L11445 -LCD

LCD/NCD Portal

Automated World Health

Local Coverage Determination (LCD) for Orthopedic Footwear

(L11445)

Contractor Information

Contractor Name CGS Administrators, LLC

Contractor Number 18003

Contractor Type DME MAC

Jurisdiction J - G

LCD Information

Document Information

LCD ID Number L11445

LCD Title Orthopedic Footwear

Contractor's Determination Number OFW

AMA CPT/ADA CDT Copyright Statement

Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.

Alabama Arkansas Colorado Florida Georgia Louisiana Mississippi North Carolina New Mexico Oklahoma Puerto Rico South Carolina Tennessee Texas Virginia Virgin Islands West Virginia

Oversight Region Region IV

DME Region LCD Covers Jurisdiction C

Original Determination Effective Date

For services performed on or after 01/01/1995 Original Determination Ending Date

Revision Effective Date

For services performed on or after 08/05/2011

Revision Ending Date

CMS National Coverage Policy

CMS Pub. 100-3, Medicare National Coverage Determinations Manual, Chapter 1, Section 280.10 Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must (1) be eligible for a defined Medicare benefit category, (2) be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, and (3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

Statutory coverage criteria for orthopedic footwear are specified in the related Policy Article.

Prosthetic shoes (L3250) are covered if they are an integral part of a prosthesis for patients with a partial foot amputation (ICD-9 diagnosis codes 755.31, 755.38, 755.39, 895.0-896.3). Claims for prosthetic shoes for other ICD-9 diagnosis codes will be denied as not medically necessary.

Coding Information

Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service

GY - Item or service statutorily excluded or does not meet the definition of any Medicare benefit KX - Requirements specified in the medical policy have been met

LT - Left side RT - Right side

HCPCS CODES:

A9283 FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH

L3000 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL, EACH L3001 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SPENCO, EACH

L3002 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE OR EQUAL, EACH L3003 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SILICONE GEL, EACH

L3010 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPPORT, EACH

L3020 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/ METATARSAL SUPPORT, EACH

L3030 FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH

L3031 FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, EACH

L3040 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, EACH L3050 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, METATARSAL, EACH

L3060 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL/ METATARSAL, EACH L3070 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL, EACH L3080 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, METATARSAL, EACH

L3090 FOOT, ARCH SUPPORT, NON-REMOVABLE ATTACHED TO SHOE, LONGITUDINAL/METATARSAL, EACH L3100 HALLUS-VALGUS NIGHT DYNAMIC SPLINT

L3140 FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES L3150 FOOT, ABDUCTION ROTATATION BAR, WITHOUT SHOES L3160 FOOT, ADJUSTABLE SHOE-STYLED POSITIONING DEVICE

L3170 FOOT, PLASTIC, SILICONE OR EQUAL, HEEL STABILIZER, EACH

L3201 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, INFANT L3202 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, CHILD L3203 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIOR L3204 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANT L3206 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, CHILD L3207 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, JUNIOR L3208 SURGICAL BOOT, EACH, INFANT

L3209 SURGICAL BOOT, EACH, CHILD L3211 SURGICAL BOOT, EACH, JUNIOR L3212 BENESCH BOOT, PAIR, INFANT L3213 BENESCH BOOT, PAIR, CHILD L3214 BENESCH BOOT, PAIR, JUNIOR

L3215 ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACH L3216 ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH INLAY, EACH

L3217 ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACH L3219 ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH

L3221 ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACH

L3222 ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACH

L3224 ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS)

L3225 ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) L3230 ORTHOPEDIC FOOTWEAR, CUSTOM SHOE, DEPTH INLAY, EACH

L3250 ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETIC SHOE, 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 L3260 SURGICAL BOOT/SHOE, EACH

L3265 PLASTAZOTE SANDAL, EACH

L3300 LIFT, ELEVATION, HEEL, TAPERED TO METATARSALS, PER INCH L3310 LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH L3320 LIFT, ELEVATION, HEEL AND SOLE, CORK, PER INCH

L3330 LIFT, ELEVATION, METAL EXTENSION (SKATE)

L3332 LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH L3334 LIFT, ELEVATION, HEEL, PER INCH

L3340 HEEL WEDGE, SACH L3350 HEEL WEDGE

L3360 SOLE WEDGE, OUTSIDE SOLE L3370 SOLE WEDGE, BETWEEN SOLE L3380 CLUBFOOT WEDGE

L3390 OUTFLARE WEDGE

L3400 METATARSAL BAR WEDGE, ROCKER

L3410 METATARSAL BAR WEDGE, BETWEEN SOLE L3420 FULL SOLE AND HEEL WEDGE, BETWEEN SOLE L3430 HEEL, COUNTER, PLASTIC REINFORCED

L3440 HEEL, COUNTER, LEATHER REINFORCED L3450 HEEL, SACH CUSHION TYPE

L3455 HEEL, NEW LEATHER, STANDARD L3460 HEEL, NEW RUBBER, STANDARD L3465 HEEL, THOMAS WITH WEDGE

L3470 HEEL, THOMAS EXTENDED TO BALL L3480 HEEL, PAD AND DEPRESSION FOR SPUR L3485 HEEL, PAD, REMOVABLE FOR SPUR

L3500 ORTHOPEDIC SHOE ADDITION, INSOLE, LEATHER L3510 ORTHOPEDIC SHOE ADDITION, INSOLE, RUBBER

L3520 ORTHOPEDIC SHOE ADDITION, INSOLE, FELT COVERED WITH LEATHER L3530 ORTHOPEDIC SHOE ADDITION, SOLE, HALF

L3540 ORTHOPEDIC SHOE ADDITION, SOLE, FULL

L3550 ORTHOPEDIC SHOE ADDITION, TOE TAP STANDARD L3560 ORTHOPEDIC SHOE ADDITION, TOE TAP, HORSESHOE

L3570 ORTHOPEDIC SHOE ADDITION, SPECIAL EXTENSION TO INSTEP (LEATHER WITH EYELETS) L3580 ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TO VELCRO CLOSURE

