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LCD L33641: Orthopedic Footwear

LCD L33641, Orthopedic Footwear, is the Local Coverage Determination that Noridian Healthcare Solutions, LLC and CGS Administrators, LLC apply to claims from 56 states (AK, AL, AR, AS, AZ, CA, CNMI, CO and others), effective 2020-01-01 and first in force 2015-10-01. The policy text runs 586 words, and its billing and coding article A52481 lists 84 ICD-10-CM codes that support medical necessity. No other contractor publishes a policy with this title.

QuickIntell editorial content · Legacy registry date · Review not verified

Data effective
Data currency: Medicare Coverage Database LCD export release of September 24, 2026 (effective September 20, 2026). Next CMS release: weekly (Thursdays) for the MCD.
Contractor
Noridian Healthcare Solutions, LLC; CGS Administrators, LLC
States and territories
56
AK AL AR AS AZ CA CNMI CO CT DC DE FL GA GU HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY
Revision effective
2020-01-01
Original effective
2015-10-01
Policy text
586 words
Covered ICD-10 codes (articles)
84

Where this LCD applies

Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.

Contracts that apply LCD L33641
ContractContractorTypeStates
19003Noridian Healthcare Solutions, LLCDME MACAK AS AZ CA CNMI GU HI IA ID KS MO MT ND NE NV OR SD UT WA WY
18003CGS Administrators, LLCDME MACAL AR CO FL GA LA MS NC NM OK PR SC TN TX VA VI WV
17013CGS Administrators, LLCDME MACIL IN KY MI MN OH WI
16013Noridian Healthcare Solutions, LLCDME MACCT DC DE MA MD ME NH NJ NY PA RI VT

Billing and coding: diagnoses and procedure codes

Since 2019 the codes live in the companion article rather than the LCD. Article A52481 (Orthopedic Footwear - Policy Article) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.

A52481: Orthopedic Footwear - Policy Article (Article, effective 2023-11-01)

Covered ICD-10-CM codes
84
1 group
Non-covered ICD-10-CM codes
0
Procedure codes listed
0
Full article
cms.gov record
First 24 covered ICD-10-CM codes in A52481
ICD-10-CMDescription (FY2027)
Q72.00—
Q72.01—
Q72.02—
Q72.03—
Q72.30—
Q72.31—
Q72.32—
Q72.33—
Q72.70—
Q72.71—
Q72.72—
Q72.73—
S98.011A—
S98.011D—
S98.012A—
S98.012D—
S98.019A—
S98.019D—
S98.021A—
S98.021D—
S98.022A—
S98.022D—
S98.029A—
S98.029D—

