Shoes and Foot Orthotics: CA – UnitedHealthcare West Benefit Interpretation Policy

Shoes and Foot Orthotics

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UnitedHealthcare West Benefit Interpretation Policy

Effective 04/01/2024

UnitedHealthcare

West

Benefit Interpretation Policy

Shoes and Foot Orthotics

Policy Number: BIP167.N

Effective Date: April 1, 2024



Instructions for Use

Table of Contents Page

Federal/State Mandated Regulations .......................................... 1

State Market Plan Enhancements ................................................ 1

Covered Benefits ........................................................................... 1

Not Covered ................................................................................... 2

Definitions ...................................................................................... 3

References ..................................................................................... 3

Policy History/Revision Information ............................................. 3

Instructions for Use ....................................................................... 3

Federal/State Mandated Regulations

California Health and Safety Code 1367.19

http://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC&sectionNum=1367.19.

On and after January 1, 1991, every health care service plan, except a specialized health care service plan, that covers hospital,

medical, or surgical expenses on a group basis shall offer coverage as an option for special footwear needed by persons who

suffer from foot disfigurement under such terms and conditions as may be agreed upon between the group contract holder and

the plan.

As used in this section, foot disfigurement shall include, but not be limited to, disfigurement from cerebral palsy, arthritis, polio,

spina bifida, diabetes, and foot disfigurement caused by accident or developmental disability.

State Market Plan Enhancements

Foot Orthotics/Footwear: Coverage for specialized footwear for foot disfigurement may be available if the subscriber’s

employer purchased a footwear supplemental benefit. If your health plan includes a footwear supplemental benefit, a brochure

describing it will be enclosed with these materials.

Covered Benefits

Important Note: Covered benefits are listed in

Federal/State Mandated Regulations

State Market Plan

Enhancements

, and

Covered Benefits

sections. Always refer to the

Federal/State Mandated Regulations

and

State Market Plan

Enhancements

sections for additional covered services/benefits not listed in this section.

Refer to the member's Evidence of Coverage (EOC)/Schedule of Benefit (SOB) for additional information.

Shoes and foot orthotics are covered in the following scenarios (CMS 2003):

Prosthetic shoe when used as a structural device to replace all of a foot or when a large portion of the member's forefoot

(front part) is missing.

Orthopedic shoe is covered when it is permanently attached to a medically necessary orthopedic brace.

Related Benefit Interpretation Policies

• Diabetic Management, Services and Supplies

• Durable Medical Equipment (DME), Prosthetics,

Corrective Appliances/Orthotics (Non-Foot

Orthotics) and Medical Supplies

• Durable Medical Equipment (DME), Prosthetics,

Corrective Appliances/ Orthotics (Non-Foot

Orthotics) and Medical Supplies Grid

• Foot Care and Podiatry Services

UnitedHealthcare of California (HMO)

UnitedHealthcare Benefits Plan of California (EPO/POS)

Shoes and Foot Orthotics

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UnitedHealthcare West Benefit Interpretation Policy

Effective 04/01/2024

Therapeutic Shoe

o One pair of Depth or one pair of Custom-Molded therapeutic Shoes per calendar year for members diagnosed with

diabetes:

 The shoes must be prescribed, fitted and furnished by a podiatrist or other qualified individual (e.g., a pedorthist,

orthotist or prosthetist);

 The shoes must meet this policy’s definition for Depth or Custom-Molded Shoes (refer to the

Definitions

section);

 The managing physician, who is responsible for diagnosing and treating the member’s systemic condition, must

do all the following:

Document in the medical record that the member has diabetes;

Certify that the member is being treated under a comprehensive plan of care for his/her diabetes;

Certify that the member needs therapeutic shoes;

Document in the member’s record that the member has one or more of the following conditions:

Peripheral neuropathy with the evidence of callus formation

History of previous ulceration

History of pre-ulcerative calluses

Foot deformity

Previous amputation of the foot of part of the foot

Poor circulation

Notes:

o A pair of therapeutic shoes is covered even if only one foot suffers from diabetic foot disease (each shoe is equally

equipped so that the affected limb, as well as the remaining limb, is protected).

o Specialized footwear, including Foot Orthotics and custom-made or standard orthopedic shoes, is only covered for

members with diabetic foot disease or when an orthopedic shoe is permanently attached to a medically necessary

orthopedic brace.

o Inserts

 The member must have the appropriate footwear to accommodate the Insert.

