N.J. Admin. Code § 10:54-5.33

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:54-5.33 - Orthopedic footwear services

(a) For purposes of the New Jersey Medicaid/NJ FamilyCare program, "an orthopedic shoe" means footwear, with or without accompanying appliances, used to prevent or correct gross deformities of the feet, which is properly fitted as to length and width, and consists of the following basic parts:

1. Correct straight last line;

2. Heels with sufficient bearing surface;

3. Toe with ample room for function;

4. Sole of sufficient weight for foot protection;

5. Rigid shank;

6. Properly fitting upper;

7. Smooth and protective lining; and

8. Snug fitting heel counter.

(b) Except as provided at 10:49-2.3, orthopedic footwear shall be reimbursed under the New Jersey Medicaid/NJ FamilyCare program when prior authorized in accordance with 10:55-1.5(c) and prescribed under the following conditions:

1. When attached to a brace or bar;

2. When part of the normal (customary, usual) post-operative or post-fracture treatment program; and/or

3. When used to correct or adapt to gross foot deformities.

(c) Services for flat foot conditions (regardless of the underlying etiology and encompassing all phases of services in connection with flat feet) shall be reimbursed as a Medicaid/NJ FamilyCare program covered service only under the following circumstances:

1. Treatment which is an integral part of post-fracture or post-operative treatment plan;

2. Supportive devices (for example, arch supports, specific additions to shoes and the like) prescribed to palliate pain and other symptoms associated with the condition;

3. Treatment where the talo-crural joint is involved; or

4. Treatment where there may be attachment of supportive device to a brace or bar.

(d) Orthopedic footwear and foot orthotics require a personally signed and dated order (prescription) by the prescribing physician for prosthetic and orthotic appliances, repair and replacement of parts for custom-made prosthetic and orthotic appliances, and orthopedic footwear. The prescription shall include the following:

1. Patient's name, age, address and Health Benefits Identification (HBID) Number;

2. Relevant diagnosis(es) (including the ICD-9-CM code(s) for dates of service before October 1, 2015, and the ICD-10-CM code(s) for dates of service on or after October 1, 2015) supporting the need for the orthopedic footwear and/or foot orthotics; and

3. Detailed description of the prosthetic and orthotic appliance order. Terminology such as "leg brace", "artificial limbs", or "orthopedic shoes" on a prescription is unacceptable.

(e) Prior authorization for all orthopedic footwear and foot orthotics shall be obtained by the provider of the services from the Office of Utilization Management, Division of Medical Assistance and Health Services, Mail Code #15, PO Box 712, Trenton, New Jersey 08625-0712, except for all components of orthopedic footwear attached to a bar or brace (including the bar, brace and/or shoe) which must be obtained from the appropriate Medical Assistance Customer Center. (For a directory of the (MACCs), see N.J.A.C. 10:49, Appendix K.) (See also N.J.A.C. 10:55, Prosthetic and Orthotics Services Chapter, for other prosthetic and orthotic services.)

N.J. Admin. Code § 10:54-5.33

Amended by 48 N.J.R. 962(b), effective 6/6/2016