Orthotics protect, restore or improve function of moveable parts of the body with orthopedic appliances or apparatus. Orthotic appliances or apparatus support, align, prevent or correct deformities.
Indications and Limitations of Coverage
Prosthetic shoes (L3250) are covered if they are an integral part of a prosthesis for patients with a partial foot amputation (diagnosis codes 755.31, 755.38, 755.39, 895.0-896.3). Claims for prosthetic shoes for other diagnosis codes will be denied as not medically necessary. Effective January 26, 2009, a provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement, in the form of a Pre-Service Denial Notice, should be maintained in the provider's records.
Shoes, inserts, and modifications are covered in limited circumstances. They are covered in selected patients with diabetes for the prevention or treatment of diabetic foot ulcers. However, different codes (A5500-A5511) are used for footwear provided under this benefit. See CareFirst Medicare Advantage Medical Policy Bulletin O-17 on Therapeutic Shoes for Diabetics for details.
Shoes are also covered if they are an integral part of a covered leg brace described by codes L1900, L1920, L1980-L2030, L2050, L2060, L2080, or L2090. Oxford shoes (L3224, L3225) are covered in these situations. Other shoes, e.g. high top, depth inlay or custom for non-diabetics, etc. (L3649), are also covered if they are an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace.
Heel replacements (L3455, L3460), sole replacements (L3530, L3540), and shoe transfers (L3600-L3640) involving shoes on a covered brace are also covered. Inserts and other shoe modifications (L3000-L3170, L3300-L3450, L3465-L3520, L3550-L3595) are covered if they are on a shoe that is an integral part of a covered brace and if they are medically necessary for the proper functioning of the brace.
Reasons for Noncoverage
Shoes and related modifications, inserts, heel/sole replacements or shoe transfers billed without a KX modifier will be denied as noncovered because coverage is statutorily excluded.
According to a national policy determination, a shoe and related modifications, inserts, and heel/sole replacements, are covered only when the shoe is an integral part of a brace. A matching shoe which is not attached to a brace and items related to that shoe must not be billed with a KX modifier and will be denied as noncovered because coverage is statutorily excluded. The provider can bill the member.
Shoes which are incorporated into a brace must be billed by the same supplier billing for the brace. Shoes which are billed separately (i.e., not as part of a brace) will be denied as noncovered. A KX modifier must not be used in this situation. The provider can bill the member.
Shoes are denied as noncovered when they are put on over a partial foot prosthesis or other lower extremity prosthesis (L5010-L5600) which is attached to the residual limb by other mechanisms because there is no benefit for these items. The provider can bill the member.
A foot pressure off-loading/supportive device (A9283) is denied as noncovered because there is no benefit category for these items. The provider can bill the member.
With the exception of the situations described above, orthopedic footwear billed using codes L3000-L3649 will be denied as noncovered. The provider can bill the member.
An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected procedure code.
An order is not required for a heel or sole replacement or transfer of a shoe to a brace.
When billing for a shoe that is an integral part of a leg brace or for related modifications, inserts, heel/sole replacements or shoe transfer, a KX modifier must be added to the code. If the shoe or related item is not an integral part of a leg brace, the KX modifier must not be used.
When billing for prosthetic shoes (L3250) and related items, a diagnosis code (specific to the 5th digit), describing the condition which necessitates the prosthetic shoes, must be included on each claim for the prosthetic shoes and related items.
When code L3649 with a KX modifier is billed, the claim must include a narrative description of the item provided as well as a brief statement of the medical necessity for the item. This must be entered in the narrative field of an electronic claim.
Oxford shoes that are an integral part of a brace are billed using codes L3224 or L3225 with a KX modifier. For these codes, one unit of service is each shoe. Oxford shoes that are not part of a leg brace must be billed with codes L3215 or L3219 without a KX modifier.
Other shoes (e.g., high top, depth inlay or custom shoes for non-diabetics, etc.) that are an integral part of a brace are billed using code L3649 with a KX modifier. Other shoes that are not an integral part of a brace must be billed using codes L3216, L3217, L3221, L3222, L3230, L3251-L3253, or L3649 without a KX modifier.
Depth-inlay or custom molded shoes for diabetics (A5500-A5501) and related inserts and modifications (A5503-A5511) are billed using these A codes whether or not the shoe is an integral part of a brace. (See CareFirst Medicare Advantage Medical Policy Bulletin O-17 on Therapeutic Shoes for Diabetics for coverage, documentation, and additional coding guidelines.)
Code A9283 (Foot pressure off-loading/supportive device) is used for an item that is designed primarily to reduce pressure on the sole or heel of the foot but that does not meet the definition of:
It may be a shoe-like item, an item that is used inside a shoe and may or may not extend outside the shoe, or an item that is attached to a shoe. It may be prefabricated or custom fabricated.
Code L3250 may be used only for a shoe that is custom fabricated from a model of a patient and has a removable custom fabricated insert designed for toe or distal partial foot amputation. The shoe serves to hold the insert on the leg. Code L3250 must not be used for a shoe that is put on other types of leg prostheses (L5010-L5600) that are attached to the residual limb by other mechanisms.
The right (RT) and left (LT) modifiers must be used with footwear codes. When bilateral items are provided on the same date of service, bill both on the same claim line using the LTRT modifier and 2 units of service.
This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Medicare Advantage plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Medicare Advantage retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Medicare Advantage. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.