 Limitations:

Three (pairs) Inserts per calendar year for Custom-Molded Shoes (including Inserts provided with the shoes);

Four (pairs) Inserts per calendar year for depth shoes (including the non-customized removable Inserts

provided with the shoes).

o Modifications of Custom-Molded or Depth Shoes (e.g., wedges, offset heels, Velcro closures, Inserts for missing toes,

etc.) instead of obtaining a pair of Inserts in any combination.

Replacements, repairs and adjustments to foot orthotics are covered when medically necessary and authorized by the

member's network medical group or UnitedHealthcare.

For each individual, coverage of the footwear and inserts is limited to one of the following within one calendar year:

o No more than one (1) pair of custom-molded shoes (which includes inserts provided with the shoes) and two (2)

additional pairs of inserts

o No more than one (1) pair of depth shoes and three (3) pairs of inserts (not including the non-customized removal

inserts provided with such shoes)

o Inserts

o Substitution of modifications for Inserts

Refer to the Benefit Interpretation Policies titled Foot Care and Podiatry Services,

Durable Medical Equipment (DME),

Prosthetics, Corrective Appliances/Orthotics (Non-Foot Orthotics) and Medical Supplies Grid, and Diabetic Management,

Services and Supplies

Not Covered

Foot Orthotics are not a covered benefit unless the member meets the above diabetic foot disease criteria or as required by

state mandates or market plan enhancement (refer to the

Federal/State Mandated Regulations

State Market Plan

Enhancements

, and

Covered Benefits

sections),

Therapeutic shoes except as described above in the

Covered Benefits

section.

Shoes and Foot Orthotics

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UnitedHealthcare West Benefit Interpretation Policy

Effective 04/01/2024

Orthopedic shoes or other supportive devices for the feet except as described above in the

Covered Benefits

section.

Orthopedic shoes for subluxations of the foot.

Supportive devices for the feet other than described above in the

Covered Benefits

section.

Definitions

Custom-Molded Shoes: Shoes that are constructed over a positive model of the member’s foot; made from leather or other

suitable material of equal quality, have removable inserts that can be altered or replaced as the member’s condition warrants;

and have some form of shoe closure.

Depth Shoes: Shoes that have a full-length heel-to-toe filler that, when removed, provides a minimum of 3/16 inch of additional

depth used to accommodate custom molded or customized inserts, are made of leather or other suitable material of equal

quality, have some form of foot closure, and are available in full and half sizes with a minimum of three widths so that the sole is

graded to the size and width of the upper portions of the shoes according to the American standard last sizing schedule (the

numerical shoe sizing system used for shoes sold in the United States).

Inserts: Total contact, multiple density, removable inlays that are directly molded to the member’s foot or a model of the

member’s foot or directly carved from a member-specific, rectified electronic model and that are made of suitable material with

regard to the member’s condition.

References

Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services, § 290 Foot Care; Revised; Available

at Medicare Benefit Policy Manual, Chapter 15, §290 – Foot Care

. Accessed January 2024.

DME MAC LCDs for Orthopedic Footwear (L33641). Accessed January 2024.

Medicare Benefit Policy Manual, Chapter 15, §140 - Therapeutic Shoes for Individuals with Diabetes. Accessed January 2024.

Policy History/Revision Information

Date

Summary of Changes

04/01/2024

Definitions

Removed definition of:

o Prosthetic Shoe

o Therapeutic Shoe

Updated definition of “Depth Shoes”

Supporting Information

Updated

References

section to reflect the most current information

Archived previous policy version BIP167.M

Instructions for Use

Covered benefits are listed in three (3) sections:

Federal/State Mandated Regulations

State Market Plan

Enhancements

, and

Covered Benefits

. All services must be medically necessary. Each benefit plan contains its own specific provisions for coverage,

limitations, and exclusions as stated in the member’s Evidence of Coverage (EOC)/Schedule of Benefits (SOB). If there is a

discrepancy between this policy and the member’s EOC/SOB, the member’s EOC/SOB provision will govern.