Procedure codes named in the LCD

A9283 (Foot Pressure Off Loading/Supportive Device, Any Type, Each), 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), L3040 (Foot, Arch Support, Removable, Premolded, Longitudinal, Each), L3050 (Foot, Arch Support, Removable, Premolded, Metatarsal, Each), L3060 (Foot, Arch Support, Removable, Premolded, Longitudinal/ Metatarsal, Each), L3070 (Foot, Arch Support, Non-Removable Attached To Shoe, Longitudinal, Each), L3080 (Foot, Arch Support, Non-Removable Attached To Shoe, Metatarsal, Each), L3090 (Foot, Arch Support, Non-Removable Attached To Shoe, Longitudinal/Metatarsal, Each), L3100 (Hallus-Valgus Night Dynamic Splint, Prefabricated, Off-The-Shelf), L3140 (Foot, Abduction Rotation Bar, Including Shoes), L3150 (Foot, Abduction Rotation Bar, Without Shoes), L3160 (Foot, Adjustable Shoe-Styled Positioning Device), L3170 (Foot, Plastic, Silicone Or Equal, Heel Stabilizer, Prefabricated, Off-The-Shelf, Each), L3201 (Orthopedic Shoe, Oxford With Supinator Or Pronator, Infant), L3202 (Orthopedic Shoe, Oxford With Supinator Or Pronator, Child), L3203 (Orthopedic Shoe, Oxford With Supinator Or Pronator, Junior), L3204 (Orthopedic Shoe, Hightop With Supinator Or Pronator, Infant), L3206 (Orthopedic Shoe, Hightop With Supinator Or Pronator, Child), L3207 (Orthopedic Shoe, Hightop With Supinator Or Pronator, Junior), L3208 (Surgical Boot, Each, Infant), L3209 (Surgical Boot, Each, Child), L3211 (Surgical Boot, Each, Junior), L3212 (Benesch Boot, Pair, Infant), L3213 (Benesch Boot, Pair, Child), L3214 (Benesch Boot, Pair, Junior), 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), L3224 (Orthopedic Footwear, Woman'S Shoe, Oxford, Used As An Integral Part Of A Brace (Orthosis)), L3225 (Orthopedic Footwear, Man'S Shoe, Oxford, Used As An Integral Part Of A Brace (Orthosis)), L3230 (Orthopedic Footwear, Custom Shoe, Depth Inlay, Each), L3250 (Orthopedic Footwear, Custom Molded Shoe, Removable Inner Mold, Prosthetic Shoe, Each), L3251 (Foot, Shoe Molded To Patient Model, Silicone Shoe, Each), L3252 (Foot, Shoe Molded To Patient Model, Plastazote (Or Similar), Custom Fabricated, Each), L3253 (Foot, Molded Shoe Plastazote (Or Similar) Custom Fitted, Each), L3254 (Non-Standard Size Or Width), L3255 (Non-Standard Size Or Length), L3257 (Orthopedic Footwear, Additional Charge For Split Size), L3260 (Surgical Boot/Shoe, Each), L3265 (Plastazote Sandal, Each), L3300 (Lift, Elevation, Heel, Tapered To Metatarsals, Per Inch), L3310 (Lift, Elevation, Heel And Sole, Neoprene, Per Inch), L3320 (Lift, Elevation, Heel And Sole, Cork, Per Inch), L3330 (Lift, Elevation, Metal Extension (Skate)), L3332 (Lift, Elevation, Inside Shoe, Tapered, Up To One-Half Inch), L3334 (Lift, Elevation, Heel, Per Inch), L3340 (Heel Wedge, Sach), L3350 (Heel Wedge), L3360 (Sole Wedge, Outside Sole), L3370 (Sole Wedge, Between Sole), L3380 (Clubfoot Wedge), L3390 (Outflare Wedge), L3400 (Metatarsal Bar Wedge, Rocker), L3410 (Metatarsal Bar Wedge, Between Sole), L3420 (Full Sole And Heel Wedge, Between Sole), L3430 (Heel, Counter, Plastic Reinforced), L3440 (Heel, Counter, Leather Reinforced), L3450 (Heel, Sach Cushion Type), L3455 (Heel, New Leather, Standard), L3460 (Heel, New Rubber, Standard), L3465 (Heel, Thomas With Wedge), L3470 (Heel, Thomas Extended To Ball), L3480 (Heel, Pad And Depression For Spur), L3485 (Heel, Pad, Removable For Spur), L3500 (Orthopedic Shoe Addition, Insole, Leather), L3510 (Orthopedic Shoe Addition, Insole, Rubber), L3520 (Orthopedic Shoe Addition, Insole, Felt Covered With Leather), L3530 (Orthopedic Shoe Addition, Sole, Half), L3540 (Orthopedic Shoe Addition, Sole, Full), L3550 (Orthopedic Shoe Addition, Toe Tap Standard), L3560 (Orthopedic Shoe Addition, Toe Tap, Horseshoe), L3570 (Orthopedic Shoe Addition, Special Extension To Instep (Leather With Eyelets)), L3580 (Orthopedic Shoe Addition, Convert Instep To Velcro Closure), L3590 (Orthopedic Shoe Addition, Convert Firm Shoe Counter To Soft Counter), L3595 (Orthopedic Shoe Addition, March Bar), L3600 (Transfer Of An Orthosis From One Shoe To Another, Caliper Plate, Existing), L3610 (Transfer Of An Orthosis From One Shoe To Another, Caliper Plate, New), L3620 (Transfer Of An Orthosis From One Shoe To Another, Solid Stirrup, Existing), L3630 (Transfer Of An Orthosis From One Shoe To Another, Solid Stirrup, New), L3640 (Transfer Of An Orthosis From One Shoe To Another, Dennis Browne Splint (Riveton), Both Shoes), L3649 (Orthopedic Shoe, Modification, Addition Or Transfer, Not Otherwise Specified).

Coverage indications, limitations and medical necessity

For any item to be covered by Medicare, it must (1) be eligible for a defined Medicare benefit category, (2) be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, and (3) meet all other applicable Medicare statutory and regulatory requirements.

The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:

• The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

• The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

• Refer to the Supplier Manual for additional information on documentation requirements.

• Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

Statutory coverage criteria for orthopedic footwear are specified in the related Policy Article.

Prosthetic shoes (L3250) are covered if they are an integral part of a prosthesis for a beneficiary with a partial foot amputation (refer to the ICD-10 Codes section in the LCD-related Policy Article). Claims for prosthetic shoes for other diagnosis codes will be denied as not medically necessary.

GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

Summary of evidence (opening)

NA

the full summary and analysis of evidence are in the CMS record.

Dates, lineage and related policies

Original determination effective
2015-10-01
Current revision effective
2020-01-01
Last reviewed by the contractor
2019-01-08
MCD version
21
Derived from
L11456

The contractor lists one National Coverage Determination as related: NCD 280.10 Prosthetic Shoe. Where an NCD speaks, it controls; the LCD can only address what the NCD leaves open.

Other related documents: A55426 (Article).

Using this policy on a claim

Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub and CGS Administrators, LLC hub list every other active policy from the same contractor.

Frequently asked questions

What does LCD L33641 cover?

For any item to be covered by Medicare, it must (1) be eligible for a defined Medicare benefit category, (2) be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member, and (3) meet all other applicable Medicare statutory and regulatory requirements. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.

Which states does LCD L33641 apply to?

Noridian Healthcare Solutions, LLC and CGS Administrators, LLC apply it to Medicare claims in AK, AL, AR, AS, AZ, CA, CNMI, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.

Which diagnosis codes support medical necessity under LCD L33641?

The companion article article A52481 lists 84 ICD-10-CM codes in 1 group that support medical necessity; the first 24 appear on this page and the complete list is in the article on cms.gov.

How do I appeal a denial under LCD L33641?

The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.

Disclaimer

The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.