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2.7.2.2.3 Foot Orthoses
Foot orthoses include, but are not limited to, foot inserts, orthopedic shoes, wedges, and lifts.
Foot orthoses will be considered for prior authorization for clients with documentation of all the following:
• The client has symptoms associated with the particular foot condition.
•The client has failed to respond to a course of appropriate, conservative treatment, including physical therapy, injections, strapping, or anti-inflammatory medications.
•The client has at least one of the following:
•Torsional conditions, such as metatarsus adductus, tibial torsion, or femoral torsion.
•Structural deformities.
•Hallux valgus deformities.
•In-toe or out-toe gait.
•Musculoskeletal weakness.
In addition to the general indication requirements, foot orthoses will be considered for prior authorization with documentation of the following criteria for specific orthotic devices:
Foot Inserts
Removable foot inserts will be considered for prior authorization for clients with documentation of at least one of the following medical conditions:
•Diabetes mellitus.
•History of amputation of the opposite foot or part of either foot.
•History of foot ulceration or pre-ulcerative calluses of either foot.
•Peripheral neuropathy with evidence of callus formation of either foot.
•Deformity of either foot.
•Poor circulation of either foot.
Removable foot inserts may be covered independently of orthopedic shoes with documentation that the client has appropriate footwear into which the insert can be placed.
A University of California at Berkeley (UCB) removable foot insert will be considered for prior authorization with documentation that the device is required to correct or treat at least one of the following conditions:
•A valgus deformity and significant congenital pes planus with pain.
•A structural problem that results in significant pes planus, such as Down syndrome.
•Acute plantar fasciitis.
Orthopedic Shoes
Orthopedic shoes must be prescribed by a licensed physician (M.D. or D.O.) or a podiatrist. An orthopedic shoe is used by clients whose feet, although impaired, are essentially intact. An orthopedic shoe differs from a prosthetic shoe, which is used by clients who are missing all or most of the forefoot.
Orthopedic shoes will be considered for prior authorization when at least one of the following criteria is met:
•The shoe is permanently attached to a brace.
•The shoe is necessary to hold a surgical correction, postoperative casting, or serial or clubfoot casting.
An orthopedic shoe may be prior authorized up to one year from the date of the surgical procedure.
Only one pair of orthopedic shoes will be prior authorized every three months. Two pairs of shoes may be purchased at the same time; in such situations, however, additional requests for shoes will not be considered for another six months.
Requests for orthopedic shoes that do not meet the criteria listed above may be considered for prior authorization with documentation of medical necessity.
Wedges and Lifts
Wedges and lifts must be prescribed by a licensed physician (M.D. or D.O.) or a podiatrist and must be for treatment of unequal leg length greater than one-half inch.
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