Could you please provide the NYSHIP orthotics policy? Hopefully, the policy will outline the criteria for medical necessity and specify the waiting period required when a patient needs a second pair. Does it state how many pair of orthotics a patient has benefits for?
New York State Health Insurance Program (NYSHIP) is administered by the New York State Department of Civil Service. It is a health insurance program often provided to New York state employees. It is also used for students of some state universities and in other situations as well.
NYSHIP has both a PPO and many different HMO's. The PPO is known as "The Empire Plan." This is explained further here: https://www.suny.edu/media/suny/content-assets/documents/benefits/nyship/Health-Insurance-Choices-2024.pdf
You will see on pages 10 and 11 of that document how many HMO options there are under NYSHIP. Each of these HMO plans have their own coverage policies. Therefore, there is no NYSHIP orthotic coverage policy. The first step is to determine which of the many plans that exist under NYSHIP the patient has (Empire versus one of the many HMO's), then determine benefits through that plan. Many of these plans do not list a public policy for this service of orthotics and instead require prior authorization of payment before initiating the service.
Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2023 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA).
Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Certified Professional Coder
Certified Professional Medical Auditor
Lehrman Consulting, LLC