Custom Orthotics Covered by Insurance

Custom orthotics covered by insurance? The reality is that unless you have a serious underlying condition like diabetes, getting coverage will be extremely difficult as many insurance companies have unique clauses denying coverage for custom orthotics. 

Key Takeaways

• Insurance coverage for custom orthotics is limited and also quite complex. The language can be confusing, leaving room for claims to be denied for minor errors.
• Coverage is often provided for devices required as a medical necessity. However, determining medical necessity can be tough.
• Coverage will often only be available for severe foot conditions and those that are diabetes-related.
• Coverage can be denied for many reasons including inability to prove medical necessity, insufficient documentation, using the wrong HCBCS code, and even getting your prescription or device from non-enrolled doctors and providers.
• All insurance plans are not the same and do not provide the same extent of coverage. So, coverage for custom orthotics will ultimately depend on the type of insurance plan you have.
• There are a few alternatives, like Flexible Spending Account and Health Savings Accounts

How Insurance Companies Determine Coverage for Orthotics

Most insurance companies provide coverage for orthotics based on the following criteria:

Device Qualification

For any orthotic device to be covered in any health insurance plan, it must qualify as a DME Durable Medical Equipment meeting the following criteria:

• Prescribed by a healthcare provider with the appropriate licensing.
• Prescribed for a medical reason and not to improve athletic performance or comfort.
• Designed for repeated use.

However, even if your orthotics meet the criteria as a “Durable Medical Equipment” will not automatically be covered as there are other considerations depending on the insurer (as we will discuss later). 

Medical Necessity

Medical necessity is a core requirement to be eligible for coverage. According to healthcare.gov, a health care service will be considered necessary or a necessity if it is required to "diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine."

So, even if a medical device meets the DME criteria, it has to pass the medical necessity test. For most insurance companies, this means the following:

• A healthcare practitioner has carried out a thorough assessment and diagnosis to determine that the individual has a condition that significantly hampers their mobility and ability to function normally.
• Other treatment options have been exhausted with no positive results.
• The recommended orthotic device is considered an option that will either improve or correct the condition, or at least prevent it from getting worse.

Specifics of Individual Insurance Plans

All insurance plans are not the same and do not provide the same extent of coverage. This means that, even if the device meets the DME requirement and qualifies as a medical necessity, whether or not your insurer will cover the device will ultimately depend on the plan you have with them.

Some examples of provisions that may be included in a plan include the following:

• Not including custom shoe inserts that are not part of a brace.
• Limiting coverage to specific health conditions: An example is Medicare's plan that specifically covers orthotics for foot conditions that are diabetes-related.
• Restriction to approved providers: Some insurers will only cover devices gotten from approved providers. For example, Medicare states clearly that it "will only cover your therapeutic shoes if your doctors and suppliers are enrolled in Medicare."

Orthotic Coverage Provided by 3 Major Insurance Companies

Insurance for orthotics is determined by the insurance company and the provisions of the actual plan you choose. As you'll see from three examples below, while you may think custom orthotics are covered, the details reveal how difficult it truly is to get custom orthotics covered by insurance. 

Important Note: You must read all fine print from your carrier to get a full picture of what is/isn't covered. Even if your podiatrist/clinician says custom orthotics are covered, they are likely not experts on your individual plan! It's on you to know your own coverage. 

Medicare

According to the official Medicare website, medicare.gov, its Medicare Part B offers coverage for orthotic inserts. However, you are only eligible if "you have diabetes and severe diabetes-related foot disease."

In Medicare Part C, also known as Medicare Advantage and offered by private insurers, you get the same coverage as Part B. However, depending on the insurer, you may get plans with expanded coverage, which will of course, attract additional premiums.

Aetna

In Aetna's policy limitations and exclusions, most of its plans "exclude coverage of orthopedic shoes, foot orthotics, or other supportive devices of the feet" except when they meet the following conditions:

• It is a key part of a leg brace, and the cost of the brace covers the orthotic inserts.
• They are rehabilitative foot orthotics required as part of post-traumatic casting or post-surgical care.

