BlueCross and BlueShield of Montana Medical Policy/Codes
Chapter: Durable Medical Equipment
Current Effective Date: December 27, 2013
Original Effective Date: December 27, 2013
Publish Date: September 27, 2013

An orthotic (orthosis) is a rigid or semi-rigid device used to support or align body parts, prevent or correct deformities, protect a body function, improve or restore the function of movable body parts, or assist a dysfunctional joint.  Orthotics may redirect or restrict motion of an impaired body part.  An orthotic is used in the treatment of an illness or injury for therapeutic support, protection, restoration, or function of an impaired body part.  Examples of orthotics include braces, splints, immobilizers, and trusses.

Spring-loaded dynamic splints and bi-directional SPS devices are intended to stretch joints that have reduced range of motion (ROM) secondary to immobilization, surgery, fracture, dislocation, or any of a number of non-traumatic disorders.  The goal is to restore functioning ROM to a joint by causing permanent elongation of tissues, without compromising the stability and integrity of the connective tissue and joint.  Dynamic splints are spring-loaded, adjustable-tension controlled devices that provide a low load, prolonged stretch to joints over 6-12 hours, usually while the patient is asleep.  This process is called creep-based loading.  SPS devices are also manually adjustable and apply a static force to the tissues.  The joint is moved to an end range stretch position and is held there for a set period of time.  The tissues relax or stretch in response to this end range stress.  The device is then adjusted to a new position of stretch and held there.  This process, called stress-relaxation loading, is repeated periodically throughout an SPS session, which usually requires 30-minute sessions three times per day for permanent stretch to occur.   Examples of dynamic splints include, but are not limited to, Dynasplint™, ProGlide®, DeROM®, Ultraflex®, DeRoyal®, and Advance Dynamic®.  JAS® is one example of an SPS device.

Orthotic devices for the foot may be used to change the conformity of congenitally deformed bones and joints by applying continuous force over a period of months or years.  Orthotics may also be used to relieve symptoms and produce more normal function in deformities caused by disease or congenital etiologies by providing support or altering weight bearing.  Diagnosis, patient history and biomechanical evaluation determine the therapeutic benefit of functional orthotics.

Biomechanical problems are best treated with custom-made orthoses, while weight-bearing problems can usually be treated successfully with good quality, cushioned, over the counter shoe inserts.  Biomechanical evaluation includes range of motion studies, measuring joint angles, tightness or laxity of muscle and gait analysis.  This is usually done bilaterally on the lower extremities to evaluate biomechanical imbalances and deformities.  The results of the biomechanical exam are used to assist in diagnosis and treatment.

Foot orthotics, or podiatric appliances, can be either functional or accommodative.  An accommodative foot orthotic does not address functional abnormality.  These are used to cushion, pad or relieve pressure from a painful or injured area on the bottom of the foot, e.g., calluses, sore bones, etc.  They are generally more flexible and soft than functional foot orthoses.  A functional orthotic is a device designed for the shape of the foot to accommodate or correct abnormal function.  While supporting and balancing the foot, a functional orthotic controls the way the foot works (function) for either therapeutic or preventative purposes.

Functional foot orthoses are useful in the treatment of a very wide range of painful conditions of the foot and lower extremities, including toe joint pain, arch and instep pain, ankle pain and heel pain.  Since abnormal foot function can cause abnormal leg, knee and hip function, functional foot orthoses are commonly used to treat painful tendinitis and bursitis conditions in the ankle, knee and hip, in addition to shin splints in the legs.  Some types of functional foot orthoses may also be designed to accommodate painful areas on the bottoms of the foot, just like accommodative foot orthoses.

Pediatric Dysfunctional Flatfoot is a complicated series of symptoms and joint changes of the midfoot, rearfoot and ankle that result in flattened appearance of the arch in a skeletally immature individual.  Symptoms and deformities that may be present if flatfoot is allowed to progress include:

  • Abnormal wear of shoes;                           
  • Biomechanically induced dermatologic conditions such as corns, calluses, blisters, etc.;
  • Flexible hammertoes and claw toe deformities;
  • Genu recurvatum;                          
  • Hallux Abducto-Valgus deformities;
  • Leg, ankle and/or foot pain and fatigue;
  • Limb length inequality;
  • Night cramps/prolonged growing pains;
  • Apophysitis;
  • Splayfoot;
  • Symptomatic of tibiale externum;
  • Plantar fasciitis;
  • Tailor’s bunion;
  • Lower leg tendonitis;
  • Avascular necrosis (Freiberg’s, Kohler’s);
  • Equinus.

