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Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^® and Keystone Health Plan^® Central. Independent licensees of the BlueCross BlueShield Association serving 21 counties in Central Pennsylvania and the Lehigh Valley. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.

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Medical policy: Foot Orthotics and Other Podiatric Appliances

Policy number: MP 6.028

Clinical benefit

Minimize safety risk or concern.
Minimize harmful or ineffective interventions.
Assure appropriate level of care.
Assure appropriate duration of service for interventions.
Assure that recommended medical prerequisites have been met.
Assure appropriate site of treatment or service.

Effective date: 10/1/2026

Policy

Accommodative or functional foot orthotics may be considered medically necessary to meet the specific needs of an individual when prescribed by a physician for a condition of the lower extremity for which orthotics have proven benefit. (See Policy guidelines.)

Medical necessity criteria for replacements of or modifications to existing customized shoes is based on the same criteria noted for the shoe itself. Replacement of a pair of shoes, or modifications, should be based on necessity (e.g., worn out, loss of effectiveness, change in foot size/shape, change in foot structure, or development of new skin breakdown, ulceration, or deformity, etc.), not for convenience or style change. Due to wear and tear with normal use, orthotics may need refurbishing or be completely replaced periodically.

Foot orthotics are considered investigational for any condition or criteria not listed above as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

The provider requesting/ordering the DME should be a provider with whom the member has established a relationship and is involved in the ongoing care of the member and the condition for which the DME/orthotic is prescribed.

Policy guidelines

Orthopedic shoes and devices are described as Oxford shoes or other shoes, e.g., high top, depth inlay or custom for non-diabetics, heel replacements, sole replacements, and shoe transfers.

Examples of lower extremity conditions that could benefit from orthotics include, but are not limited to:

Calcaneal spurs (heel spurs)
Chronic ankle instability
Chronic calcaneal bursitis
Chronic metatarsalgia
Chronic plantar fasciitis
Chronic tendinopathy of the foot or ankle
Hallux rigidus
Inflammatory conditions (i.e., sesamoiditis; submetatarsal bursitis; synovitis; tenosynovitis; synovial cyst; osteomyelitis; rheumatoid disease; and osteoarthritis)
Medial osteoarthritis of the knee (lateral wedge insoles)
Musculoskeletal/arthropathic deformities (including deformities of the joint or skeleton that impairs walking in a normal shoe, e.g., bunions, hallux valgus, talipes deformities, tendonitis, pes cavus deformities, hammertoes, anomalies of toes)
Neurologically impaired feet (including neuroma; tarsal tunnel syndrome; ganglionic cyst; and neuropathies involving the feet, including those associated with diabetes)
Painful pes cavus deformity
Painful pes plano valgus deformity
Vascular conditions (including poor circulation, peripheral vascular disease, Buerger's disease, and chronic thrombophlebitis)

Cross-references

MP 6.061 Therapeutic Shoes for Persons with Diabetes
MP 6.062 Ankle-Foot and Knee-Ankle-Foot Orthoses

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to the FEP Medical Policy Manual. The FEP Medical Policy Manual can be found at: FEP Medical Policy Manual.

Description/Background

Accommodative foot orthotics are fabricated from either a cast impression or other suitable means of capturing an individual’s foot impression. They are designed to reduce pressure, friction, and shearing forces on the plantar surface of the foot. It is important that these devices are in full contact with the foot to appropriately offload pressure areas and reduce friction areas. These devices will wear out quicker than functional orthotics. Use of accommodative orthotics in individuals with at-risk foot types is necessary to reduce risk of ulceration, infection, and limb loss. At-risk individuals include those with diabetes, as well as those with neuropathy or insensate feet. Accommodative orthotics are also helpful for individuals with significant pain from pressure areas.

Functional foot orthotics are fabricated from a cast impression or other suitable means of capturing an individual’s foot impression. These orthotics are made from semirigid or rigid materials to control abnormal, excessive, or undesired motion of the foot.

Surveys show that 90 percent of patients complain of foot pain in more than one location. While such patients may have early findings of a bunion or bunionette, flattening of the metatarsal arch, or similar changes, the pain pattern cannot be attributed to a specific diagnosis. In most such cases, a trial of custom orthotics appears preferable to other treatments.

In a review of nine studies, with 487 patients suffering from a variety of conditions causing forefoot pain, custom orthotics were found to be the most effective intervention for reducing pain. A study using ultrasound to monitor the effectiveness of custom orthotics on plantar forefoot pain reported a significant reduction in symptoms and disability, and subsequently, a significant decrease in intermetatarsal bursitis.

The American College of Foot and Ankle Surgeons consider foot orthotics to be conservative treatment that can be used as initial therapy for heel pain.

