L3161 — Foot, adductus positioning device, adjustable
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- The appendix guidance: "The type of shoe and orthotic must be determined based on the severity of the pathology." (clinical documentation of pathology severity required)
- For diabetic/at-risk patients: ongoing follow-up recommended: "As a preventive measure, this group of patients should be followed on a regular basis for the development of pathology to ensure quick interventions as needed." (documentation of monitoring/follow-up)
- When shoe modification vs. custom device decision is relevant: documentation that "shoe modifications will not accommodate the foot deformity" is required prior to issuing depth shoes or custom devices (implied by text referencing stepwise approach).
- Where specific device features are requested, medical record should document the "desired function," specific materials, design and construction, and clinical rationale for why lesser interventions are inadequate (explicit in prescription recommendation above).
Key Coverage Criteria
- Orthosis (foot orthotics) and/or prosthesis is medically necessary when care is prescribed by a physician, nurse practitioner, podiatrist or other health professional who is qualified to prescribe orthotics and/or prosthetics according to State law.
- Orthosis or prosthesis is medically necessary when the orthosis or prosthesis will significantly improve or restore physical functions required for mobility related activities of daily living (MRADL's).
- Orthosis or prosthesis is medically necessary when the member’s participating physician or licensed health care practitioner has determined that the orthosis or prosthesis will allow the member to perform ADLs based on physical examination of the member.
- Custom-molded shoes are medically necessary for diabetes when the member has a foot deformity that cannot be accommodated by a depth shoe and the shoes are constructed over a positive model of the member's foot; have removable inserts; have some sort of shoe closure; and are made from leather or suitable material of equal quality.
- ICD-10: G60.3 Idiopathic progressive neuropathy
- ICD-10: G60.8 Other hereditary and idiopathic neuropathies
1 Active Policy
AETNA-CPB-0451 — Foot Orthotics
Related Codes
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