Even for plans that provide coverage for foot orthotics for specific conditions like chronic or acute plantar fasciitis, chronic ankle instability, heel spurs, and other listed conditions, this coverage does not include custom foot inserts, which are classified under HCPCS code L3000.

The conclusion we can draw from the above is that Aetna’s coverage for orthotics is limited and will only cover severe cases, especially where braces are required.

Cigna

In addition to providing coverage for some types of orthotics under similar terms as the other insurers, Cigna also provides coverage for DMEs (Durable Medical Equipment) with the HCPCS code range of L3000 to L3031, which includes custom foot orthosis. They must, however, be for a specific list of conditions.

One of these approved conditions is congenital, or acquired foot deformity under the following strict guidelines:

• The deformity must be caused by symptomatic rigid flat foot, posterior tibial tendon dysfunction, or mid or hind-foot arthritis.
• The deformity causes a level of pain that results in impaired gait, disruption of balance, or reduced mobility, all of which interfere with the member's daily functions.
• Conservative treatments have been exhausted without success.
• The health care provider believes that the orthotic device will improve the condition.

Once again, coverage appears to be available only for really extreme cases, and even at that, under strict conditions.

Other major insurers, like UnitedHealthCare and BCBS partners, operate similar frameworks. For BCBS, there will be slight differences depending on respective state regulations.

Conditions that May Qualify for Custom Orthotics Insurance Coverage

After carefully studying the coverages provided by major insurers for custom orthotics, we can conclude that coverage is only likely to be provided for custom orthotics for the following conditions:

Diabetes-Related Foot Condition

Most insurance companies will provide coverage for custom orthotics when required for foot conditions that are diabetes-related. Examples include:

• Diabetes-linked foot conditions
• Ulceration or history of ulcers
• Poor circulation (peripheral vascular disease)
• Severe diabetic neuropathy.

It is, however, important to note that patients with diabetes are not automatically covered. They must meet the criteria set by the insurance company. According to Aetna, "therapeutic shoes and inserts for diabetes are considered experimental, investigational, or unproven when these criteria are not met."

Severe Foot Deformities

Insurers like UHC and Aetna provide orthotics coverage for severe foot deformities that meet specific criteria. Some of the required criteria include:

• Chronic pain caused by the deformity
• Change in gait and balance
• Impaired function arising from the deformity

Having these deformities, like club foot, flat foot, high arch hammertoes, or bunions, does not automatically qualify an individual for insurance coverage. The qualifying criteria have to be met, which means that a foot deformity that does not cause severe pain may not be covered.

Musculoskeletal or Neurological Disorders

A lot of insurance companies will provide coverage for orthotics required for muscular or neurological issues that affect an individual's stability and gait. These include:

• Stroke-related foot drop
• Muscular dystrophy
• Cerebral palsy
• Multiple Sclerosis

Note that coverage may be denied if the device required is considered to be a training aid, for preventive purposes, or sports-related. Coverage may also be denied if the symptoms are considered mild and not clearly linked to a neurological diagnosis.

Post-Surgical or Post-Traumatic Conditions

The major insurers will provide coverage for post-surgical needs, like recovery from reconstructive, joint fusion, or tendon transfer surgeries. They will also cover post-traumatic conditions, like improperly healed foot or ankle fractures.

Coverage will often not extend beyond an acceptable recovery period or for conditions that the insurer believes that an over-the-counter brace could have sufficed. They will also not provide coverage for orthotics required for injuries classified as strains, minor sprains, or temporary.

Arthritis and Degenerative Joint Disease

Some insurers offer health insurance plans that provide Orthotics coverage for osteoarthritis and rheumatoid arthritis. Examples include severe rheumatoid arthritis-related toe deformity or a mid-foot or hind-foot collapse that causes arthritis.

Coverage will, however, be denied for cases where options like physical therapy, injections, and footwear changes have not been exhausted. Cases of generalized joint pain or mild arthritis that cause occasional pain, which the insurer considers manageable with over-the-counter inserts, will also not be covered.

Chronic Pain or Mobility Issues

Insurance companies, like UHC, have plans that offer coverage for chronic pain and conditions that limit mobility. In most cases, the coverage is dependent on the establishment of the following:

• The pain can be linked to a diagnosed medical condition
• Conservative treatment options like, physical therapy, OTC inserts, and medication, have failed to yield the desired outcome.