Orthopedic shoes are shoes used to prevent or correct disorders of the bones, joints, muscles, ligaments and cartilage of the legs and feet. Custom-made orthopedic shoes are shoes fabricated over special modified lasts in accordance with prescriptions and specifications to accommodate gross or greater foot deformities or shortening of a leg at least 1 and 1/2 inches or greater.

Custom-made orthopedic shoes may be necessary when a physician or podiatrist determines that the severity of the foot condition is such that a lesser means (e.g., inlay shoes, shoe modifications, etc.) cannot adequately compensate for the deformity or there is a leg discrepancy length at least of 1 and 1/2 inches in length or greater. Initial custom-made orthopedic shoes, lasts, and patterns normally are obtained when the severity of the foot disability requires the physical presence of the member for casts, measurements, and possible trial fittings.

A shoe modification is a medically prescribed alteration(s) to a shoe(s) to accommodate minor foot deformities, disabilities, or leg shortening of less than 1 and 1/2 inches. Shoe modifications (e.g., rocker soles, shoe buildups, metatarsal bars, shoe stretching, Thomas heels, tongue pads, velcro closures, modified lacers, etc.) may be applied to personally purchased shoes, upon medical determination of need, to compensate for minor foot deformities.

Depth inlay shoes are prefabricated shoes with a higher toe box to accommodate for hammer toes and other deformities. This shoe may also accommodate the insertion of special inserts. These shoes are traditionally made of plastizote or other pressure absorbent material. Inlay shoes may be necessary after it has been determined that shoe modifications will not accommodate the foot deformity and that an insole or additional space is necessary.

Definitions

Inserts: Medically necessary inserts are those that are total contact, multiple densities (or appropriate offloading materials for accommodative orthotics and semirigid or rigid materials for functional orthotics), removable inlays that are directly molded to the member's foot or a model of the member's foot and are made of a material suitable for the member's condition.

Metatarsal bars: These are exterior bars that are placed behind the metatarsal heads in order to remove pressure from the metatarsal heads. The bars are of various shapes, heights, and construction depending on the exact purpose.

Offset heels: This is a heel flanged at its base either in the middle, to the side, or a combination, that is then extended upward to the shoe in order to stabilize extreme positions of the hind foot.

Rigid rocker bottoms: These are exterior elevations with apex positions for 51% to 75% distance measured from the back end of the heel. The apex is a narrowed or pointed end of an anatomical structure. The apex must be positioned behind the metatarsal heads and tapering off sharply to the front tip of the sole. Apex height helps to eliminate pressure at the metatarsal heads. The steel in the shoe ensures rigidity. The heel of the shoe tapers off in the back in order to cause the heel to strike in the middle of the heel.

Roller bottoms (sole or bar): These are the same as rocker bottoms, but the heel is tapered from the apex to the front tip of the sole.

Wedges (posting): Wedges are either of hind foot, fore foot, or both and may be in the middle or to the side. The function is to shift or transfer weight upon standing or during ambulation to the opposite side for added support, stabilization, equalized weight distribution, or balance.

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as permitted by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the member’s benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Covered when medically necessary

Procedure codes
A9283	L3000	L3001	L3002	L3003
L3010	L3020	L3030	L3031	L3040
L3050	L3060	L3070	L3080	L3090
L3100	L3140	L3150	L3160	L3161
L3170	L3201	L3202	L3203	L3204
L3206	L3207	L3215	L3216	L3217
L3219	L3221	L3222	L3224	L3225
L3230	L3250	L3251	L3252	L3253
L3254	L3255	L3257	L3265	L3300
L3310	L3320	L3330	L3332	L3334
L3340	L3350	L3360	L3370	L3380
L3390	L3400	L3410	L3420	L3430
L3440	L3450	L3455	L3460	L3465
L3470	L3480	L3485	L3500	L3510
L3520	L3530	L3540	L3550	L3560
L3570	L3580	L3590	L3595	L3600
L3610	L3620	L3630	L3640	L3649

