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PROVIDER POLICIES &PROCEDURESFOOT ORTHOTICSThe purpose of this Clinical Guideline is to provide guidance to providers enrolled in the ConnecticutMedical Assistance Program (CMAP Providers) on the requirements for prior authorization of footorthotics. This includes both the applicable medical necessity criteria for approval of coverage throughthe prior authorization process for HUSKY members and the applicable procedures and guidelines of theprior authorization process.Foot orthotics are removable shoe inserts that do not extend beyond the ankle and may include heelwedges and arch supports, which are available commercially or may be custom-made. The goal oftreating conditions with foot orthotics is to decrease pain and increase function by controlling foot motion,reducing shock absorption, and minimizing stress forces. Foot orthotics are placed in a shoe (shoeinserts) to assist in restoring or maintaining normal alignment of the foot, relieve stress from strained orinjured soft tissues, bony prominences, deformed bones and joints, and inflamed or chronic bursae. Theymay also correct some foot deformities and provide shock absorption to the foot. Foot orthoses may beused to treat conditions including those involving impaired peripheral circulation and sensation, whenthey are attached to a prosthetic shoe or orthosis, for a neurologic or neuromuscular condition and forcongenital or acquired foot conditions.Foot orthotics may be accommodative or functional. Accommodative foot orthoses are custom or noncustominlays fabricated for the purpose of providing relief from callosities and pressure points, andmaintaining the integrity of the longitudinal arch and/or the metatarsal heads. The devices can be madeof several different types of materials and can be fabricated from plaster molds of the feet or electronic(computer) imaging in a semi-weight bearing or non-weight bearing, neutral position, with correctionsbuilt in to prevent abnormal compensation during the gait cycle.A shoe modification is a medically prescribed alteration(s) to a shoe(s) to accommodate minor footdeformities, disabilities, or leg shortening of less than 1 and ½ inches. Shoe modifications, e.g., rockersoles, shoe buildups, metatarsal bars, shoe stretching, Thomas heels, tongue pads, Velcro closures,modified lacers, etc., may be applied to shoes, upon medical determination of need, to compensate forminor foot deformities.CLINICAL GUIDELINEPrior authorization is required for foot orthotics including inserts, arch supports, and modifications toorthopedic shoes. Foot orthotics can be considered medically necessary for members who meet thefollowing criteria and for whom other treatment methods have been ruled out prior to recommending footorthotics.Custom-fabricated foot orthosis (es) are typically considered medically necessary when there is failure,contraindication, or intolerance to a prefabricated foot orthosis for ANY of the following conditions:• Impaired peripheral sensation and/or altered peripheral circulation (e.g., diabetic neuropathy andperipheral vascular disease);Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment.Payment is based on the member having active coverage, benefits and policies in effect at the time of service.1To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Gridssummaries on www.huskyhealth.com by clicking here [See DME/Prosthetics and Orthotics].. For a definitive list of benefits and servicelimitations, CMAP Providers may access the CMAP provider fee schedules and regulations at www.ctdssmap.com.

• The foot orthosis is an integral part of a leg brace and is necessary for the proper functioning ofthe brace;• The foot orthosis is used to compensate for a missing portion of the foot (e.g., amputation) and isnecessary for the alleviation or correction of illness, injury or congenital defect;• Neurologic or neuromuscular condition (e.g., cerebral palsy, hemiplegia, spina bifida) producingspasticity, mal-alignment or pathological positioning of the foot where there is reasonableexpectation of improvement;• Plantar fasciitis, following failure of conservative medical management (e.g.,stretching/strengthening of calf muscles, taping, strapping, nonsteroidal anti-inflammatorymedications, reduced activity and physical therapy) including, unless contraindicated, at least asix-week trial of a prefabricated or custom-fitted orthosis; and• Acquired or congenital foot deformity when ALL of the following criteria are met:1. The deformity is the result of ONE of the following:a. Symptomatic rigid flatfootb. Posterior tibial tendon dysfunctionc. Mid- or hind-foot arthritis2. The deformity is associated with significant pain that interferes with activities of daily livingand there is impaired gait, balance, or mobility as a result of the condition.3. Conservative medical management has failed.4. There is a reasonable expectation that the condition will improve through the use of theorthotic device.• Other foot condition or deformity, either acquired or congenital, that interferes with activities ofdaily living and has resulted in impaired gait, balance, or mobility where supportive shoes and/orother intervention has been unsuccessful.Orthopedic footwear including inserts (L3000-L3030), arch supports (L3040-L3090) and othermodifications to shoes (L3649, L5000) for individuals who do not have diabetes is generally consideredmedically necessary in the following circumstances:• Heel replacements, sole replacements and shoe transfers involving shoes on a medicallynecessary lower extremity orthosis(es)• Inserts and other shoe modifications (e.g., arch supports) if they are on a shoe that is an integralpart of a medically necessary lower extremity orthosis(es) or prosthesis(es) and is medicallynecessary for the proper functioning of the orthosis(es) or prosthesis(es)• Other orthotic modifications will be considered on a case-by-case basis in consideration of thepatient’s ambulation status, sensation, skin integrity, symptoms, and orthopedic alignment.Orthopedic footwear including inserts and modification to shoes for individuals with diabetes is generallyconsidered medically necessary if ALL of the following criteria are met:1. The individual has diabetes mellitus; and2. The individual has one or more of the following conditions:a. Previous amputation of the other foot or part of either foot, orb. History of previous foot ulceration of either foot, orc. History of pre-ulcerative calluses of either foot, ord. Peripheral neuropathy with evidence of callus formation of either foot, ore. Foot deformity of either foot, orf. Poor circulation in either foot.3. The certifying physician who is managing the individual’s systemic diabetic condition has certifiedthat indications (1) and (2) above are met and that he/she is treating the individual under aPlease note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment.Payment is based on the member having active coverage, benefits and policies in effect at the time of service.2To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Gridssummaries on www.huskyhealth.com by clicking here [See DME/Prosthetics and Orthotics].. For a definitive list of benefits and servicelimitations, CMAP Providers may access the CMAP provider fee schedules and regulations at www.ctdssmap.com.

