APMA is investigating reports from members in several states that Anthem is seeking repayment of previously paid commercial claims for foot orthotics, including claims dating back to 2024.
Anthem’s Orthopedic Footwear (CG-DME-20) policy generally limits coverage of orthopedic footwear, including inserts and other shoe modifications, for non-diabetic patients to situations where the item is part of a medically necessary leg brace and is necessary for the brace to function properly. While the policy has been in place for some time, members have raised concerns about recent retrospective recoupments, including situations where practices report that Anthem previously indicated the service was covered or that prior authorization was not required.
APMA is working to better understand what is driving these recoupments and is gathering information from affected practices. We are also reviewing the issues raised by prior authorization, benefit verification, payer coverage policies, and state laws governing retrospective recoupments.
If you have received an Anthem recoupment request related to foot orthotics, please let us know. Helpful information includes the HCPCS code billed, type of Anthem plan, the stated reason for the recoupment, and any documentation received from Anthem before the item was dispensed. Please redact all patient-identifying information.
APMA is also developing additional guidance for members and will share more information as it becomes available.
Contact the APMA Advocacy Department with any questions at advocacy@apma.org.