ICD-10-CM diagnosis codes	Description
E10.40	Type 1 diabetes mellitus with diabetic neuropathy, unspecified
E10.41	Type 1 diabetes mellitus with diabetic mononeuropathy
E10.42	Type 1 diabetes mellitus with diabetic polyneuropathy
E10.51	Type 1 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E10.59	Type 1 diabetes mellitus with other circulatory complications
E10.610	Type 1 diabetes mellitus with diabetic neuropathic arthropathy
E10.618	Type 1 diabetes mellitus with other diabetic arthropathy
E10.620	Type 1 diabetes mellitus with diabetic dermatitis
E10.621	Type 1 diabetes mellitus with foot ulcer
E11.21	Type 2 diabetes mellitus with diabetic nephropathy
E11.40	Type 2 diabetes mellitus with diabetic neuropathy, unspecified
E11.41	Type 2 diabetes mellitus with diabetic mononeuropathy
E11.42	Type 2 diabetes mellitus with diabetic polyneuropathy
E11.51	Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
E11.59	Type 2 diabetes mellitus with other circulatory complications
E11.610	Type 2 diabetes mellitus with diabetic neuropathic arthropathy
E11.618	Type 2 diabetes mellitus with other diabetic arthropathy
E11.620	Type 2 diabetes mellitus with diabetic dermatitis
E11.621	Type 2 diabetes mellitus with foot ulcer
G57.50	Tarsal tunnel syndrome, unspecified lower limb
G57.51	Tarsal tunnel syndrome, right lower limb
G57.52	Tarsal tunnel syndrome, left lower limb
G57.53	Tarsal tunnel syndrome, bilateral lower limbs
G57.60	Lesion of plantar nerve, unspecified lower limb
G57.61	Lesion of plantar nerve, right lower limb
G57.62	Lesion of plantar nerve, left lower limb
G57.63	Lesion of plantar nerve, bilateral lower limbs
G60.0	Hereditary motor and sensory neuropathy
G60.3	Idiopathic progressive neuropathy
G60.8	Other hereditary and idiopathic neuropathies
G61.81	Chronic inflammatory demyelinating polyneuritis
G61.82	Multifocal motor neuropathy
G61.89	Other inflammatory polyneuropathies
I70.233	Atherosclerosis of native arteries of right leg with ulceration of ankle
I70.234	Atherosclerosis of native arteries of right leg with ulceration of heel and midfoot
I70.235	Atherosclerosis of native arteries of right leg with ulceration of other part of foot
I70.243	Atherosclerosis of native arteries of left leg with ulceration of ankle
I70.244	Atherosclerosis of native arteries of left leg with ulceration of heel and midfoot
I70.245	Atherosclerosis of native arteries of left leg with ulceration of other part of foot
I73.00	Raynaud's syndrome without gangrene
I73.01	Raynaud's syndrome with gangrene
I73.1	Thromboangiitis obliterans [Buerger's disease]
I73.81	Other specified peripheral vascular diseases
I80.00	Phlebitis and thrombophlebitis of superficial vessels of unspecified lower extremity
I80.01	Phlebitis and thrombophlebitis of superficial vessels of right lower extremity
I80.02	Phlebitis and thrombophlebitis of superficial vessels of left lower extremity
I80.03	Phlebitis and thrombophlebitis of superficial vessels of lower extremities, bilateral
I80.231	Phlebitis and thrombophlebitis of right tibial vein
I80.232	Phlebitis and thrombophlebitis of left tibial vein
I80.233	Phlebitis and thrombophlebitis of tibial vein, bilateral
I80.239	Phlebitis and thrombophlebitis of unspecified tibial vein
I80.241	Phlebitis and thrombophlebitis of right peroneal vein
I80.242	Phlebitis and thrombophlebitis of left peroneal vein
I80.243	Phlebitis and thrombophlebitis of peroneal vein, bilateral
I80.249	Phlebitis and thrombophlebitis of unspecified peroneal vein
I80.251	Phlebitis and thrombophlebitis of right calf muscular vein
I80.252	Phlebitis and thrombophlebitis of left calf muscular vein
I80.253	Phlebitis and thrombophlebitis of calf muscular vein, bilateral
I80.259	Phlebitis and thrombophlebitis of unspecified calf muscular vein
I87.2	Venous insufficiency (chronic) (peripheral)
M05.071	Felty's syndrome, right ankle and foot
M05.072	Felty's syndrome, left ankle and foot
M05.079	Felty's syndrome, unspecified ankle and foot
M05.171	Rheumatoid lung disease with rheumatoid arthritis of right ankle and foot
M05.172	Rheumatoid lung disease with rheumatoid arthritis of left ankle and foot
M05.179	Rheumatoid lung disease with rheumatoid arthritis of unspecified ankle and foot
