositional arthroplasty was updated.

The Description of Services, Clinical Evidence, and References sections were updated to reflect current information.

6InterQual procedure-specific criteria referenced

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ModifiedUnitedHealthcarePolicy CS342.L

Surgery of the Foot

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Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot

Policy CodePolicy CS342.L

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionBefore covered hallux limitus or rigidus correction, document persistent pain despite a reasonable trial of conservative treatment.

SourceLink

POLICY UPDATE CHANGES

The policy's definition of interposition or interpositional arthroplasty was updated.

The Description of Services, Clinical Evidence, and References sections were updated to reflect current information.

6InterQual procedure-specific criteria referenced

4Procedures identified as unproven or not medically necessary

10Applicable procedure codes listed

2Hallux rigidus correction approaches with explicit criteria

Covered and Non-Covered Foot Procedures

InterQual-covered foot procedures

Surgery of the foot is proven and medically necessary in certain circumstances when the applicable InterQual clinical coverage criteria are met.

Applicable InterQual procedure criteria: Meet the applicable InterQual CP: Procedures criteria for arthrodesis or arthroplasty of the interphalangeal joint of the second through fifth toes; first metatarsophalangeal joint exostectomy or bunionectomy; distal transpositional first metatarsal osteotomy; proximal first metatarsal osteotomy; proximal phalanx osteotomy of the first toe with or without bunionectomy; or plantar fascial release.

Refer to the applicable InterQual criteria.

Hallux limitus or rigidus without implant

Covered when all of the following are met.

Hallux limitus or rigidus correction without implant

Procedure: Correction of the first metatarsophalangeal joint with cheilectomy, debridement, and capsular release without implant.
Diagnosis and imaging: Diagnosis of hallux limitus or hallux rigidus with radiographic imaging confirming mild to moderate pathology.Mild to moderate
A grading scale such as the Coughlin and Shurnas or Hattrup and Johnson Classification may be used.
ONE OR MORE conservative treatments
- Orthotics, shoe modification, such as a high and wide toe box or rocker bottom sole, and/or shoe inserts.
- Medical therapy, including nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections.
- Activity modification.
- Debridement of hyperkeratotic lesions, if present.
Symptoms: Persistent pain despite a reasonable trial of conservative treatment.Persistent pain after reasonable conservative treatment trial

Hallux rigidus with implant

Covered when all of the following are met.

Hallux rigidus correction with implant

Procedure: Correction of the first metatarsophalangeal joint with cheilectomy, debridement, and capsular release with a hemi-implant arthroplasty or total implant arthroplasty.
Diagnosis and imaging: Diagnosis of hallux rigidus with radiographic imaging confirming moderate to severe pathology.Moderate to severe
A grading scale such as the Coughlin and Shurnas or Hattrup and Johnson Classification may be used.
ONE OR MORE conservative treatments
- Orthotics, shoe modification, such as a high and wide toe box or rocker bottom sole, and/or shoe inserts.

Severe hallux rigidus without implant

Not medically necessary and unproven.

Severe hallux rigidus without implant: Correction of the first metatarsophalangeal joint with cheilectomy, debridement, and capsular release without implant for severe hallux rigidus.Severe hallux rigidus

A grading scale such as the Coughlin and Shurnas or Hattrup and Johnson Classification may be used. The procedure is unproven and not medically necessary due to insufficient evidence of efficacy.

Interposition/interpositional arthroplasty

Not medically necessary and unproven.

Interposition arthroplasty: Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, for treating limitations in motion or degenerative changes.

Unproven and not medically necessary due to insufficient evidence of efficacy.

Osteochondral allograft or autograft transplant

Not medically necessary and unproven.

Osteochondral transplant: Osteochondral allograft or autograft transplant for treating cartilage defects of the foot.

Unproven and not medically necessary due to insufficient evidence of efficacy.

First or second MTP interposition arthroplasty

Not medically necessary and unproven.