Adult Dysfunctional Flatfoot is a group of disorders associated with abnormal pronation of the foot.  The etiologies for adult flatfoot are varied including congenital, biomechanical, systemic disease, traumatic and iatrogenic.  Consequently, the reported diagnosis may be one of the following:


  • Ligamentous laxity,
  • Calcaneal valgus,
  • Congenital convex pes valgus (vertical talus),
  • Tarsal coalition,
  • Neuromuscular conditions,
  • Gastroc-soleal equinus,
  • Abnormal talar ontogeny,
  • Limb Length discrepancy,
  • Torsional and/or angulational leg deformities;


  • Torsional and/or angulational leg deformities,
  • Compensated ankle equinus,
  • Subtalar joint varus or valgus,
  • Compensated metatarsus adductus,
  • Medial column hypermobility,
  • Compensated limb length discrepancy;

Systemic disease

  • Neuromuscular disorders  (e.g., Poliomyelitis, Cerebral Palsy, Multiple sclerosis, Charcot Marie Tooth),
  • Metabolic diseases producing peripheral neuropathy (e.g., Charcot joint),
  • Inflammatory arthritis;


  • Fracture of tarsal coalition,
  • Malaligned foot, ankle or leg fracture,
  • Posterior tendon laceration, rupture or avulsion,
  • Lisfranc’s joint dislocation or fracture;


  • Overcorrection of metatarsus adductus or clubfoot,
  • Overcorrection or under correction of equinus,
  • Overcorrection or under correction of ankle or tarsal osteotomy,
  • Malposition of fusion,
  • Disruption of the posterior tibial tendon secondary to navicular or perinavicular surgery,
  • First metatarsal elevatus secondary to osteotomy or fusion of the first ray.

Posterior Tendon Dysfunction is pain and swelling along the course of the posterior tibial tendon frequently between the medial malleolus and navicular.  The patient may have weakened ability or inability to single heel-rise, accompanied with arch flattening and increasing heel valgus.

Spastic Peroneal Flatfoot is usually associated with a subtalar joint coalition.  Gait is antalgic with pain in the midfoot, rearfoot and ankle areas.  Subtalar joint motion is virtually absent with a reactive tightness of peroneal musculature occurring to evert the foot to a comfortable position. The calcaneus is in valgus, and tarsal pain is aggravated by activity.


  • Bunion—inflammation and thickening of the bursa of the joint of the great toe, usually associated with marked enlargement of the joint and lateral displacement of the toe
  • Callus—localized hyperplasia of the horny layer of the epidermis due to pressure or friction
  • Corn—a horny induration or thickening of the stratum corneum of the skin of the toes, caused by friction and pressure from poorly fitting shoes or hose; it forma a conical mass pointing down into the corium, producing pain and inflammation; hard corn (heloma durum) usually located on the outside of the little toe or the upper surfaces of the other toes; soft corn (heloma molle) found between the toes, usually the 4th-5th toes.
  • Hallux—great toe
  • Hallux dolorosus—a condition, usually associated with flatfoot, in which walking causes severe pain in the metatarsophalangeal joint (MPJ) of the great toe; syn: painful toe
  • Hallux extensus—a deformity in which the great toe is held rigidly in the extended position.
  • Hallux flexus—Hammertoe; syn: Hallux maleous
  • Hallux rigidus—a condition in which stiffness appears in the first MPJ; usually associated with the development of bone spurs on the dorsal surface; syn: stiff toe
  • Hallux valgus—a deviation of the tip of the great toe, or main axis of the toe, toward the outer or lateral side of the foot
  • Hallux varus—deviation of the main axis of the great toe to the inner side of the foot away from the second toe
  • Metatarsus latus—broadened foot, due to spreading of the anterior part of the foot resulting from separation of the heads of the metatarsal bones from each other; also called broad foot or spread foot; syn: talipes transversoplanus
  • MPJ—metatarsophalangeal joint
  • OTC—over the counter; can be obtained with or without a prescription
  • Pes planus—flatfoot; syn: talipes planus
  • Stock Orthotics—syn: OTC, off-the-shelf
  • Talipes—deformity of the foot, which is twisted out of shape or position; also called clubfoot
  • Talipes calcaneovalgus—talipes calcaneus and talipes valgus combined; the foot is dorsiflexed, everted, and abducted
  • Talipes calcaneovarus—talipes calcaneus and talipes varus combined; the foot is dorsiflexed, inverted, and adducted
  • Talipes calcaneus—a deformity due to weakness or absence of the calf muscles, in which the axis of the calcaneus becomes vertically oriented; commonly seen in poliomyelitis
  • Talipes cavus—an exaggeration of the normal arch of the foot; syn: contracted foot, pes cavus, talipes plantaris
  • Talipes equinovalgus—talipes equinus and talipes valgus combined; the foot is plantarflexed, everted, and abducted; syn: equinovalgus, pes equinovalgus
  • Talipes equinovarus—talipes equinus and talipes varus combined; the foot is plantarflexed, inverted, and adducted; syn: clubfoot, equinovarus, pes equinovarus
  • Talipes equinus—permanent plantar flexion of the foot so that only the ball rests on the ground; it is commonly combined with talipes varus
  • Talipes plantaris—talipes in which there is an exaggerated abnormal arch of the foot; syn: talipes cavus, talipes arcuatus
  • Talipes valgus—permanent eversion of the foot, the inner side alone of the sole resting on the ground; it is usually combined with a breaking down of the plantar arch; syn: pes abductus, pes pronatus, pes valgus
  • Talipes varus—inversion of the foot, the outer side of the sole only touching the ground; usually some degree of talipes equinus is associated with it, and often talipes cavus; syn: pes adductus, pes varus

Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions.  Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.  If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.


An orthotic device may be considered eligible for benefit coverage when:

  • It is legislatively mandated; OR
  • It meets benefit contract criteria for coverage and/or is not specifically excluded from coverage; AND
  • It is considered medically necessary.

An orthotic device may be considered medically necessary when:

  • It is prescribed by a physician, chiropractor, and/or other qualified provider; AND
  • It is medically necessary for therapeutic support, protection, restoration, or function of an impaired body part.

Orthotic devices include, but are not limited to:

  • braces for leg, arm, neck, back, and shoulder;
  • corsets for the back or for use after special surgical procedures;
  • splints for extremities;
  • trusses (including Sykes hernia control device);
  • orthopedic shoes when either one or both shoes are an integral part of a leg brace [See Legislation Section];
  • foot orthotics and supportive devices [See Legislation Section and Foot Orthotic Section];
  • oral orthotics (For additional information on oral orthotics see SUR705.010 Temporomandibular Joint (TMJ) Disorders (TMJD), and SUR706.009 Sleep Related Breathing Disorders, Medical and Surgical Management).

NOTE:  Coverage of foot orthotics is defined separately (SEE BELOW)

Stock orthotics (i.e., over-the-counter and/or off-the-shelf; items that do not require a physician’s prescription) may be contract exclusions.  Member contract benefit may vary.  Check contracts for coverage eligibility. 

Stock orthotics include, but are not limited to:

  • arch supports and other foot support devices and foot orthotics, including transferrable shoe inserts—see Legislation section; see coverage of Foot Orthotics below;
  • elastic stockings;
  • garter belts; and/or
  • orthopedic shoes, except when either one or both shoes are an integral part of a leg brace—see Legislation section.

Spring-loaded dynamic splints and bi-directional static progressive stretch (SPS) splints may be considered medically necessary for use on the knee, ankle, toe, elbow, wrist, or finger in the following situations only:

  • when the patient is not responding favorably (i.e., has a measurable lack of progress) using conventional management methods of restoring joint motion (e.g., physical therapy, standard splinting, non-steroidal anti-inflammatory medications [NSAIDS], etc.) following a sub-acute injury or postoperative period, i.e., at least three weeks, but less than four months, after injury or surgery; and/or
  • in the acute postoperative period for patients who have a prior documented history of joint motion stiffness/loss, and are having additional surgical procedures to improve motion in that joint.

Spring-loaded dynamic splints and bi-directional SPS splints are considered not medically necessary for all other indications, including, but not limited to:

  • management of chronic contractures and joint stiffness due to joint trauma, fractures, burns, head and spinal cord injury, rheumatoid arthritis, plantar fasciitis, multiple sclerosis, muscular dystrophy, or cerebral palsy; and/or
  • when conventional methods of treating stiff or contracted joints have not been attempted; and/or
  • use on the shoulder; and/or
  • any other indications not listed above.