M05.271	Rheumatoid vasculitis with rheumatoid arthritis of right ankle and foot
M05.272	Rheumatoid vasculitis with rheumatoid arthritis of left ankle and foot
M05.279	Rheumatoid vasculitis with rheumatoid arthritis of unspecified ankle and foot
M05.371	Rheumatoid heart disease with rheumatoid arthritis of right ankle and foot
M05.372	Rheumatoid heart disease with rheumatoid arthritis of left ankle and foot
M05.379	Rheumatoid heart disease with rheumatoid arthritis of unspecified ankle and foot
M05.471	Rheumatoid myopathy with rheumatoid arthritis of right ankle and foot
M05.472	Rheumatoid myopathy with rheumatoid arthritis of left ankle and foot
M05.479	Rheumatoid myopathy with rheumatoid arthritis of unspecified ankle and foot
M05.571	Rheumatoid polyneuropathy with rheumatoid arthritis of right ankle and foot
M05.572	Rheumatoid polyneuropathy with rheumatoid arthritis of left ankle and foot
M05.579	Rheumatoid polyneuropathy with rheumatoid arthritis of unspecified ankle and foot
M05.671	Rheumatoid arthritis of right ankle and foot with involvement of other organs and systems
M05.672	Rheumatoid arthritis of left ankle and foot with involvement of other organs and systems
M05.679	Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems
M05.771	Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement
M05.772	Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
M05.779	Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement
M05.871	Other rheumatoid arthritis with rheumatoid factor of right ankle and foot
M05.872	Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
M05.879	Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot
M06.071	Rheumatoid arthritis without rheumatoid factor, right ankle and foot
M06.072	Rheumatoid arthritis without rheumatoid factor, right ankle and foot
M06.079	Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot
M06.271	Rheumatoid bursitis, right ankle and foot
M06.272	Rheumatoid bursitis, left ankle and foot
M06.279	Rheumatoid bursitis, unspecified ankle and foot
M06.371	Rheumatoid nodule, right ankle and foot
M06.372	Rheumatoid nodule, left ankle and foot
M06.379	Rheumatoid nodule, unspecified ankle and foot
M06.871	Other specified rheumatoid arthritis, right ankle and foot
M06.872	Other specified rheumatoid arthritis, left ankle and foot
M06.879	Other specified rheumatoid arthritis, unspecified ankle and foot
M10.071	Idiopathic gout, right ankle and foot
M10.072	Idiopathic gout, left ankle and foot
M10.079	Idiopathic gout, unspecified ankle and foot
M12.071	Chronic post-rheumatic arthropathy [Jaccoud], right ankle and foot
M12.072	Chronic post-rheumatic arthropathy [Jaccoud], left ankle and foot
M12.079	Chronic post-rheumatic arthropathy [Jaccoud], unspecified ankle and foot
M12.171	Kaschin-Beck disease, right ankle and foot
M12.172	Kaschin-Beck disease, left ankle and foot
M12.179	Kaschin-Beck disease, unspecified ankle and foot
M12.271	Villonodular synovitis (pigmented), right ankle and foot
M12.272	Villonodular synovitis (pigmented), left ankle and foot
M12.279	Villonodular synovitis (pigmented), unspecified ankle and foot
M12.571	Traumatic arthropathy, right ankle and foot
M12.572	Traumatic arthropathy, left ankle and foot
M12.579	Traumatic arthropathy, unspecified ankle and foot
M14.671	Charcot's joint, right ankle and foot
M14.672	Charcot's joint, left ankle and foot
M14.679	Charcot's joint, unspecified ankle and foot
M05.679	Rheumatoid arthritis of unspecified ankle and foot with involvement of other organs and systems
M05.771	Rheumatoid arthritis with rheumatoid factor of right ankle and foot without organ or systems involvement
M05.772	Rheumatoid arthritis with rheumatoid factor of left ankle and foot without organ or systems involvement
M05.779	Rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot without organ or systems involvement
M05.871	Other rheumatoid arthritis with rheumatoid factor of right ankle and foot
M05.872	Other rheumatoid arthritis with rheumatoid factor of left ankle and foot
M05.879	Other rheumatoid arthritis with rheumatoid factor of unspecified ankle and foot
M06.071	Rheumatoid arthritis without rheumatoid factor, right ankle and foot
M06.072	Rheumatoid arthritis without rheumatoid factor, right ankle and foot
