CurrentUnitedHealthcarePolicy CS342OH.F

Surgery of the Foot (for Ohio Only)

UnitedHealthcare medical policy (Ohio only) defining medical necessity criteria and coverage stance for selected foot surgeries (including hallux rigidus correction with implant, cheilectomy, bunionectomies, plantar fascial release) and stating osteochondral allograft/autograft transplantation is unproven and not medically necessary.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for Ohio Only)

Policy CodePolicy CS342OH.F

Change TypeRevised languagedefinitions addedreferences updated

Effective DateOct 1, 2025

Next Review Date

Key ActionDocument and apply InterQual CP: Procedures medical necessity criteria when determining coverage for listed foot surgeries.

SourceLink

POLICY UPDATE CHANGES

Modified Coverage Rationale language to explicitly name Hemi-Implant and Total Implant Arthroplasty for hallux rigidus correction with implant.

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

Updated related policy reference link for Extracorporeal Shock Wave Therapy (ESWT) for Musculoskeletal Conditions and Soft Tissue Indications (Ohio only).

Updated Clinical Evidence and References sections to reflect current literature.

1Not Medically Necessary Procedures (osteochondral grafts)

1Procedures requiring InterQual criteria

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Coverage Summary

UnitedHealthcare Ohio-only medical policy CS342OH.F provides a mixed coverage stance for selected foot surgeries. Many listed procedures are covered when InterQual CP: Procedures medical necessity criteria are met, while correction of hallux rigidus with implant (explicitly named as Hemi-Implant or Total Implant Arthroplasty) is covered when specific diagnostic, radiographic, and conservative-treatment criteria are met. Osteochondral allograft or autograft transplantation is stated as unproven and not medically necessary for foot cartilage defects due to insufficient evidence. Effective date: October 1, 2025. Last review date: January 1, 2026.

Surface thresholds and scope

Radiographic gradingModerate to severe pathology as defined by Coughlin and Shurnas or Hattrup and Johnson classifications (e.g., Coughlin/Shurnas 2-4; Hattrup and Johnson II-III)

Geographic scopeOhio only

Primary criteria sourceInterQual CP: Procedures

Medical-Necessity Criteria

General Proven and Medically Necessary Procedures (when InterQual criteria met)

Covered when InterQual CP: Procedures medical necessity criteria are met for the listed procedures:

ALL of the following

ONE OF
- Arthrodesis or Arthroplasty, Interphalangeal Joint, Second-Fifth Toes (CPT 28285 referenced)
- Cheilectomy, First Metatarsophalangeal (MTP) Joint (CPT 28289 referenced)
- Exostectomy, First MTP Joint (Bunionectomy) (CPTs 28292-28299 referenced)
- Osteotomy, Distal Transpositional, First Metatarsal (MT) (Bunionectomy) (CPT 28296 referenced)

Coding

Listed Relevant Procedure CPT Codes (reference only)CPT

28285	Correction, hammertoe (e.g., interphalangeal fusion, partial or total phalangectomy)
28289	Hallux rigidus correction with cheilectomy, debridement and capsular release of the first MTP joint; without implant
28291	Hallux rigidus correction with cheilectomy, debridement and capsular release of the first MTP 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

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Provider Actions

Documentation Required

Use InterQual criteria for medical necessity

When determining coverage for the listed foot surgeries, document and apply the InterQual CP: Procedures medical necessity criteria referenced in the policy. Include citation of the InterQual criteria link in the patient record or prior authorization submission as applicable.

InterQual CP: Procedures referenced in policy (link noted in source)

Documentation Required

Document failed conservative therapy for hallux rigidus with implant

For hallux rigidus correction with implant (Hemi-Implant or Total Implant Arthroplasty, CPT 28291), document: radiographic confirmation of moderate-to-severe disease using an accepted grading scale (e.g., Coughlin & Shurnas or Hattrup & Johnson) and persistent pain after a reasonable trial of conservative measures. Conservative measures to document trial of include orthotics or shoe modification (high/wide toe box, rocker sole) or shoe inserts, medical therapy (NSAIDs, analgesics, or intra‑articular injections), activity modification, and debridement of hyperkeratotic lesions if present.

Affected code: 28291
Required documentation: radiographic grading (Coughlin & Shurnas or Hattrup & Johnson), and documented trials of orthotics/shoe modification, medical therapy, activity modification, and debridement if present

Background and Evidence

This policy applies only in the state of Ohio and uses InterQual CP: Procedures as the primary medical/surgical criteria source for determining medical necessity for the listed foot surgeries.

Surgery of the foot is described as proven and medically necessary in certain circumstances; the policy lists specific procedures (for example, interphalangeal arthrodesis/arthroplasty, cheilectomy, bunionectomy/exostectomy, various osteotomies, and plantar fascial release) that require application of the InterQual criteria to establish coverage.

For hallux rigidus correction with implant, the policy explicitly names Hemi-Implant or Total Implant Arthroplasty (cheilectomy, debridement, and capsular release with implant) and requires radiographic confirmation of moderate-to-severe disease plus failed conservative therapies for coverage.

The policy states that osteochondral allograft or autograft transplantation for foot cartilage defects is unproven and not medically necessary because the available evidence is insufficient.

Definitions in the policy distinguish implant terminology, clarifying that Hemi-Implant Arthroplasty and Total Implant Arthroplasty replace joint surfaces with prosthetic implants and that Interposition Arthroplasty (joint resurfacing using a spacer) is a distinct procedure and is excluded from the implant definitions.

Evidence Type	Key Finding
Systematic review/meta-analysis (de Bot et al., 2022)	Compared arthrodesis to metallic hemiarthroplasty for end‑stage hallux rigidus: clinical outcomes, complication rates, and revisions were comparable; arthrodesis had the lowest pain scores; authors noted limited RCTs and mainly short‑to‑mid‑term follow‑up.
Systematic review (small case series) (Artioli et al., 2023)	Surgical management of osteochondral lesions of the first metatarsal head based on small case series (n=90 overall); osteochondral autograft most used; improvements reported in AOFAS and VAS but small samples and heterogeneity limit conclusions—insufficient evidence for definitive recommendations.
NICE interventional guidance (IPG727, 2022)	For synthetic cartilage implant insertion for first MTPJ OA (hallux rigidus): short‑term safety shows no major concerns but evidence on effectiveness is limited in quantity and quality; recommend use only with clinical governance, consent, audit or research (advanced disease for whom arthrodesis is unsuitable) and otherwise in the research context.

Definitions

Hemi-Implant Arthroplasty: A surgical procedure to replace one side of a joint with a prosthetic implant (partial joint replacement). This definition explicitly does not include Interposition Arthroplasty.

Interposition Arthroplasty: A surgical procedure that removes damaged bone and places a spacer (for example, a soft tissue graft) between bones to minimize contact; also known as joint resurfacing.

Total Implant Arthroplasty: A surgical procedure to replace both sides of a joint with prosthetic implants (total joint replacement). This definition explicitly does not include Interposition Arthroplasty.

Revision History

2025-10-01revised

Coverage Rationale language for Hallux Rigidus (Correction With Implant) modified to explicitly name '(Hemi-Implant or Total Implant Arthroplasty)' when describing cheilectomy, debridement, and capsular release with implant as proven and medically necessary.

2025-10-01added

Definitions added for Hemi-Implant Arthroplasty, Interposition Arthroplasty, and Total Implant Arthroplasty to clarify implant terminology and distinguish interposition arthroplasty.

2026-01-01clarified