Effective Date: 4/1/2018

1. PURPOSE
   1. To provide guidelines on how Horizon NJ Health (HNJH) shall consider reimbursement of foot orthotic shoes and inserts when prescribed by an eligible provider for an eligible member. This policy outlines the appropriate quantity of units HNJH will allow within a calendar year for the HCPCS codes listed below. This policy applies to all professional providers.
2. SCOPE AND APPLICABILITY
   1. This policy will be reviewed annually, revising procedures as necessary to reflect changes to specific guidelines.
   2. This policy applies to Horizon Healthcare of New Jersey, Inc., Horizon Healthcare Services, Inc. and Horizon Insurance Company (collectively “Horizon”)
      1. Across the following Government Programs lines of business:
         • Medicaid
         • MLTSS
         • DSNP
         • Participating and Non Participating Providers
         • All Medicaid, DSNP & MLTSS members 22 years of age and older
         • All government programs lines of business

      * This policy does not apply to Medicare, Medicare Advantage, Medicare Advantage PPO, Medicare Advantage PPO-SHBP plans & Medicaid, MLTSS, DSNP members ages 21 and under.

3. POLICY
   1. When the below foot orthotics shoes and inserts are eligible for coverage, HNJH shall consider reimbursement as follows:
      1. For procedure codes L3000, L3001, L3002, L3003, L3010, L3020, L3030 and L3031 up to 4 units (2 LT & 2 RT) or 2 pairs of foot orthotic inserts may be provided to the same member during a calendar year.
      2. For procedure codes L3215, L3216, L3217, L3219, L3221 and L3222 up to 2 units (1 LT & 1 RT) or 1 pair of foot orthotic shoes may be provided to the same member during a calendar year.
      3. This policy enforces the denial of units billed above the maximum allowed within a calendar year for the foot orthotic shoes & inserts HCPCS codes listed above.
      4. Exceptions to (4a) & (4b) above shall be made on a case-by-case basis via Post-Service review. Determination will be made by HNJH on the need for additional service and the specific emergency situations, which shall be documented by the provider and submitted with supporting medical records to the address below.

      Mail:	Fax:
      Horizon NJ Health P.O. BOX 63000 NEWARK, NJ 07101	973-522-4678

      The CPT codes and nomenclature used in this Policy are subject to revision and/or change by the American Medical Association.  In the event of such changes, the Policy will continue to be in force, albeit applied to the new or amended coding so issued until such time as the Policy is reviewed and updated to reflect the new or amended coding.

4. LIMITATIONS AND EXCLUSIONS
   1. While reimbursement is considered, payment determination is subject to, but not limited to:
      1. Members Benefit(s)
      2. Provider Participation Agreement
      3. Routine claim editing logic, including but not limited to incidental or mutually exclusive logic.
      4. Mandated or legislative required criteria will always supersede
      5. e. All foot orthotic shoes and inserts with a billed amount over $500 require an authorization
5. DEFINITIONS

   HCPCS CODE	DESCRIPTION
   L3000	FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL, EACH
   L3001	FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SPENCO, EACH
   L3002	FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, PLASTAZOTE OR EQUAL, EACH
   L3003	FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, SILICONE GEL, EACH
   L3010	FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPPORT, EACH
   L3020	FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/ METATARSAL SUPPORT, EACH
   L3030	FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH
   L3031	FOOT, INSERT/PLATE, REMOVABLE, ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, EACH
   L3215	ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACH
   L3216	ORTHOPEDIC FOOTWEAR, LADIES SHOE, DEPTH INLAY, EACH
   L3217	ORTHOPEDIC FOOTWEAR, LADIES SHOE, HIGHTOP, DEPTH INLAY, EACH
   L3219	ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH
   L3221	ORTHOPEDIC FOOTWEAR, MENS SHOE, DEPTH INLAY, EACH
   L3222	ORTHOPEDIC FOOTWEAR, MENS SHOE, HIGHTOP, DEPTH INLAY, EACH