M06.079	Rheumatoid arthritis without rheumatoid factor, unspecified ankle and foot
M06.271	Rheumatoid bursitis, right ankle and foot
M06.272	Rheumatoid bursitis, left ankle and foot
M06.279	Rheumatoid bursitis, unspecified ankle and foot
M06.371	Rheumatoid nodule, right ankle and foot
M06.372	Rheumatoid nodule, left ankle and foot
M06.379	Rheumatoid nodule, unspecified ankle and foot
M06.871	Other specified rheumatoid arthritis, right ankle and foot
M06.872	Other specified rheumatoid arthritis, left ankle and foot
M06.879	Other specified rheumatoid arthritis, unspecified ankle and foot
M10.071	Idiopathic gout, right ankle and foot
M10.072	Idiopathic gout, left ankle and foot
M10.079	Idiopathic gout, unspecified ankle and foot
M12.071	Chronic post-rheumatic arthropathy [Jaccoud], right ankle and foot
M12.072	Chronic post-rheumatic arthropathy [Jaccoud], left ankle and foot
M12.079	Chronic post-rheumatic arthropathy [Jaccoud], unspecified ankle and foot
M12.171	Kaschin-Beck disease, right ankle and foot
M12.172	Kaschin-Beck disease, left ankle and foot
M12.179	Kaschin-Beck disease, unspecified ankle and foot
M12.271	Villonodular synovitis (pigmented), right ankle and foot
M12.272	Villonodular synovitis (pigmented), left ankle and foot
M12.279	Villonodular synovitis (pigmented), unspecified ankle and foot
M12.571	Traumatic arthropathy, right ankle and foot
M12.572	Traumatic arthropathy, left ankle and foot
M12.579	Traumatic arthropathy, unspecified ankle and foot
M14.671	Charcot's joint, right ankle and foot
M14.672	Charcot's joint, left ankle and foot
M14.679	Charcot's joint, unspecified ankle and foot
M17.0	Bilateral primary osteoarthritis of knee
M17.10	Unilateral primary osteoarthritis, unspecified knee
M17.11	Unilateral primary osteoarthritis, right knee
M17.12	Unilateral primary osteoarthritis, left knee
M17.2	Bilateral post-traumatic osteoarthritis of knee
M17.30	Unilateral post-traumatic osteoarthritis, unspecified knee
M17.31	Unilateral post-traumatic osteoarthritis, right knee
M17.32	Unilateral post-traumatic osteoarthritis, left knee
M17.4	Other bilateral secondary osteoarthritis of knee
M17.5	Other unilateral secondary osteoarthritis of knee
M17.9	Osteoarthritis of knee, unspecified
M19.071	Primary osteoarthritis, right ankle and foot
M19.072	Primary osteoarthritis, left ankle and foot
M19.079	Primary osteoarthritis, unspecified ankle and foot
M19.171	Post-traumatic osteoarthritis, right ankle and foot
M19.172	Post-traumatic osteoarthritis, left ankle and foot
M19.179	Post-traumatic osteoarthritis, unspecified ankle and foot
M19.271	Secondary osteoarthritis, right ankle and foot
M19.272	Secondary osteoarthritis, left ankle and foot
M19.279	Secondary osteoarthritis, unspecified ankle and foot
M20.10	Hallux valgus (acquired), unspecified foot
M20.11	Hallux valgus (acquired), right foot
M20.12	Hallux valgus (acquired), left foot
M20.20	Hallux rigidus, unspecified foot
M20.21	Hallux rigidus, right foot
M20.22	Hallux rigidus, left foot
M20.30	Hallux varus (acquired), unspecified foot
M20.31	Hallux varus (acquired), right foot
M20.32	Hallux varus (acquired), left foot
M20.40	Other hammer toe(s) (acquired), unspecified foot
M20.41	Other hammer toe(s) (acquired), right foot
M20.42	Other hammer toe(s) (acquired), left foot
M20.5X1	Other deformities of toe(s) (acquired), right foot
M20.5X2	Other deformities of toe(s) (acquired), left foot
M20.5X9	Other deformities of toe(s) (acquired), unspecified foot
M20.60	Acquired deformities of toe(s), unspecified, unspecified foot
M20.61	Acquired deformities of toe(s), unspecified, right foot
M20.62	Acquired deformities of toe(s), unspecified, left foot
M21.071	Valgus deformity, not elsewhere classified, right ankle
M21.072	Valgus deformity, not elsewhere classified, left ankle
M21.079	Valgus deformity, not elsewhere classified, unspecified ankle
M21.171	Varus deformity, not elsewhere classified, right ankle
M21.172	Varus deformity, not elsewhere classified, left ankle
M21.179	Varus deformity, not elsewhere classified, unspecified ankle
M21.271	Flexion deformity, right ankle and toes
M21.272	Flexion deformity, left ankle and toes
M21.279	Flexion deformity, unspecified ankle and toes
M21.371	Foot drop, right foot
