CurrentUnitedHealthcarePolicy CS342PA.I

Surgery of the Foot (for Pennsylvania Only)

UnitedHealthcare medical policy (Pennsylvania only) defining medical necessity criteria for foot surgical procedures (including hallux limitus/rigidus cheilectomy with/without implant, osteotomies, bunionectomy, plantar fascial release) and stating certain procedures (osteochondral grafts) are unproven/not medically necessary. InterQual criteria referenced for many procedures.

Policy Summary

PayerUnitedHealthcare

PolicySurgery of the Foot (for Pennsylvania Only)

Policy CodePolicy CS342PA.I

Change TypeRevised coverage rationaledefinitions addedreferences updated

Effective DateOct 1, 2025

Next Review Date

Key ActionProviders must document radiographic imaging confirming severity and a reasonable trial of conservative treatments to support medical necessity for cheilectomy with or without implant.

SourceLink

POLICY UPDATE CHANGES

Updated Coverage Rationale language to explicitly state cheilectomy with implant (Hemi-Implant or Total Implant Arthroplasty) is proven and medically necessary when criteria are met.

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

Added/updated related policy reference links for Extracorporeal Shock Wave Therapy (ESWT) (Pennsylvania).

Updated Clinical Evidence and References sections to reflect current information.

2Hallux procedures with explicit covered criteria (without vs with implant)

1Procedures specified as unproven/not medically necessary (osteochondral grafts)

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Coverage Summary

This UnitedHealthcare (Pennsylvania-only) medical policy CS342PA.I addresses Surgery of the Foot and defines medical necessity criteria for procedures treating hallux limitus/rigidus and other forefoot conditions. The policy covers cheilectomy (with or without implant), osteotomies, bunionectomy, and plantar fascial release when InterQual-specified clinical criteria are met. It states that cheilectomy with implant (including Hemi-Implant or Total Implant Arthroplasty) is proven and medically necessary when the listed criteria are satisfied, while osteochondral allograft/autograft transplantation is considered unproven and not medically necessary due to insufficient evidence. The policy applies only in Pennsylvania and will be evaluated per state exceptions when requests do not meet the stated criteria.

Policy level details

Effective date2025-10-01

Last review2025-11-01

Policy numberCS342PA.I

Scope summaryUnitedHealthcare medical policy (Pennsylvania only) defining medical necessity criteria for foot surgical procedures (including hallux limitus/rigidus cheilectomy with/without implant, osteotomies, bunionectomy, plantar fascial release) and stating certain procedures (osteochondral grafts) are unproven/not medically necessary. InterQual criteria referenced for many procedures.

Coverage stancemixed — surgery of the foot is proven and medically necessary in certain circumstances; osteochondral grafts are unproven/not medically necessary

Radiographic severity grading thresholdUse Coughlin and Shurnas or Hattrup and Johnson scales to classify mild, moderate, or severe (policy references grade examples: 0–4)

Medical-Necessity Criteria

General Coverage Rationale

Surgery of the foot is proven and medically necessary in certain circumstances. For specific medical necessity clinical coverage criteria, refer to the InterQual CP Procedures for listed surgeries.

ANY of the following

Arthrodesis or Arthroplasty, Interphalangeal Joint, Second-Fifth Toes (see InterQual criteria)
Exostectomy, First Metatarsophalangeal (MTP) Joint (Bunionectomy) (see InterQual criteria)
Osteotomy, Distal Transpositional, First Metatarsal (MT) (Bunionectomy) (see InterQual criteria)
Osteotomy, Proximal, First Metatarsal (MT) (Bunionectomy) (see InterQual criteria)

Coding

Applicable CPT procedure 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 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

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Provider Actions

Documentation Required

Document imaging and conservative therapy

Providers must document radiographic imaging confirming severity (mild/moderate/severe per referenced scales) and a reasonable trial of conservative treatments (orthotics/shoe modification, medical therapy, activity modification, debridement if present) to support medical necessity for cheilectomy with or without implant.

Radiographic imaging confirming severity using a grading scale such as Coughlin and Shurnas or Hattrup and Johnson (classify mild, moderate, or severe).
Trial of orthotics or shoe modification (e.g., high and wide toe box, rocker bottom sole) and/or shoe inserts.
Trial of medical therapy (NSAIDs, analgesics, or intra-articular injections).
Activity modification.
Debridement of hyperkeratotic lesions if present.

Prior Authorization

Pennsylvania-specific policy application and exceptions

Background & Evidence

Background: Hallux rigidus (stiff great toe) commonly arises from degenerative joint disease and causes pain, swelling, osteophyte formation, and limited motion; surgery is indicated when conservative measures fail. Cheilectomy (removal of dorsal osteophytes and resection to restore range of motion) is used for early/mild disease and can be combined with osteotomy; advanced or moderate-to-severe disease may require arthrodesis or implant arthroplasty.

Indications and rationale: Cheilectomy without implant is proven and medically necessary for mild to moderate hallux limitus/rigidus when radiographic imaging (e.g., Coughlin and Shurnas or Hattrup and Johnson grading) confirms severity and persistent pain follows a reasonable trial of conservative therapy (orthotics/shoe modification, NSAIDs or injections, activity modification, and debridement of hyperkeratotic lesions if present). Cheilectomy without implant is not medically necessary for severe hallux rigidus due to insufficient evidence. Cheilectomy with implant (specified as Hemi-Implant or Total Implant Arthroplasty) is proven and medically necessary for moderate to severe hallux rigidus when similar imaging and conservative-treatment criteria are met.

Evidence summary and guidance: Systematic reviews and meta-analyses have compared arthrodesis, metallic hemiarthroplasty, and implant arthroplasty with mixed results—arthrodesis may provide greater pain reduction while implant arthroplasty preserves motion; overall evidence is limited by study quality and follow-up. Multiple reviews note insufficient high-quality RCTs to definitively rank procedures, and severity grading using Hattrup & Johnson or Coughlin & Shurnas is commonly used to classify mild, moderate, or severe disease.

Osteochondral grafting: Osteochondral allograft or autograft transplantation for cartilage defects of the foot is considered unproven and not medically necessary because evidence is limited to small case series with heterogeneous techniques and outcomes; larger comparative studies with longer follow-up are needed.

Policy implementation notes: For detailed medical necessity determinations for listed procedures (arthrodesis/arthroplasty, exostectomy/bunionectomy, various osteotomies, and plantar fascial release), the policy references InterQual CP: Procedures criteria. In addition, NICE guidance (IPG727, 2022) on synthetic cartilage implants recommends limited or research-context use with governance, audit, and reporting requirements.

Definitions

Term	Definition
Hemi-Implant Arthroplasty	A surgical procedure to replace one side of a joint with a prosthetic implant; also known as partial joint replacement. This does not include Interposition Arthroplasty.
Interposition Arthroplasty	A surgical procedure to remove some damaged bone and place a spacer (e.g., soft tissue graft) between two bones to minimize contact on either side of the joint; also known as joint resurfacing.
Total Implant Arthroplasty	A surgical procedure to replace both sides of a joint with prosthetic implants; also known as total joint replacement. This does not include Interposition Arthroplasty.

Revision History

2025-10-01material

Revised Coverage Rationale language: explicitly state cheilectomy with implant (Hemi-Implant or Total Implant Arthroplasty) is proven and medically necessary when criteria are met.

2025-11-01non-materialLatest

Added definitions for Hemi-Implant Arthroplasty, Interposition Arthroplasty, and Total Implant Arthroplasty to clarify surgical procedure types.

2025-11-01