Clinical Guideline - Orthopedic Footwear PDF Print E-mail

1. Description

This document addresses orthopedic footwear including shoes, inserts and modification to shoes for individuals who do not have diabetes.

2. Clinical Indications

2.1. Medically Necessary

Shoes, inserts, and modifications are considered medically necessary only in the limited circumstances described below:

  • Shoes are considered medically necessary if they are an integral part of a leg brace that is medically necessary.
  • Heel replacements, sole replacements and shoe transfers involving shoes on a medically necessary leg brace are also considered medically necessary.
  • Inserts and other shoe modifications (such as lifts, wedges, arch supports and other additions) are considered medically necessary if they are on a shoe that is an integral part of a medically necessary leg brace, if they are medically necessary for the proper functioning of the brace.
  • Prosthetic shoes are considered medically necessary if they are an integral part of a prosthesis for individuals with a partial foot amputation.

2.2. Not Medically Necessary

Orthopedic footwear that does not meet the criteria above is considered not medically necessary.

A matching shoe that is not attached to a brace and items related to that shoe are considered not medically necessary.

Shoes are considered not medically necessary when they are put on over partial foot prosthesis or other lower extremity prosthesis that is attached to the residual limb by mechanisms other than being an integral part of the prosthesis.

3. Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

L3000-L3031 Foot insert, removable [includes codes L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031]
L3040-L3060 Foot, arch supports, removable [includes codes L3040, L3050, L3060]
L3070-L3090 Foot, arch supports, non-removable attached to shoe [includes codes L3070, L3080, L3090]
L3160 Foot, adjustable shoe-styled positioning device
L3170 Foot, plastic heel stabilizer
L3224-L3225 Orthopedic footwear, used as an integral part of a brace (orthosis)
L3230 Orthopedic footwear, custom shoes, depth inlay
L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoes, each
L3251 Foot, shoe molded to patient model; silicone shoe, each
L3252 Foot, shoe molded to patient model; plastazote (or similar), custom fabricated, each
L3253 Foot, molded shoe plastazote (or similar) custom fitted, each
L3254 Non-standard size or width
L3255 Non-standard size or length
L3257 Orthopedic footwear, additional charge for split size
L3265 Plastazote sandal, each
L3300-L3334 Lifts [includes codes L3300, L3310, L3320, L3330, L3332, L3334]
L3340-L3350 Heel wedges [includes codes L3340, L3350]
L3360-L3370 Sole wedges [includes codes L3360, L3370]
L3390 Outflare wedge
L3400-L3410 Metatarsal bar wedges [includes codes L3400, L3410]
L3420 Full sole and heel wedge, between sole
L3430-L3485 Heels [includes codes L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485]
L3500-L3595 Orthopedic shoe additions [includes codes L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595]
L3600-L3630 Transfer of an orthosis from one shoe to another [includes codes L3600, L3610, L3620, L3630]
HCPCS Modifiers
LT Left side
RT Right side

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