K0628
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- History of pre-ulcerative calluses of either foot;or
- History of previous foot ulceration of either foot;or
- I. Therapeutic shoes, inserts, or modifications to therapeutic shoes are consideredmedically necessaryif the following criteria are met:
- The individual has diabetes mellitus;and
- The individual has one or more of the following conditions:Previous amputation of the other foot or part of either foot;orHistory of previous foot ulceration of either foot;orHistory of pre-ulcerative calluses of either foot;orPeripheral neuropathy with loss of protective sensation in the foot and with evidence of callus formation of either foot;orFoot deformity of either foot;orPeripheral vascular disease involving the treated foot;and
- Previous amputation of the other foot or part of either foot;or
1 Active Policy
ANTHEM-CG-DME-19 — CG-DME-19 Therapeutic Shoes, Inserts, or Modifications for Individuals with Diabetes
Related Codes
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