The following orthotic devices are considered not medically necessary:

  • orthotics that have not been prescribed by a physician, chiropractor, and/or other qualified provider;
  • orthotics that are not necessary to treat an existing medical condition;
  • orthotic devices for sports-related activities (e.g., knee brace to prevent injury to the knees while playing football); and/or
  • upgraded splints, e.g., decorative items; functionality or features beyond what is required for management of the patient’s current medical condition.

FOOT ORTHOTICS (Functional and Accommodative Podiatric Appliances)

NOTE:  Foot orthotics (podiatric appliances) may be subject to contract limitations or exclusions, and/or state legislation.  Check contracts and legislation carefully for coverage and limitations.

When foot orthotics are a covered benefit (i.e., orthopedic shoes, inserts, arch supports, footwear, lifts, wedges, heels, and miscellaneous shoe additions), the following criteria apply to functional and accommodative foot orthotics:

FUNCTIONAL FOOT ORTHOTICS may be considered medically necessary for:

  • Symptomatic Pediatric Dysfunctional Flatfoot;
  • Symptomatic Adult Dysfunctional Flatfoot;
  • Symptomatic Posterior Tibial Tendon Dysfunction;
  • Symptomatic Spastic Peroneal Flatfoot with or without Subtalar Coalition;
  • Postoperative treatment following surgical correction of foot deformities, i.e.,
    1. Hallux Abducto-Valgus,
    2. Hallux limitus/rigidus,
    3. Multiple Hammertoes,
    4. Joint fusions,
    5. Joint or bone resections due to arthritis or infection,
    6. Partial Amputations;
  • Postoperative treatment following surgical treatment of congenital conditions of the foot and ankle, i.e.,
    1. Calcaneovalgus,
    2. Talipes calcaneous,
    3. Talipes equinous,
    4. Equino-cavovarus; and/or
  • Treatment of the conditions listed in the following table when the listed prerequisites have been determined:



Duration of symptoms

Previous failed treatments

Confirmation that patient is ambulatory

Hallux Abducto- Valgus (1st metatarsophalangeal joint [MPJ] Bunion)

>3 months

  • Accommodating shoe wear
  • Padding
  • Cortisone injections


Hallux Limitus/Rigidus (Degenerative 1st MPJ)

>3 months

  • Accommodating shoe wear
  • Padding
  • Cortisone injections



>3 months

  • Accommodating shoe wear
  • Padding
  • Cortisone injections


Tailor’s Bunions (5th MPJ Area)

>3 months

  • Accommodating shoe wear
  • Padding
  • Cortisone injections



>3 months

  • Accommodating shoe wear
  • Padding
  • Over the counter (OTC) insoles
  • Cortisone injections


Plantar Fasciitis/ Heel Spur Syndrome

>3 months

  • Proper shoe wear
  • OTC Arch supports worn > 6 weeks
  • Stretching/Ice Therapy
  • Cortisone injections



>3 months

  • Proper shoe wear
  • Padding
  • OTC insoles/Arch supports


Chronic Ankle Instability                             

>1 year

  • Ankle support utilized for activities
  • OTC arch support worn > 6 weeks


ACCOMMODATIVE FOOT ORTHOTICS are considered not medically necessary as they do not address structural or functional abnormalities, they are primarily for comfort, and/or they are OTC items (with or without a prescription).

Policy Guidelines

Diabetic shoes and foot orthotics should be billed using codes A5500-A5513, which is the same as Medicare.

All medically necessary supplies adjustment repair or replacements of covered orthotic devices are eligible for coverage.  Replacement is provided, usually after the device's normal life span (wear and tear, malfunction of the device, and\or for growth adjustments).


Generally, conventional methods are effective in restoring ROM; these include a variety of exercises and devices, depending on the joint or tissue involved.  Exercises include passive ROM, assisted-active ROM, and active ROM, and involve the interaction of the patient with a physical therapist.  Dynamic splinting devices and static progressive stretch devices are patient-controlled, non-motorized stretch devices that have been widely used in the orthopedic and physical therapy communities for selected patients who fail to improve with conventional treatment.  A study of post-traumatic loss of motion at the wrist by Bonutti et al. showed that the patients gained an average of 19 degrees extension and 18 degrees flexion, in an average treatment time of eight weeks.  Bonutti et al. also studied SPS for the elbow, showing an average of 69% increase in ROM, and no deterioration in ROM at one-year follow up.  There are no published studies that support the use of dynamic or SPS stretching devices for management of chronic contractures and joint stiffness due to joint trauma, fractures, burns, head and spinal cord injury, rheumatoid arthritis, plantar fasciitis, multiple sclerosis, muscular dystrophy, or cerebral palsy; when conventional methods of treating stiff or contracted joints have not been attempted; or for use on the shoulder.