comprehensive plan of care for his/her diabetes and that the individual needs the inserts ormodifications to therapeutic shoes.4. Other orthotic modifications will be considered on a case-by-case basis in consideration of thepatient’s ambulation status, sensation, skin integrity, symptoms, and orthopedic alignment.A modification of a custom molded or depth shoe is typically considered medically necessary as asubstitute for an insert. Although not intended as a comprehensive list, the following are the mostcommon shoe modifications:• Rigid rocker bottoms• Roller bottoms• Wedges• Metatarsal bars• Offset heelsThe following orthotic devices are generally NOT considered medically necessary:• Separate orthotic devices for an additional pair of shoes• Orthoses primarily for improved athletic performance or sports participation• Orthoses considered experimental, investigational or unproven (this list may not be all-inclusiveincluding) including:1. Custom-fabricated foot orthosis for the treatment of hallux valgus or hallux rigidus footdeformity2. Magnetic insole (i.e., orthosis with magnetic foil)• Foot orthotics not ordered by the treating providerCustom-fabricated foot orthoses and orthopedic footwear including inserts, arch supports andmodifications to shoes, that do not meet the above criteria are generally not considered medicallynecessary. Additional evidence must be provided for individual consideration to support medicalnecessity in situations that do not meet the criteria listed above.COVERAGE:Foot orthotics are a covered benefit for those members who demonstrate medical necessity as definedabove.EFFECTIVE DATEThis Clinical Guideline is effective for prior authorization requests for foot orthotics for HUSKY A, C and Dmembers on or after October 1, 2012.LIMITATIONSFoot orthotics are NOT covered for members enrolled in the HUSKY B Program Health Plan. Band 1and Band 2 HUSKY B members may be eligible for these items under the HUSKY Plus Program.HUSKY Plus provides supplemental coverage of children with intensive physical health needs forservices not covered under the HUSKY B plan, only Band 1 and 2 children may qualify. Call 1-860-837-6200 for more information.Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment.Payment is based on the member having active coverage, benefits and policies in effect at the time of service.3To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Gridssummaries on www.huskyhealth.com by clicking here [See DME/Prosthetics and Orthotics].. For a definitive list of benefits and servicelimitations, CMAP Providers may access the CMAP provider fee schedules and regulations at www.ctdssmap.com.

