Does Cigna Cover Custom Orthotics

Cigna provides coverage for custom orthotics but only when they are deemed to be medically necessary by Cigna’s stringent coverage requirements. The extent and details of the coverage you will get for custom orthotics will ultimately be determined by the Cigna plan you subscribe to.

Key Takeaways

• Cigna covers custom orthotics, but under very strict medical necessity criteria that exclude most users.
• Medical necessity does not automatically qualify you for approval. The underlying cause must not be outside the list of conditions approved for medical necessity consideration by Cigna.
• The exact coverage for custom orthotics is determined by the plan you are subscribed to and your state of residence.
• In most Cigna plans, coverage for custom orthotics is limited to services and products from in-network providers and suppliers.
• When preauthorization is required, purchases made without it will be denied.
• Before subscribing to any plan, be sure that it offers coverage for custom orthotics under terms that you qualify for.

Understanding Cigna’s Coverage Policy for Custom Orthotics

Cigna’s coverage for custom orthotics is not as straightforward as giving a yes or no answer. Yes, in broad terms, Cigna covers custom orthotics, referred to as "custom foot orthosis" under the "orthotic devices and shoes" category of its Medical Coverage Policy document. However, this coverage is given under really strict terms, making it almost impossible for most users who need custom orthotics to get coverage for them

Factors that will affect whether or not you will qualify for custom orthotics coverage with Cigna include:

• Medical necessity that meets Cigna’s strict requirements.
• Diagnosis, to show that the need for custom orthotics is the result of an approved condition.

• The specifics of the plan to which you subscribe.

Medical Necessity

The medical necessity requirement is meant to show that the device is required to facilitate function and not for comfort. It’s, however, important to note that medical necessity, on its own, does not automatically guarantee coverage.

In fact, Cigna clearly states in its Medical Coverage Policy document that it will only consider custom orthotics a medical necessity “when there is failure, contraindication, or intolerance to a prefabricated foot orthosis” and under a specific list of conditions, which include the following:

• The orthotic device is an important part of a leg brace, required for the brace to function properly.
• There is a case of non-functioning peripheral sensation, inadequate peripheral circulation, or both.
• There is a case of neuromuscular or neurological condition that has resulted in spasticity, or an abnormal or pathological alignment of the foot. In this case, there must be a reasonable expectation that custom orthotics will help improve the condition.
• The applicant suffers from a congenital or acquired foot deformity that meets all the following criteria:
  • The deformity is caused by posterior tibial tendon dysfunction, symptomatic rigid flat foot, or mid or hind-foot arthritis.
  • The deformity causes such pain that normal daily activity is hampered, gait is impaired, and it also affects mobility and balance.
  • Conservative treatment options have been exhausted with no positive results.
  • Healthcare providers are positive that the use of custom orthotics will improve the condition.

• The custom orthotics are required to compensate for a missing portion of the foot. This can be as a result of amputation or other causes, making it necessary to help correct or alleviate defects arising from injury, illnesses, or congenital conditions.

Cigna clearly states that “A custom-fabricated foot orthosis (HCPCS codes L3000-L3031) for any other indication is not covered or reimbursable.”

From the above, it means that a person with a foot deformity not caused by posterior tibial tendon dysfunction, symptomatic rigid flat foot, or mid or hind-foot arthritis will not be covered for custom orthotics. It also means that, unless the company is convinced that custom orthotics can help improve the condition, coverage will not be provided, even if all other conditions have been met.

In general, Cigna will not provide coverage if the custom orthotics are required for generalized foot pain, arch discomfort, athletic performance, or even plantar fasciitis.

Diagnosis

Given Cigna’s definition of medical necessity, some examples of conditions that may qualify for coverage if other criteria are met include:

• Diabetes mellitus, chronic kidney disease, leprosy, and tarsal tunnel syndrome - These can cause impaired peripheral sensation.
• Non-Diabetic Peripheral Neuropathy - This can be caused by chemotherapy and vitamin B12 deficiency and can also result in impaired peripheral sensation.
• Peripheral artery disease, scleroderma, Raynaud's disease, and cold injury or frostbite - Which can all cause altered peripheral circulation.