2009 Update

A search of peer reviewed literature through November 2009 identified no new clinical trial publications or any additional information that would change the coverage position of this medical policy.


Disclaimer for coding information on Medical Policies          

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.           

The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.           

Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.

ICD-9 Codes

Refer to the ICD-9-CM manual.

Procedural Codes: 97760, 97762, A4566, A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, E1800, E1801, E1802, E1805, E1806, E1810, E1811, E1812, E1815, E1816, E1818, E1820, E1821, E1825, E1830, E1831, E1840, E1841, K0672, L0112, L0113, L0120, L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200, L0220, L0430, L0450, L0452, L0454, L0456, L0458, L0460, L0462, L0464, L0466, L0468, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0700, L0710, L0810, L0820, L0830, L0861, L0970, L0972, L0974, L0976, L0978, L0980, L0120, L0984, L0999, L1000, L1001, L1005, L1010, L1020, L1025, L1030, L1040, L1050, L1060, L1070, L1080, L1085, L1090, L1100, L1110, L1120, L1200, L1210, L1220, L1230, L1240, L1250, L1260, L1270, L1280, L1290, L1300, L1310, L1499, L1600, L1610, L1620, L1630, L1640, L1650, L1652, L1660, L1680, L1685, L1686, L1690, L1700, L1710, L1720, L1730, L1755, L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2040, L2050, L2060, L2070, L2080, L2090, L2106, L2108, L2112, L2114, L2116, L2126, L2128, L2132, L2134, L2136, L2180, L2182, L2184, L2186, L2188, L2190, L2192, L2200, L2210, L2220, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2385, L2387, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2570, L2580, L2600, L2610, L2620, L2622, L2624, L2627, L2628, L2630, L2640, L2650, L2660, L2670, L2680, L2750, L2755, L2760, L2768, L2780, L2785, L2795, L2800, L2810, L2820, L2830, L2840, L2850, L2861, L2999, L3000, L3001, L3002, L3003, L3010, L3020, L3030, L3031, L3040, L3050, L3060, L3070, L3080, L3090, L3100, L3140, L3150, L3160, L3170, L3201, L3202, L3203, L3204, L3206, L3207, L3208, L3209, L3211, L3212, L3213, L3214, L3215, L3216, L3217, L3219, L3221, L3222, 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, L3650, L3671, L3674, L3677, L3702, L3710, L3720, L3730, L3740, L3760, L3762, L3763, L3764, L3765, L3766, L3806, L3807, L3808, L3891, L3900, L3901, L3904, L3905, L3906, L3908, L3912, L3913, L3915, L3917, L3919, L3921, L3923, L3925, L3927, L3929, L3931, L3933, L3935, L3942, L3956, L3960, L3961, L3962, L3967, L3971, L3973, L3975, L3976, L3977, L3978, L3980, L3982, L3984, L3995, L3999, L4000, L4002, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110, L4130, L4205, L4210, L4350, L4360, L4370, L4386, L4392, L4394, L4396, L4398, L4631, S0395, S8450, S8451, S8452, [Deleted 1/2012: L1500, L1510, L1520, L3964, L3965, L3966, L3968, L3969, L3970, L3972, L3974, L4380], [Deleted 1/2011: L3660, L3670, L3672, L3673, L3675]
  1. Bonutti, P.M., Windau J.E., et al.  Static progressive stretch to establish elbow range of motion.  Clinical Orthopaedics and Related Research (1994 June) 303:128-34.
  2. Burr, N., Pratt, A.L., et al.  An Alternative splinting and rehabilitation protocol for metacarpophalangeal joint arthroplasty in patients with rheumatoid arthritis.  Journal of Hand Therapy (2002 January-March) 15(1):41-7.
  3. Harvey, L., Herbert, R., et al.  Does stretching induce lasting increases in joint ROM? A systematic review.  Physiotherapy Research International (2002) 7(1):1-13.
  4. Orthotics.  Chicago, Illinois: Blue Cross Blue Shield Association Medical Policy Reference Manual (2003 January) Durable Medical Equipment 1.03.01.
  5. Kirby, Kevin.  Functional and accommodative foot orthoses.  Podiatry (accessed on May 26, 2006).
September 2013  New 2013 BCBSMT medical policy.
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