First or second MTP interposition arthroplasty: Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, for treating limitations in motion or degenerative changes.

Unproven and not medically necessary because evidence of efficacy is insufficient. Applies to either the first or second metatarsophalangeal joint and any method.

Cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint without an implant is excluded as medically necessary when treating severe hallux rigidus.

Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint is excluded for treatment of limitations in motion or degenerative changes, regardless of the method used.

Osteochondral allograft or autograft transplantation is excluded as medically necessary for treating cartilage defects of the foot.

Correction of severe hallux rigidus with cheilectomy, debridement, and capsular release without an implant is unproven and not medically necessary because of insufficient evidence of efficacy.

Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint is unproven and not medically necessary for treating limitations in motion or degenerative changes.

Osteochondral allograft or autograft transplantation is unproven and not medically necessary for treating cartilage defects of the foot because of insufficient evidence of efficacy.

Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is unproven and not medically necessary for treating limitations in motion or degenerative changes because evidence of efficacy is insufficient.

Applicable Procedure Codes and Severity Coding

Applicable 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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Hallux Limitus or Rigidus Without Implant

Applicable CPT code28289 — Hallux rigidus correction with cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint; without implant.

Radiographic criterionImaging must confirm mild to moderate pathology.

Clinical coverage requirementPersistent pain must remain despite a reasonable trial of conservative treatment, such as orthotics or shoe modification, medical therapy, activity modification, or debridement of hyperkeratotic lesions when present.

Hallux Rigidus With Implant

Applicable CPT code28291 — Hallux rigidus correction with cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint; with implant.

Radiographic criterion

Documentation and Medical-Necessity Requirements

Note

Use Applicable InterQual Criteria

For medical-necessity clinical coverage criteria, refer to the applicable InterQual^® CP: Procedures criteria before requesting surgery of the foot.

Arthrodesis or Arthroplasty, Interphalangeal Joint, Second-Fifth Toes
Exostectomy, First Metatarsophalangeal (MTP) Joint (Bunionectomy)
Osteotomy, Distal Transpositional, First Metatarsal (MT) (Bunionectomy)
Osteotomy, Proximal, First Metatarsal (MT) (Bunionectomy)
Osteotomy, Proximal Phalanx, First Toe ± Bunionectomy
Plantar Fascial Release
Access the InterQual criteria through the UnitedHealthcare provider clinical criteria resource.

Documentation Required

Document Conservative Treatment and Persistent Pain

Before covered correction of hallux limitus or rigidus, document persistent pain despite a reasonable trial of conservative treatment. This requirement applies to correction without an implant and correction with a hemi-implant or total implant arthroplasty.

Clinical Background

Hallux rigidus causes pain and stiffness at the first metatarsophalangeal joint. It may progress from hallux limitus, characterized by partial restriction of motion, to end-stage rigidity. Cheilectomy may preserve motion in early or mild disease, while arthrodesis or arthroplasty may be used for more advanced disease; conservative measures are generally attempted before surgery.

Arthroplasty Terminology

Hemi-Implant Arthroplasty

ProcedureA surgical procedure to replace one side of a joint with a prosthetic implant.

Also known asPartial joint replacement.

DistinctionIt does not include interposition arthroplasty.

Interposition/Interpositional Arthroplasty

ProcedureA surgical procedure that removes some damaged bone and places a spacer between two bones to minimize contact on either side of the joint.

Spacer materialsThe spacer may be derived from the individual, a donor, or a graft made from animal or synthetic materials.

Distinction

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot

Policy CodePolicy CS342.L

Change TypeModified

Effective DateOctober 1, 2026

Next Review DateN/A

Key ActionBefore covered hallux limitus or rigidus correction, document persistent pain despite a reasonable trial of conservative treatment.

SourceLink

On This Page

Medical therapy, including nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections.

Activity modification.

Debridement of hyperkeratotic lesions, if present.

Symptoms: Persistent pain despite a reasonable trial of conservative treatment.Persistent pain after reasonable conservative treatment trial

Imaging must confirm moderate to severe pathology.

