Blue Cross/BlueShield Reimbursement for Orthotics
The ICS has received a number of member calls reporting an increase in Blue Cross/Blue Shield of Illinois (BCBSIL) claim denials for foot orthotics. Two major reasons are cited for the denials: 1) BCBSIL will not reimburse for orthotics created from a digital scanner; and 2) BCBSIL requires that the patient has tried a number of alternatives, conservative treatments that have failed in order for the orthotic to qualify as “medically necessary.”
BCBSIL cites the 2011 HCPCS L3020 code in support of its refusal to accept scanner techniques because the code requires that the insert be “molded to patient model.” The ICS understands that scanner technology can be as or more accurate than patient molds. However, BCBSIL is firm on their position at this time.
In addition, the BCBSIL Medical Policy DME103.001 on Orthotics requires that the device be deemed “medically necessary.” In order to demonstrate medical necessity, BCBSIL requires that a number of other treatments have been tried and have failed before orthotics are ordered. The medical policy lists specific treatment procedures that must have been attempted, and the duration, for each diagnosis for which orthotics are prescribed. These can be viewed on the BCBSIL website.
The ICS disagrees with BCBSIL’s policy, and we believe BCBSIL’s position contradicts some of the very sources on which it relies. However, we feel it is our obligation at this time to make certain that our members are informed of what BCBSIL requires for reimbursement for foot orthotic procedures and devices. Essentially, in order to be considered for reimbursement, you must use patient molds rather than scanners, and you must try all of the treatments listed in BCBSIL Medical Policy DME103.001. By having this information, ICS members may make informed choices regarding the submission of claims for these items.
As always, the ICS continues to monitor this issue and will advise members of developments.
To find the BCBS-IL Medical Policies visit: http://medicalpolicy.hcsc.net/medicalpolicy/disclaimer.do?corpEntCd=IL1#hlink. Once you have Agreed to their terms, search any CPT® code on the left to find the appropriate medical policy.