• Stroke (Cerebrovascular Accident), multiple sclerosis, cerebral palsy, Parkinson's disease, spinal cord injury, and muscular dystrophy - These can all result in neurological/neuromuscular conditions.

Outside of this list, or any condition that can result in qualifying neuromuscular or neurological conditions, insufficient peripheral circulation, and non-functioning peripheral sensation, you’re likely not going to get coverage for custom orthotics from Cigna.

Plan Type

What we've described above is Cigna's general policy for custom orthotic coverage. However, some plans may offer more or even less coverage. For example, an employer-sponsored plan may offer more coverage for custom orthotics than a HMO plan or even another employer-sponsored plan.

It is therefore important that you understand exactly what the plan you choose covers. This may not be written in very plain language, so you may need to ask a lot of questions or have an expert explain it to you.

How to Check Your Cigna Plan for Orthotic Coverage

Here's a step-by-step guide to help you confirm the actual custom orthotics coverage that comes with your plan.

Step 1 - Summary of Benefits and Coverage

Carefully study your plan's Summary of Benefits and Coverage (SBC). This documentation comes with every plan. If you do not know where to find it, 

1. Log in to your account at mysigna.com
2. Select "Coverage" and then "View Plan Document."

3. Download your SBC document.

Look for the sections that discuss "Durable Medical Equipment," "Orthotic Devices," or "Custom Foot Orthosis." Ensure you read to understand important requirements like:

• What constitutes medical necessity
• Preauthorization requirement

• Frequency of replacement

Take note of the provisions, and if you do not understand any section, make a note of it.

Step 2 - Exclusions and Limitations

The first part of the SBC tells you what you stand to gain with the plan, but the exclusions and limitations section explains what you won’t be getting or conditions under which you may not get what you were supposed to get as described in the SBC.

Reading through these documents can be tedious and confusing. So, to make things easier, just search for the word "orthotics" so you can be taken to sections that discuss exclusion and limitations with regard to custom orthotics.

It is important that you fully understand the limitations and exclusions described in this document. Again, if there are things that are confusing to you, make a note of them.

Step 3 - Talk to Cigna Customer Service

Very few people read their SBC and understand everything. Having gone through your SBC, you should have noted the areas that were unclear. Ready with these marked sections, reach out to Cigna Member Services. Look for their contact number on the back of your insurance card.

Before making the call, be sure to have the following:

• Your member ID and plan type
• If you already work with a provider, have their name and tax ID

• The HCPCS or CPT code (you can always seek help from the person you speak with if you are unsure of this).

When you speak with Cigna's representative, start by getting their name and a reference number for the call. This is important just in case some information you receive at this point leads to a dispute in the future.

To get clarification on your plan's coverage for custom orthotics, you can ask the following questions:

• Does my plan cover custom orthotics? Specify that you're referring to foot orthotics with HCPCS codes L3000-L3060.
• Under what conditions will custom orthotics qualify as a medical necessity?
• Will preauthorization be required?
• Am I required to only use in-network providers?

• What is the frequency or replacement limit?

Answers to the questions above should provide greater clarity. Feel free to add any other questions you consider important.

How to Increase Your Chances of Getting Your Claim Approved

At this point, you need to ensure that you do everything by the book to increase your chances of having your claim approved. Here are a few things you can do:

Ask Your Healthcare Provider to Verify Coverage

Find out if your healthcare provider is familiar with Cigna's verification process. They can help you request preauthorization or submit a coverage verification request directly to Cigna. This will entail sending the following details:

• A diagnosis code
• The procedure code

• Documentation to support medical necessity claims

This will confirm your policy coverage and also enable you to get preauthorization where required.

Confirm Network Requirements

In many Cigna plans, only claims from in-network providers and suppliers will be considered. Given this, you should do the following:

• Confirm that both your healthcare provider and supplier for custom orthotics are in-network.
• Have your provider and supplier confirm their in-network status on Cigna’s portal.