PROCEDUREAll requests for orthotics and prosthetics will be reviewed under and all final determinations of medicalnecessity will be made under Connecticut General Statute Section 17b-259b. Coverage determinationswill be based upon a review of requested and/or submitted case-specific information to include evidencebasedevaluations.Information Required for Review:A clinical assessment by the patient’s physician (preferably an orthopedist or podiatrist) BEFORE thepatient is referred for foot orthotics is required. This clinical assessment should also include thephysician’s specific recommendation for types of orthotics, including additions/modifications andaccompany the request for prior authorization for the foot orthotics which will also provide the necessaryclinical information for appropriate medical review and decision. The assessment can also include theother medical approaches being used to address the patient’s needs, including other DME, medications,and therapies; including the following:1. Prescription/ signed letter of medical necessity;2. Completed State of Connecticut, Department of Social Services Outpatient Prior AuthorizationRequest Form;3. Treatment history, including effectiveness of treatment, orthotics, and medications;4. Clinical assessment to include:• Current list of ambulatory aids/orthotics with current skill level for each;• Ambulatory skills with and without orthoisis• Patient’s current health status, functional abilities, level of activity and level of comfort;• Date of purchase, condition, and fit of current orthotics and shoes;• Primary diagnosis(es)• Foot/ankle/forefoot muscle strength, range of motion, and any deformities or asymmetries• Vascular, skin and sensory status• Observational gait assessment (swing and stance phase)5. Documentation confirming that the member’s medical condition cannot be addressed viaalternative medical approaches, functional strategies, or other/existing DME; e.g., muscularstretching, strengthening exercises, taping, NSAIDS, over-the-counter insoles, and/or supportiveshoes or athletic shoes. Other forms of treatment have been considered and ruled out. Customfabricatedfoot orthotics are not medically necessary unless there is clinical documentation thatnon-custom, prefabricated foot orthotics are not appropriate for the condition or diagnosis.6. Other pertinent information as requested by Medical Management and/or Utilization ManagementDepartments.7. A detailed product description and quotation including manufacturer, model/part number, productdescription, HCPC code, unit(s), quantity, DSS fee schedule allowed amount and retail pricesubmitted by the DME vendor.Review Process:1. Requests for foot orthotics must be submitted by the billing provider/vendor.2. Requests for items should be submitted to CHNCT via fax at 203-265-3994 using the OutpatientPrior Authorization Request Form located on the HUSKY Health website atwww.huskyhealth.com. Requests for foot orthotics will be reviewed by the CHNCT UtilizationManagement Department in accordance with the procedures and time-frames in place forreviewing requests for DME and medical-surgical supplies. CHNCT has up to 14 calendar daysto notify the provider of their decision. If additional information is requested, the provider has upto 14 calendar days to submit the requested information.Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment.Payment is based on the member having active coverage, benefits and policies in effect at the time of service.4To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Gridssummaries on www.huskyhealth.com by clicking here [See DME/Prosthetics and Orthotics].. For a definitive list of benefits and servicelimitations, CMAP Providers may access the CMAP provider fee schedules and regulations at www.ctdssmap.com.

CODES:CodeL3000L3001L3002L3003L3010L3020L3030L3040L3050L3060L3070L3080L3090L3649L5000DescriptionFoot insert, removable, molded to patient model, UCB type, Berkeley shell, eachFoot insert, removable, molded to patient model, Spenco, eachFoot insert, removable, molded to patient model, Plastazote or equal, eachFoot insert, removable, molded to patient model, silicone gel, eachFoot insert, removable, molded to patient model, longitudinal arch support, eachFoot insert, removable, molded to patient model, longitudinal./metatarsal support, eachFoot insert, removable, formed to patient foot, eachFoot, arch support, removable, premolded, longitudinal, eachFoot, arch support, removable, premolded, metatarsal, eachFoot, arch support, removable, premolded, longitudinal/metatarsal, eachFoot, arch support, nonremovable, attached to shoe, longitudinal, eachFoot, arch support, nonremovable, attached to shoe, metatarsal, eachFoot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, eachOrthopedic shoe, modification, addition or transfer, not otherwise specifiedPartial foot, shoe insert with longitudinal arch, toe fillerDEFINITIONS1. HUSKY A: Connecticut’s implementation of health insurance under the federal Medicaid program(Title XIX) for children, parents or relative caretakers. Eligibility is for families earning below 185% aswell as pregnant women under 250% of the federal poverty level and other groups pursuant toSection 17b-266 of the Connecticut General Statutes.2. HUSKY B: The health insurance plan for children and youth, up to the age of nineteen, establishedpursuant to Title XXI (CHIP) of the Social Security Act, the provisions of Sections 17b-289 to 17b-303, inclusive, of the Connecticut General Statutes, and Section 16 of Public Act 97-1 of the Octoberspecial session. This program provides subsidized health insurance for uninsured children in familiesearning from 185% to 300% of the federal poverty level. Unsubsidized coverage is available underHUSKY B for families earning more than 300% of the federal poverty level.3. HUSKY C: Connecticut’s implementation of health insurance under the federal Medicaid program(Title XIX) for individuals who are aged, blind or disabled (ABD) and certain other groups such asrefugees.4. HUSKY D: Connecticut’s implementation of health insurance under the federal Medicaid program(Title XIX) for low income adults age 19 to 64, also known as Medicaid for Low Income Adults (LIA).5. HUSKY Health Program: The HUSKY A, HUSKY B, HUSKY C, HUSKY D and HUSKY LimitedBenefit programs, collectively.6. HUSKY Limited Benefit Program or HUSKY, LBP: Connecticut’s implementation of limited healthinsurance coverage under Medicaid for individuals with tuberculosis or for family planning purposesand such coverage is substantially less than the full Medicaid coverage.7. Medically Necessary or Medical Necessity: (as defined in Connecticut General Statutes § 17b-259b) Those health services required to prevent, identify, diagnose, treat, rehabilitate or amelioratean individual's medical condition, including mental illness, or its effects, in order to attain or maintainPlease note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment.Payment is based on the member having active coverage, benefits and policies in effect at the time of service.5To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Grids summarieson www.huskyhealth.com or www.charteroakhealthplan.com by clicking here [See DME/Prosthetics and Orthotics].. For a definitive list ofbenefits and service limitations, CMAP Providers may access the CMAP provider fee schedules and regulations at www.ctdssmap.com.