Eligible implant approachesThe correction may use hemi-implant arthroplasty or total implant arthroplasty.

Hattrup and Johnson / Coughlin and Shurnas Severity

MildNo radiographic evidence of osteoarthritis; clinical finding is no pain with or without mild stiffness. Hattrup and Johnson: mild; Coughlin and Shurnas: grade 1.

ModerateModerate osteophyte formation with joint-space narrowing and subchondral sclerosis; clinical findings include moderate to severe pain constant at the extremes of motion and moderate to severe stiffness. Hattrup and Johnson: moderate; Coughlin and Shurnas: grade 2.

SevereMarked osteophyte formation with loss of joint space and cystic changes, with or without subchondral changes; clinical findings include nearly constant pain or pain throughout the range of motion, including midrange. Hattrup and Johnson: severe; Coughlin and Shurnas: grade 3 or 4.

Conservative treatment may include orthotics, shoe modification (such as a high and wide toe box or rocker-bottom sole), and/or shoe inserts.
Other options include medical therapy with nonsteroidal anti-inflammatory drugs, analgesics, or intra-articular injections; activity modification; and debridement of hyperkeratotic lesions, if present.

Documentation Required

Hallux Correction Supporting Records

Support the requested hallux correction with records establishing the diagnosis, radiographic severity, persistent pain, and failure of conservative treatment. The severity documented should match the procedure requested.

For correction without an implant, document hallux limitus or hallux rigidus with radiographic imaging confirming mild to moderate pathology.
For correction with an implant, document hallux rigidus with radiographic imaging confirming moderate to severe pathology.
A grading scale such as the Coughlin and Shurnas or Hattrup and Johnson Classification may be used.
Include the duration and nature of persistent pain, the reasonable conservative-treatment trial, and the patient's response or inadequate relief.

Documentation Required

Medical Records for Review

Medical records documentation may be required to assess whether the member meets the applicable clinical criteria for coverage. Records support review but do not guarantee coverage; benefit determination remains subject to federal, state, contractual, and other applicable legal requirements.

Submit the medical records and other documentation needed to evaluate the requested service under the applicable clinical coverage criteria.
Refer to the UnitedHealthcare guidelines titled Medical Records Documentation Used for Reviews.

Denial Risk

Severe Hallux Rigidus Without Implant

Correction of the first metatarsophalangeal joint with cheilectomy, debridement, and capsular release without an implant is unproven and not medically necessary when treating severe hallux rigidus because of insufficient evidence of efficacy.

Severe hallux rigidus may be identified using a grading scale such as the Coughlin and Shurnas or Hattrup and Johnson Classification.

Denial Risk

Interposition Arthroplasty

Interposition or interpositional arthroplasty of the first or second metatarsophalangeal joint, using any method, is unproven and not medically necessary for limitations in motion or degenerative changes because of insufficient evidence of efficacy.

Flag first- or second-MTP interposition/interpositional arthroplasty for potential denial as unproven and not medically necessary.

Denial Risk

Osteochondral Transplantation

Osteochondral allograft or autograft transplantation is unproven and not medically necessary for treating cartilage defects of the foot because of insufficient evidence of efficacy.

Flag both allograft and autograft osteochondral transplantation for foot cartilage defects for potential denial.

Denial Risk

Evidence-Based Denial Risk: Interposition Arthroplasty

First- or second-MTP interposition/interpositional arthroplasty by any method carries an evidence-based denial risk because the policy finds insufficient evidence of efficacy. Do not represent this service as medically necessary under this policy for limitations in motion or degenerative changes.

Review the requested procedure and supporting documentation carefully; the policy classifies this intervention as unproven and not medically necessary.

The procedure does not replace the joint itself.

Total Implant Arthroplasty

ProcedureA surgical procedure to replace both sides of a joint with prosthetic implants.

Also known asTotal joint replacement.

DistinctionIt does not include interposition arthroplasty.