10/23/2020

NYSHIP-Orthotics Coverage

NYSHIP (NYS Empire PLan) used to allow more than one pair of prescription foot orthotics per year (L3000). Lately, we are getting occasional denials on the second pair. Have they changed their policy?

There have been no recent changes to the medical policy for orthotics by the Empire Plan. According to their benefits for patients who require orthotics or prosthetics:

“Prostheses and Orthotic Devices – You are covered for one prosthesis and/or orthotic device per affected body part meeting an individual’s functional needs. There is no copayment for the prosthesis and/or orthotic device when you use a participating provider. Replacements, when functionally necessary, are also covered. However, an orthotic device used to support, align, prevent or correct deformities or to improve the function of the foot is covered only when it is medically necessary and custom made.”

Their benefits have remained unchanged, regardless of the group that they are employed by with New York State, or if the patient has Medicare as primary to the Empire Plan. It would not be unreasonable for supporting documentation to be made available upon request if a patient requires a second set of custom orthotics within a 12 month period by the insurance as a condition of payment.