Does 28295 require prior authorization?

No, 28295 does not require prior authorization (high confidence). Code is covered without prior authorization.

What is the Medicare reimbursement rate for 28295?

Medicare facility rate: $562.81. Non-facility rate: $1065.15. Work RVU: 8.36.

HCPCS/CPT

No Prior Auth Required

Code is covered without prior authorization (high confidence)

Work RVU

8.36

Facility

$562.81

Non-Facility

$1065.15

"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).

- "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)

CARELON-small-joint-surgery-2025-11-15 — General Requirements and Documentation

CARELON-level-of-care-for-surgical-procedures-2025-11-15 — Level of Care for Surgical Procedures

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

Ask Verity about documentation requirements, denial risks, or coverage in your state.