the individual's achievable health and independent functioning provided such services are: (1)Consistent with generally-accepted standards of medical practice that are defined as standards thatare based on (A) credible scientific evidence published in peer-reviewed medical literature that isgenerally recognized by the relevant medical community, (B) recommendations of a physicianspecialtysociety, (C) the views of physicians practicing in relevant clinical areas, and (D) any otherrelevant factors; (2) clinically appropriate in terms of type, frequency, timing, site, extent and durationand considered effective for the individual's illness, injury or disease; (3) not primarily for theconvenience of the individual, the individual's health care provider or other health care providers; (4)not more costly than an alternative service or sequence of services at least as likely to produceequivalent therapeutic or diagnostic results as to the diagnosis or treatment of the individual's illness,injury or disease; and (5) based on an assessment of the individual and his or her medical condition.8. Prior Authorization: A process for approving covered services prior to the delivery of the service orinitiation of the plan of care based on a determination by CHNCT as to whether the requested serviceis medically necessary.9. Custom-fabricated orthosis: An orthosis that is specifically manufactured for an individual.Custom-fabricated devices may include custom-molded devices (e.g., molded to the individual’sspecific body part).10. Prefabricated orthosis: An orthosis manufactured in quantity without a specific individual in mind(e.g., off-the-shelf). Prefabricated orthotic devices may include custom-fitted devices (e.g., trimmed,bent or molded for use by a specific individual).11. Foot orthosis: A type of shoe insert that does not extend beyond the ankle and may include heelwedges and arch supports. The goal of treating conditions with foot orthoses is to decrease pain andincrease function. They may also correct some foot deformities and provide shock absorption to thefoot. Foot orthoses may be used to treat conditions such as those involving impaired peripheralcirculation and sensation, when they are attached to a prosthetic shoe or brace, for a neurologic orneuromuscular condition and for congenital or acquired foot conditions. HCPCS codes representingfoot orthoses provided to patients without diabetes are L3000–L3090.12. Foot Orthoses Associated with Prosthetic Shoes and Braces: Prosthetic shoes are used whenall or a portion of the foot is missing. A brace may or may not be attached to the prosthetic shoe. Theabsence of all or a portion of the foot may be the result of a congenital deformity, illness (amputationsecondary to diabetic foot ulcer) or injury (traumatic amputation). Patients with minor distalamputations typically do not require special shoes. When all digits have been amputated, a forefootfiller orthosis may be used with a commercial shoe. For more extensive partial-foot amputations (e.g.,mid-level Trans metatarsal, Chopart’s amputation), a prosthetic may be needed consisting of aconventional shoe with an ankle-foot orthosis (AFO), brace and a forefoot filler. A custom-fitted orcustom-molded foot orthosis may be used as a replacement or substitute for missing parts of the foot(e.g., due to amputation) and when it is necessary for the alleviation or correction of illness, injury orcongenital defect.13. Metatarsal bars: Exterior bars that are placed behind the metatarsal heads in order to removepressure from the metatarsal heads. The bars are of various shapes, heights, and constructiondepending on the exact purpose14. Offset heel: A heel flanged at its base either in the middle, to the side, or a combination, that is thenextended upward to the shoe in order to stabilize extreme positions of the hind foot.16. Rigid rocker bottoms: Exterior elevations with apex position for 51% to 75% distance measuredfrom the back end of the heel. The apex is a narrowed or pointed end of an anatomical structure. Theapex must be positioned behind the metatarsal heads and taper off sharply to the front tip of the sole.Apex height helps to eliminate pressure at the metatarsal heads. Rigidity is ensured by the steel inthe shoe. The heel of the shoe tapers off in the back in order to cause the heel to strike in the middleof the heel.Please note that authorization is based on medical necessity at the time the authorization is issued and is not a guarantee of payment.Payment is based on the member having active coverage, benefits and policies in effect at the time of service.To determine if a service or procedure requires prior authorization, CMAP Providers may refer to the Benefit and Authorization Gridssummaries on www.huskyhealth.com by clicking here [See DME/Prosthetics and Orthotics].. For a definitive list of benefits and servicelimitations, CMAP Providers may access the CMAP provider fee schedules and regulations at www.ctdssmap.com.6