M21.372	Foot drop, left foot
M21.379	Foot drop, unspecified foot
M21.40	Flat foot [pes planus] (acquired), unspecified foot
M21.41	Flat foot [pes planus] (acquired), right foot
M21.42	Flat foot [pes planus] (acquired), left foot
M21.541	Acquired clubfoot, right foot
M21.542	Acquired clubfoot, left foot
M21.549	Acquired clubfoot, unspecified foot
M21.611	Bunion of right foot
M21.612	Bunion of left foot
M21.619	Bunion of unspecified foot
M21.621	Bunionette of right foot
M21.622	Bunionette of left foot
M21.629	Bunionette of unspecified foot
M21.6X1	Other acquired deformities of right foot
M21.6X2	Other acquired deformities of left foot
M21.6X9	Other acquired deformities of unspecified foot
M21.70	Unequal limb length (acquired), unspecified site
M21.751	Unequal limb length (acquired), right femur
M21.752	Unequal limb length (acquired), left femur
M21.759	Unequal limb length (acquired), unspecified femur
M21.761	Unequal limb length (acquired), right tibia
M21.762	Unequal limb length (acquired), left tibia
M21.763	Unequal limb length (acquired), right fibula
M21.764	Unequal limb length (acquired), left fibula
M21.769	Unequal limb length (acquired), unspecified tibia and fibula
M24.571	Contracture, right ankle
M24.572	Contracture, left ankle
M24.573	Contracture, unspecified ankle
M24.574	Contracture, right foot
M24.575	Contracture, left foot
M24.576	Contracture, unspecified foot
M24.871	Other specific joint derangements of right ankle, not elsewhere classified
M24.872	Other specific joint derangements of left ankle, not elsewhere classified
M24.873	Other specific joint derangements of unspecified ankle, not elsewhere classified
M24.874	Other specific joint derangements of right foot, not elsewhere classified
M24.875	Other specific joint derangements left foot, not elsewhere classified
M24.876	Other specific joint derangements of unspecified foot, not elsewhere classified
M25.271	Flail joint, right ankle and foot
M25.272	Flail joint, left ankle and foot
M25.279	Flail joint, unspecified ankle and foot
M25.371	Other instability, right ankle
M25.372	Other instability, left ankle
M25.373	Other instability, unspecified ankle
M25.374	Other instability, right foot
M25.375	Other instability, left foot
M25.376	Other instability, unspecified foot
M65.871	Other synovitis and tenosynovitis, right ankle and foot
M65.872	Other synovitis and tenosynovitis, left ankle and foot
M65.879	Other synovitis and tenosynovitis, unspecified ankle and foot
M65.90	Unspecified synovitis and tenosynovitis, unspecified site
M65.971	Unspecified synovitis and tenosynovitis, right ankle and foot
M65.972	Unspecified synovitis and tenosynovitis, left ankle and foot
M65.979	Unspecified synovitis and tenosynovitis, unspecified ankle and foot
M65.98	Unspecified synovitis and tenosynovitis, other site
M65.99	Unspecified synovitis and tenosynovitis, multiple sites
M66.871	Spontaneous rupture of other tendons, right ankle and foot
M66.872	Spontaneous rupture of other tendons, left ankle and foot
M66.879	Spontaneous rupture of other tendons, unspecified ankle and foot
M67.A	Plantar fasciitis
M67.A0	Plantar fasciitis, foot
M67.A01	Plantar fasciitis, right foot
M67.A02	Plantar fasciitis, left foot
M67.A09	Plantar fasciitis, unspecified foot
M67.00	Short Achilles tendon (acquired), unspecified ankle
M67.01	Short Achilles tendon (acquired), right ankle
M67.02	Short Achilles tendon (acquired), left ankle
M67.471	Ganglion, right ankle and foot
M67.472	Ganglion, left ankle and foot
M67.479	Ganglion, unspecified ankle and foot
M67.871	Other specified disorders of synovium, right ankle and foot
M67.872	Other specified disorders of synovium, left ankle and foot
M67.873	Other specified disorders of tendon, right ankle and foot
M67.874	Other specified disorders of tendon, left ankle and foot
M67.879	Other specified disorders of synovium and tendon, unspecified ankle and foot
M71.371	Other bursal cyst, right ankle and foot
M71.372	Other bursal cyst, left ankle and foot
M71.379	Other bursal cyst, unspecified ankle and foot
M71.571	Other bursitis, not elsewhere classified, right ankle and foot
M71.572	Other bursitis, not elsewhere classified, left ankle and foot
M71.579	Other bursitis, not elsewhere classified, unspecified ankle and foot