• If you do not already have a healthcare provider and supplier, you can search Cigna’s directory to choose from their in-network list. Click on “Find a Doctor” on Cigna’s homepage to visit their directory.

Using out-of-network providers and suppliers may mean an outright denial of your claim. Depending on your plan, it may also mean you will have to pay out of pocket and then claim reimbursement later.

Keep All Documentation

Documentation is a very important part of the claims process. Even if your claim is denied, having a record of all your correspondence with Cigna, letters of authorization, estimates, doctor's reports, and all other relevant documents can help you win on appeal.

What You Require to Make a Successful Claim with Cigna

If you have met the conditions stipulated by Cigna for custom orthotics coverage, you will need the following to make a claim:

• Doctor’s Prescription - The device has to be prescribed by a qualified healthcare provider. Remember that Cigna requires the use of in-network providers, including doctors.
• Proof of Medical Necessity - A certified medical professional will need to show that the orthotic device is required for a medical necessity. Cigna will then review to ensure that the diagnosis meets their criteria for medical necessity.
• Proper Documentation - This plays a major role in the approval or denial of your claim.  Your documentation must include:
  • Doctor's Statement - This will show why the custom orthotics is a medical necessity and how it can help with the condition.
  • Clinical Notes - This will include test results, attempted treatment options, and any other relevant information.
  • Itemized Bill - Here, a breakdown of the cost of getting the custom orthotics will be given.
• Preauthorization - Depending on your plan, Cigna may require that you get preauthorization before purchasing custom orthotics. This will entail a review of the diagnosis and prescription, verification of the need for custom orthotics, and confirmation that both the healthcare provider and supplier are approved by Cigna.

Why Cigna May Deny a Claim

Below are some of the most common reasons why your claim may be denied by Cigna.

• Custom Orthotics Required for Non-Medical Reasons - If Cigna determines that you need the custom orthotics for comfort, improved sports performance, or other reasons not related to a medical necessity, the claim will be denied.
• Medical Necessity Not Covered - If your prescription is based on an actual medical necessity, but the underlying cause is outside the list of conditions approved by Cigna, your claim will be denied.
• Use of Out-of-Network Providers and Suppliers - In its exclusions and limitations document, Cigna states clearly that it won’t approve "services obtained from a Non-Participating/Out-of-Network Provider, except for treatment of an Emergency Medical Condition.” So, if your doctor and/or provider is out-of-network, your claim will likely be denied. Even if you claim that it was an emergency situation, your chances of getting approved are slim.
• No Preauthorization - If your plan requires that you get preauthorization before getting custom orthotics, your claim will be denied if you go ahead with the purchase without this preauthorization.
• Cigna Determines that OTCs Should Have Been Used - If, after reviewing your doctor’s notes and report, Cigna determines that prefabricated or over-the-counter (OTC) orthotics would have been sufficient to get the desired result, your claim will be denied. This is because, like most insurance companies, Cigna expects that the cheapest, effective treatment option should always be prioritized.
• Poor Documentation - If your documentation is incomplete or unclear, your claim will likely be denied, citing "insufficient evidence of medical necessity."

• Replacement Limit Has Been Exceeded - While Cigna promises coverage for replacement when there is an obvious anatomical change in the foot, or when the current custom orthotics have become damaged beyond repair, it is only valid over a given period. Depending on your exact plan, this can be limited to a pair every two years. Once this limit is exhausted, any other claims made will be denied.

Conclusion

A lot of folks would love to have their custom orthotic needs covered by insurance companies. From our look at Cigna’s coverage of custom orthotics, it is clear that many will not be able to access this coverage.

For folks who do qualify, you need to ensure that you do everything by the book, because a little error can result in a denial. This is why it is important that you take some time to understand the terms of your coverage. In fact, this should be done even before you purchase the plan.

For others who may not qualify for Cigna’s custom orthotics coverage, consider exploring other options like FSA and HSA. These can help you enjoy some savings on the purchase of your custom orthotics.