28291
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
7.81
Facility
$442.90
Non-Facility
$670.36
Documentation Required
- "Medical records documentation may be required to assess whether the member meets the clinical criteria for coverage but does not guarantee coverage of the service requested; refer to the protocol titled Medical Records Documentation Used for Reviews."
- Radiographic imaging confirming pathology severity (mild-to-moderate for cheilectomy without implant; moderate-to-severe for cheilectomy with implant). Example grading scales: Coughlin and Shurnas or Hattrup and Johnson Classification.
- Documentation of persistent pain despite a reasonable trial of conservative treatment, including one or more of: orthotics/shoe modification/shoe inserts; medical therapy (NSAIDs, analgesics, or intra-articular injections); activity modification.
- Documentation of debridement of hyperkeratotic lesions, if present (noted as part of clinical criteria when applicable).
Key Coverage Criteria
- - "Debridement of hyperkeratotic lesions, if present"
- - "Orthotics, shoe modification (e.g., high and wide toe box, rocker bottom sole), and/or shoe inserts"
- Surgery of the foot is proven and medically necessary in certain circumstances. For medical necessity clinical coverage criteria, refer to the InterQual® CP: Procedures:
- - "Medical therapy (NSAIDs, analgesics, or intra-articular injections)"
- InterQual® CP: Arthrodesis or Arthroplasty, Interphalangeal Joint, Second-Fifth Toes (refer to InterQual criteria for medical necessity)
- InterQual® CP: Exostectomy, First Metatarsophalangeal (MTP) Joint (Bunionectomy) (refer to InterQual criteria for medical necessity)
7 Active Policies
CARELON-small-joint-surgery-2025-11-15 — General Requirements and Documentation
UHC-POL-surgery-foot — Surgery of the Foot
UMR-POL-UMR-surgery-foot — Surgery of the Foot
SUREST-POL-SUREST-surgery-foot — Surgery of the Foot
CIGNA-0446 — Metatarsophalangeal Joint Replacement - (0446)
Related Codes
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