M71.871	Other specified bursopathies, right ankle and foot
M71.872	Other specified bursopathies, left ankle and foot
M71.879	Other specified bursopathies, unspecified ankle and foot
M72.2	Plantar fascial fibromatosis
M72.20	Plantar fascial fibromatosis, unspecified foot
M72.21	Plantar fascial fibromatosis, right foot
M72.22	Plantar fascial fibromatosis, left foot
M76.60	Achilles tendinitis, unspecified leg
M76.61	Achilles tendinitis, right leg
M76.62	Achilles tendinitis, left leg
M76.70	Peroneal tendinitis, unspecified leg
M76.71	Peroneal tendinitis, right leg
M76.72	Peroneal tendinitis, left leg
M76.811	Anterior tibial syndrome, right leg
M76.812	Anterior tibial syndrome, left leg
M76.819	Anterior tibial syndrome, unspecified leg
M76.821	Posterior tibial tendinitis, right leg
M76.822	Posterior tibial tendinitis, left leg
M76.829	Posterior tibial tendinitis, unspecified leg
M77.30	Calcaneal spur, unspecified foot
M77.31	Calcaneal spur, right foot
M77.32	Calcaneal spur, left foot
M86.171	Other acute osteomyelitis, right ankle and foot
M86.172	Other acute osteomyelitis, left ankle and foot
M86.179	Other acute osteomyelitis, unspecified ankle and foot
M86.271	Subacute osteomyelitis, right ankle and foot
M86.272	Subacute osteomyelitis, left ankle and foot
M86.279	Subacute osteomyelitis, unspecified ankle and foot
M86.371	Chronic multifocal osteomyelitis, right ankle and foot
M86.372	Chronic multifocal osteomyelitis, left ankle and foot
M86.379	Chronic multifocal osteomyelitis, unspecified ankle and foot
M86.471	Chronic osteomyelitis with draining sinus, right ankle and foot
M86.472	Chronic osteomyelitis with draining sinus, left ankle and foot
M86.479	Chronic osteomyelitis with draining sinus, unspecified ankle and foot
M86.671	Other chronic osteomyelitis, right ankle and foot
M86.672	Other chronic osteomyelitis, left ankle and foot
M86.8X71	Other osteomyelitis, right ankle and foot
M86.8X72	Other osteomyelitis, left ankle and foot
M86.8X79	Other osteomyelitis, unspecified ankle and foot
M86.679	Chronic osteomyelitis with draining sinus, unspecified ankle and foot
M89.8X7	Other specified disorders of bone, ankle and foot
M92.60	Juvenile osteochondrosis of tarsus, unspecified ankle
M92.61	Juvenile osteochondrosis of tarsus, right ankle
M92.62	Juvenile osteochondrosis of tarsus, left ankle
M92.70	Juvenile osteochondrosis of metatarsus, unspecified foot
M92.71	Juvenile osteochondrosis of metatarsus, right foot
M92.72	Juvenile osteochondrosis of metatarsus, left foot
Q66.00	Congenital talipes equinovarus, unspecified foot
Q66.01	Congenital talipes equinovarus, right foot
Q66.02	Congenital talipes equinovarus, left foot
Q66.10	Congenital talipes calcaneovarus, unspecified foot
Q66.11	Congenital talipes calcaneovarus, right foot
Q66.12	Congenital talipes calcaneovarus, left foot
Q66.211	Congenital metatarsus primus varus, right foot
Q66.212	Congenital metatarsus primus varus, left foot
Q66.219	Congenital metatarsus primus varus, unspecified foot
Q66.221	Congenital metatarsus adductus, right foot
Q66.222	Congenital metatarsus adductus, left foot
Q66.229	Congenital metatarsus adductus, unspecified foot
Q66.30	Other congenital varus deformities of feet, unspecified foot
Q66.31	Other congenital varus deformities of feet, right foot
Q66.32	Other congenital varus deformities of feet, left foot
Q66.40	Congenital talipes calcaneovalgus, unspecified foot
Q66.41	Congenital talipes calcaneovalgus, right foot
Q66.42	Congenital talipes calcaneovalgus, left foot
Q66.50	Congenital pes planus, unspecified foot
Q66.51	Congenital pes planus, right foot
Q66.52	Congenital pes planus, left foot
Q66.6	Other congenital valgus deformities of feet
Q66.70	Congenital pes cavus, unspecified foot
Q66.71	Congenital pes cavus, right foot
Q66.72	Congenital pes cavus, left foot
Q66.80	Congenital vertical talus deformity, unspecified foot
Q66.81	Congenital vertical talus deformity, right foot
Q66.82	Congenital vertical talus deformity, left foot
Q66.89	Other specified congenital deformities of feet
Q66.90	Congenital deformity of feet, unspecified, unspecified foot
Q66.91	Congenital deformity of feet, unspecified, right foot
Q66.92	Congenital deformity of feet, unspecified, left foot