Some examples of medical conditions that can lead to such qualifying pain include severe plantar fasciitis, Morton's neuroma, or metatarsalgia. Remember that this coverage does not extend to athletic performance enhancement or orthotics required to improve general comfort.

Pediatric Growth and Developmental Challenges

Insurance companies, like UHC and BCBS, offer plans that provide coverage for minors with qualifying growth and developmental challenges. Examples of such qualifying conditions include: painful flatfoot in children, severe in-toeing (pigeon toe) or out-toeing (duck feet), and other conditions that affect growth but can be corrected with the use of orthotics.

Note that mild flatfoot in children will often be considered normal since children often do not have fully developed arches until between the ages of 6 to 8. Coverage will, therefore, be denied if the insurer determines that the condition will self-correct as the child grows.

Partial Foot Loss or Amputations

Most insurance companies will provide coverage for custom orthotics for patients with partial foot loss or amputations. These include loss of toes and metatarsals. In this coverage, insurers treat these orthotics as prosthetics required to restore normalcy to the body's biomechanics.

Coverage will likely be denied if the device requested does not fall within the insurer's definition of orthotics.

Some Common Reasons Why Claims for Custom Orthotics Are Denied

Some of the common reasons why claims are denied include the following:

Poor Documentation

To make a claim that will be approved, you must provide sufficient proof that the claim meets the criteria laid out. These include:

• Proof of medical necessity
• Medical evidence of precise diagnosis
• Evidence that conservative treatment options have been tried without achieving the desired result.

To prove the above, your documentation must include:

• Detailed clinical notes
• Letter of medical necessity
• Results of tests and diagnosis

All of the above must be from a qualified and licensed healthcare provider. Some insurers will also require that this medical practitioner be enrolled with them.

Using Incorrect Billing Codes

Specific billing codes are required when making claims. These Healthcare Common Procedure Coding System (HCPCS) codes ensure that you are billing for the correct condition. For example, HCPCS codes L3000 to L3060 cover foot inserts while codes L1900 to L1990 cover ankle supports.

Note that claims will be denied when any of the following occurs:

• The claim is filed with the wrong code
• The code submitted does not match the condition as outlined in the supporting documentation
• There is no supporting documentation to back the choice of billing code.

Even when an honest mistake is made, it can lead to a denial or even an audit. You should, therefore, ensure that you know and use the correct code.

Getting Prescriptions and the Device from Unapproved Doctors and Providers

An otherwise valid claim can be denied by some insurance companies if the prescription is given by a doctor not enrolled with them. The same rule will also often apply with the provider of the device.

A good example is Medicare which insists that both the prescription and supply of the devices must be from doctors and healthcare providers enrolled with them. It, therefore, means that going outside of the network for prescription and the device will lead to your claim being denied.

Limits on Frequency and Replacements

Insurance companies often have a limited number of orthotics that will be covered within a given period. For example, Aetna will only cover two pairs inserts in addition to the pair in the custom molded shoes, in a calendar year per member.

This means that any claims made after this quota has been reached will be denied.

Improve Your Chances for Approval with this Checklist

If you are sure that your condition meets the criteria that have been discussed in this article, then this checklist will help ensure that your claims are approved.

Doctor's Clinical Notes

Have your doctor's clinical notes showing the exact and detailed diagnosis, a description of the symptoms, findings from the physical examination, and how all of these affect your ability to function normally.

Keep Records and Proof of Failed Conservative Treatments

Your healthcare provider should keep a record of conservative treatments that have been tried without success. These should include:

• Date and duration of use (OTC devices)
• Records of physical therapy sessions you've had
• Medications that have been prescribed
• Any other treatment options that have been explored without success

All of these are to show to the insurer that attempts to treat the condition with conservative treatment options were made but failed.

