02/25/2022

Empire BlueCross BlueShield-Orthotics Coverage

When calling Empire Blue cross for L3000 benefits, some members they say its covered, but it’s a diagnosis driven code. Whatever diagnosis we give they say its not a covered diagnosis. Do you know what Diagnosis code works for such plans?

Orthotic coverage with a national payer like Blue Cross can be very specific based on the patient’s plan. Unfortunately, there is no guide on what diagnosis codes are always covered based on the patient’s plan. The only way to be sure that a specific condition will be covered will be to contact Empire (or the patients local Blue Cross plan for out of area plans) and receive eligibility verification to determine if they are covered or if the patient will have to pay for a non-covered service. Online resources may also be able to help make the determination if a patient’s condition is covered or not by their specific plan. It is also recommended to confirm if there are any authorization requirements that need to be satisfied in order for orthotics to be covered. Even if a diagnosis code is covered by the plan, it may still require UM or pre-certification, in order for the insurance to reimburse the DME item.