References

American Diabetes Association. Preventive foot care in people with diabetes. Diabetes Care. 2000;23 Suppl 1:S55-S56.
Ashford RL, Kippen C, Rome K. Interventions for pes planus. Cochrane Database of Systematic Reviews. 2005;(1):CD005120.
Burns J, Landorf KB, Ryan MM, et al. Interventions for the prevention and treatment of pes cavus. Cochrane Database Syst Rev. 2007;(4):CD006154.
Clark H, Rome K, Plant M, et al. A critical review of foot orthoses in the rheumatoid arthritic foot. Rheumatology (Oxford). 2006;45(2):139-145.
Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev. 2003;(3):CD000416.
Gabriner ML, Braun BA, Houston MN, Hoch MC. The effectiveness of foot orthotics in improving postural control in individuals with chronic ankle instability: A critically appraised topic. J Sport Rehabil. 2015;24(1):68-71. DOI: 10.1123/jsr.2013-0036.
Hijmans JM, Geertzen JH, Dijkstra PU, Postema K. A systematic review of the effects of shoes and other ankle or foot appliances on balance in older people and people with peripheral nervous system disorders. Gait Posture. 2007;25(2):316-323. DOI: 10.1016/j.gaitpost.2006.03.010.
Hume P, Hopkins W, Rome K, et al. Effectiveness of foot orthoses for treatment and prevention of lower limb injuries: A review. Sports Med. 2008;38(9):759-779. DOI: 10.2165/00007256-200838090-00005.
Nordian Healthcare Solutions, LLC (NHS). Orthopedic Footwear. Local Coverage Determination No. L33641. Durable Medical Equipment Medicare Administrative Carrier Jurisdiction J-A; revised January 1, 2017.
Papuga MO, Cambron J. Foot orthotics for low back pain: The state of our understanding and recommendations for future research. Foot (Edinb). 2016;26:53-57. DOI: 10.1016/j.foot.2015.12.002.
Ferrari J. Hallux valgus deformity (bunion). In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated May 20, 2025. Literature review current through Jul 2025.
Thomas JL, Christensen JC, Kravitz SR, et al. The diagnosis and treatment of heel pain: a clinical practice guideline-revision 2010. J Foot Ankle Surg. 2010;49(3 Suppl):S1-S19. doi:10.1053/j.jfas.2010.01.001. PMID: 20439021.
Fields K, Atkinson B. Evaluation and diagnosis of common causes of forefoot pain in adults. In: UpToDate Online Journal [serial online]. Waltham, MA: UpToDate; updated Mar 21, 2025. Literature review through Jul 2025.
van Netten JJ, Jannink MJ, Hijmans JM, Geertzen JH, Postema K. Long-term use of custom-made orthopedic shoes: 1.5-year follow-up study. J Rehabil Res Dev. 2010;47(7):643-649. doi:10.1682/jrrd.2010.03.0040. PMID: 21110260.
Hawke F, Burns J, Radford JA, du Toit V. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database of Systematic Reviews. 2008;(3):CD006801.
Herchenröder M, Goetz K, Stamer T, Klee M, Steinhäuser J. Physicians' experiences with indications and prescriptions of foot orthoses-A cross-sectional study in northern Germany. Heliyon. 2024;10(13):e33584. Published 2024 Jun 24. PMID: 39035521.
Edwards K, Borthwick A, McCulloch L, et al. Evidence for current recommendations concerning the management of foot health for people with chronic long-term conditions: a systematic review. J Foot Ankle Res. 2017;10:51. Published 2017 Nov 22. PMID: 29201147.
Mohaddis M, Maqsood SA, Ago E, Singh S, Naim Z, Prasad S. Enhancing Functional Rehabilitation Through Orthotic Interventions for Foot and Ankle Conditions: A Narrative Review. Cureus. 2023;15(11):e49103. Published 2023 Nov 20.
Robinson C, Major MJ, Kuffel C, Hines K, Cole P. Orthotic management of the neuropathic foot: an interdisciplinary care perspective. Prosthet Orthot Int. 2015;39(1):73-81. doi:10.1177/0309364614545422.
US Department of Health and Human Services. Lower Extremity Amputation Prevention (LEAP).

Policy history
MP 6.028	04/02/2020 Consensus review. Policy statement unchanged. References reviewed and updated.
	03/19/2021 Consensus review. Updated references. Added brand new HCPCS code K1015.
	07/20/2022 Consensus review. No change to policy statement. FEP language updated. References reviewed and updated.
	08/17/2023 Minor review. Removed frequency limitation for shoes and inserts. Removed "foot orthotics should not be considered first line therapy." List of conditions moved from policy statement to policy guidelines. Updated background and references.
	12/12/2023 Administrative update. Code K1015 deleted, new code L3161 added. Effective 01/01/2024.
	12/30/2024 Consensus review. No change to intent. Not medically necessary language updated to investigational. New references. Added ICD-10 codes.
	08/20/2025 Consensus. No changes to policy statement, updated references.
	10/22/2025 Administrative update. Removed Product Variations section and updated disclaimer.
	07/15/2026 Administrative update. Removed L3208-L3214 and L3260 from policy.
	09/11/2026 Administrative update. Added ICD-10 codes M67.A, M67.A0, M67.A01, M67.A02, M67.A09, M72.20, M72.21, M72.22, M86.8X71, M86.8X72, and M86.8X79, effective 10/01/2026.

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