Get a Letter of Medical Necessity

A letter of medical necessity should be written by a specialist and not a general physician. In the case of orthotics, it should be written by a podiatrist or an orthopedist and should include the following details:

• A history of the patient's diagnosis and treatment
• Reason why the attempted treatments failed
• An explanation of why custom orthotics, and not OTC options, are required
• How custom orthotics will improve the condition
• The long-term risk of not getting custom orthotics

This is to prove the medical necessity of the device beyond any doubt.

Get Results for Gait Analysis, Biomechanical Assessment, and Imaging

If any tests have been conducted, have all the results ready. These will include results for:

• Gait analysis
• Biomechanical assessment
• Photos showing any foot deformities, pressure sores, or ulcers
• Imaging scans, like X-rays or MRIs

Having these visual evidence gives your claim more credence.

A Specialist Should Write Your Prescription

To strengthen your case, have a specialist write both your letter of medical necessity and prescription. Having these documents written by a specialist gives them more weight.

While this may not be a general rule, some insurance companies will deny claims when prescriptions are written by a general practitioner.

Get Proper Documentation from Your Orthotist and Supplier

Some insurance companies will only approve claims involving in-network providers. You should therefore confirm this before proceeding.

In many cases, in-network providers can file claims on your behalf, removing the need for some of the documentation you would have had to present. When this is not the case, get the supplier's invoice along with their National Provider Identifier (NPI) so you can easily prove that they are duly licensed in-network providers.

Use Correct HCPCS Codes

Finally, be sure to use the right billing code. We’ve already mentioned this above, explaining why it is important. If you will be filing the claim yourself, confirm the billing code before doing so.

This checklist will help you keep tabs on everything you will need to make a solid claim.

Insurance Alternatives to Consider

One thing that is clear so far is that most people who need and use orthotics may not be able to have them covered under most of the available health insurance plans. This is because of how the insurance companies define medical necessity.

Thankfully, there are a few alternatives that you can consider, and we will quickly run through some of them here.

FSA (Flexible Spending Accounts) and HSA (Health Savings Accounts)

FSAs and HSAs provide you with an opportunity to pay for qualified medical costs with pre-tax earnings. With this alternative, you pay for custom orthotics you get with a prescription, while making some savings since the funds are not taxed.

To be sure that your purchase will be reimbursed, ensure you make your purchase from providers like Stride Soles that are FSA and HSA eligible.

Clinic and Provider Payment Plans

Some podiatry clinics and manufacturers may offer plans that allow you to pay in installments. This option to pay over some months will reduce the strain of making a one-off payment, especially considering that custom orthotics can be a bit expensive.

Promotions and Discount Programs

Be on the lookout for seasonal promotions or discounts offered by providers. A lot of providers offer discounts for every additional pair purchased. These discounts can save you up to 40% in some cases.

Aside from the fact that these discounts appear to be more common with online providers, you are also able to get medical-grade orthotics from online providers at more affordable prices than in-office providers.. 

Nonprofits and Charitable Organizations

There are charitable organizations that offer assistance to eligible candidates. Some of these organizations may offer orthotics at reduced prices or even at no cost.

You can check with your local hospital, VA office, or diabetes foundations to know if they have any such programs running.

Employer Benefits

Some employers may offer coverage for orthotics as part of their workplace wellness initiative.  You may want to check with your HR department to know if there is any such provision. It may be hidden somewhere under preventive care or office ergonomics.

Tax Deductions for Medical Expenses

As per the U.S tax code (IRC § 213), taxpayers can deduct certain qualified medical expenses that were not covered in their insurance plan. This will, however, be dependent on the percentage of the medical expense deductions from your Adjusted Gross Income (AGI) exceeding a stipulated threshold.

Currently, the threshold is 7.5% of the AGI. If your out-of-pocket medical expenses constitute more than 7.5% of your AGI, you can deduct the excess to cover the cost of a medical expense when filing your tax returns.

Conclusion

Insurance coverage for custom orthotics is not what many users would love it to be. We can see that most insurance companies will only provide coverage for really severe cases, and even then, under really strict conditions.

Having looked at this reality, we’ve provided some important information that will make it easier for your claims to be approved if you believe that you meet the criteria. For others, we’ve also looked at alternative options to consider.

With the information we have shared, you can now make an informed decision with regard to insurance for custom orthotics.