L3590 ORTHOPEDIC SHOE ADDITION, CONVERT FIRM SHOE COUNTER TO SOFT COUNTER L3595 ORTHOPEDIC SHOE ADDITION, MARCH BAR

L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTING L3610 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEW L3620 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, EXISTING L3630 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, NEW

L3640 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, DENNIS BROWNE SPLINT (RIVETON), BOTH SHOES

L3649 ORTHOPEDIC SHOE, MODIFICATION, ADDITION OR TRANSFER, NOT OTHERWISE SPECIFIED

ICD-9 Codes that Support Medical Necessity

The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on “Indications and Limitations of Coverage and/or Medical Necessity” for other coverage criteria and payment information.

For HCPCS code L3250:

755.31 TRANSVERSE DEFICIENCY OF LOWER LIMB

755.38 LONGITUDINAL DEFICIENCY TARSALS OR METATARSALS COMPLETE OR PARTIAL (WITH OR WITHOUT INCOMPLETE PHALANGEAL DEFICIENCY)

755.39 LONGITUDINAL DEFICIENCY PHALANGES COMPLETE OR PARTIAL

895.0 - 896.3

TRAUMATIC AMPUTATION OF TOE(S) (COMPLETE) (PARTIAL) WITHOUT COMPLICATION - TRAUMATIC AMPUTATION OF FOOT (COMPLETE) (PARTIAL) BILATERAL COMPLICATED

Diagnoses that Support Medical Necessity

For the specific HCPCS code indicated above, refer to the previous section.

For all other HCPCS codes, diagnoses are not specified. ICD-9 Codes that DO NOT Support Medical Necessity

For the specific HCPCS code indicated above, all ICD-9 codes that are not specified in the previous section.

For all other HCPCS codes, ICD-9 codes are not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

For the specific HCPCS code indicated above, all diagnoses that are not specified in the previous section.

For all other HCPCS codes, diagnoses are not specified.

General Information

Documentations Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider". It is expected that the patient’s medical records will reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

An order is not required for a heel or sole replacement or transfer of a shoe to a brace.

KX AND GY MODIFIERS:

When billing for a shoe that is an integral part of a leg brace or for related modifications, inserts, heel/sole replacements or shoe transfer, a KX modifier must be added to the code. If the shoe or related item is not an integral part of a leg brace, the KX modifier must not be used.

If the shoe and related modifications, inserts, and heel/sole replacements are not an integral part of a brace, the GY modifier must be added to each code.

If a KX or GY modifier is not included on the claim line, it will be rejected as missing information.

When billing for prosthetic shoes (L3250) and related items, an ICD-9 diagnosis code (specific to the 5th digit), describing the condition which necessitates the prosthetic shoes, must be included on each claim for the prosthetic shoes and related items.

When code L3649 with a KX modifier is billed, the claim must include a narrative description of the item provided as well as a brief statement of the medical necessity for the item. This must be entered in the narrative field of an electronic claim.

Refer to the Supplier Manual for more information on documentation requirements.

Appendices

Utilization Guidelines Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision

Reserved for future use. Advisory Committee Meeting Notes

Start Date of Comment Period

End Date of Comment Period

Start Date of Notice Period 01/01/1995

Revision History Number 008

Revision History Explanation Revision Effective Date: 010/01/2009

HCPCS MODIFIERS:

Added: GY modifier Revised: KX Modifier

DOCUMENTATION REQUIREMENTS:

Added: GY modifier instructions

Revision Effective Date: 03/01/2008

In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

Revision Effective Date:01/01/2008

HCPCS CODES:

Added: A9283

Revision Effective Date: 07/01/2007

INDICATIONS AND LIMITATIONS:

Removed: DMERC references DOCUMENTATIONS REQUIREMENTS:

Removed: DMERC references

Revision Effective Date: 06/01/2007

In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

Revision Effective Date: 03/01/2006

In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revison Effective Date: 01/01/2006

HCPCS CODES AND MODIFIERS:

Added: L3031

Revised: L3170, L3215, L3216, L3217, L3219, L3221, L3222, L3230

Revision Effective Date: 10/01/2005 LMRP converted to LCD and Policy Article DOCUMENTATION REQUIREMENTS:

Eliminated the requirement for an ICD-9 code on the order for L3250. Deleted reference to filing hard copy claims.

Revision Effective Date: 04/01/2003

HCPCS CODES AND MODIFIERS:

Added: EY

Discontinued: L3218, L3223 Revised: L3260

INDICATIONS AND LIMITATIONS OF COVERAGE:

Adds standard language concerning coverage of items without an order. DOCUMENTATION REQUIREMENTS:

Adds standard language concerning use of EY modifier for items without an order.

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

07/01/2002 - Replaced the ZX modifier with KX. Updated the codes for therapeutic shoes for diabetics.

07/01/2000 – Added reasonable and necessary language to Coverage and Payment Rules section. 08/05/2011 - The Jurisdiction C contractor adopted a new business name. This LCD revision only includes the

change from CIGNA Government Services to CGS Administrators, LLC. No coverage information was included in

this revision and no provider action is needed regarding this revision.

Reason for Change Maintenance (annual review with new changes, formatting, etc.)