Does Cigna Cover Orthotics? Medical Necessity, Costs, and Denials

Cigna does cover orthotics, but only when the device is prescribed to support, align, prevent, or correct a deformity, and only when your medical record backs that up with a recent physical examination. Beyond that baseline, what actually gets paid depends on the type of device, whether it’s prefabricated or custom-made, the diagnosis on the claim, and the specific terms of your plan document. Some common requests, including custom foot orthotics for plantar fasciitis, are routinely denied.{¹}

The Medical Necessity Test

Cigna’s Medical Coverage Policy 0543 sets two conditions that have to be met before any orthotic qualifies. First, the device must be prescribed to support, align, prevent, or correct a deformity. Second, your medical record must contain evidence of a physical examination within the prior twelve months documenting the condition that requires the device.{¹}

Meeting those two conditions is the floor, not the ceiling. The policy then layers specific clinical criteria on top of each device category, and your individual plan document can impose further exclusions.

Orthotic Types Cigna Will Cover

When the medical necessity criteria are met, the policy recognizes coverage across several categories.

Spinal braces. Covered for pain relief related to spinal conditions, post-surgical or post-injury healing, support for spinal deformity, and scoliosis bracing in children and adolescents. Standard braces such as Boston, Charleston, Milwaukee, and Wilmington types qualify. Certain newer devices like SpineCor are classified as experimental and excluded.

Knee braces. Fracture and rehabilitative braces are covered at initial stabilization. Patellofemoral braces are covered for documented subluxation or dislocation. Functional knee braces are covered when instability is documented and surgery isn’t an option. Unloading braces for moderate to severe single-compartment osteoarthritis are covered after other medical treatments have failed.

Ankle and ankle-foot orthoses. Prefabricated ankle braces are covered for fractures, sprains, and injuries requiring stabilization. AFOs and night splints are covered for conditions like Achilles tendonitis, certain non-fixed plantar flexion contractures, and plantar fasciitis (the night splint, specifically).

Upper limb orthoses. Covered for stabilization, support, or immobilization following neurological injury, trauma, fractures, or overuse syndromes such as carpal tunnel syndrome.

Cranial orthotic devices. Covered for infants after surgery for synostotic plagiocephaly, and for moderate to severe nonsynostotic positional plagiocephaly in infants between three and eighteen months old when specific cranial asymmetry measurements are documented in millimeters.

Diabetic therapeutic footwear. Depth shoes and custom-molded shoes are covered for patients with diabetes, peripheral vascular disease, or peripheral neuropathy that causes severe circulatory insufficiency or decreased sensation. Medically necessary shoe modifications like rigid rocker bottoms, wedges, metatarsal bars, and offset heels are also eligible.{¹}

Why Custom Devices Are Harder to Get Approved

Cigna treats prefabricated, off-the-shelf orthotics as the starting point for most conditions. A custom-fabricated device is covered only when you’ve tried and failed a prefabricated option, or when there’s a documented medical reason prefabricated devices are contraindicated or can’t be tolerated.{¹}

This fail-first rule applies across foot orthoses, knee braces, and lower limb orthoses like AFOs and KAFOs. To approve a custom knee brace, Cigna wants clinical documentation showing an abnormal limb contour, a knee deformity, or minimal muscle mass that makes a prefabricated brace impossible to fit. For custom foot orthoses, the record needs to show that conservative medical management has failed and that one of several qualifying conditions exists, such as impaired peripheral sensation, a neurological condition causing foot malalignment, or an acquired foot deformity with significant pain that interferes with daily activities. The condition also has to be expected to be permanent or long-standing, generally defined as lasting more than six months.

The Plantar Fasciitis Problem

If you’re reading this because your podiatrist suggested custom insoles for plantar fasciitis, know that Cigna considers custom-fabricated foot orthoses for plantar fasciitis not medically necessary. The insurer’s stated position is that custom devices are clinically equivalent to conventional prefabricated orthoses for this condition but cost significantly more. Claims billed with the plantar fasciitis diagnosis code (M72.2) alongside custom orthotic procedure codes are routinely denied.{¹}

Cigna does, however, cover nonambulatory night splints for plantar fasciitis. The night splint is a covered alternative for the same diagnosis when it meets the policy’s general criteria.

What Cigna Won’t Pay For

Several categories of orthotic-related items are excluded under the policy, and in some plans by the plan document itself:

Prefabricated foot orthoses are listed as not covered or reimbursable under the medical coverage policy, though individual plans may vary.
Orthopedic shoes, shoe inserts, and shoe modifications are not covered for most conditions. The exception is diabetic therapeutic footwear for patients with qualifying systemic conditions.{}²
Elastic lumbar supports, inflatable cushions, back rests, and similar comfort items that don’t treat an underlying physical condition are excluded.
Orthotics used primarily for athletic performance, or placed on uninjured body parts to prevent injury (including prophylactic knee braces), are not covered.
Devices used primarily for appearance rather than function are excluded.{}³
Powered exoskeletons like ReWalk, myoelectric upper extremity devices like MyoPro 2, and microprocessor-controlled lower limb orthotics like C-Brace are classified as experimental, investigational, or unproven.
Socks and brace sleeves used with an orthotic device, additional interfaces dispensed with the initial device, and separate orthotic devices for a second pair of shoes are all excluded.{}¹

Some individual plan documents go further. Certain Cigna individual and family plans exclude cranial banding except after surgery for synostotic plagiocephaly, and exclude all foot orthotic devices except for diabetes-related treatment.{²}{³}

Prior Authorization

Cigna requires precertification for many orthotic and prosthetic devices. The process is managed by EviCore by Evernorth, which handles clinical utilization review for Cigna commercial members.{⁴} Whether a specific device needs it depends on its HCPCS procedure code.

A complete request includes patient information, the referring physician’s details, the rendering provider’s credentials, the specific HCPCS codes, and clinical documentation such as the physician’s order, patient history, progress notes, and physical examination findings.{⁵} One thing to understand before you start: precertification approval is not a payment guarantee. You still have to be eligible under your plan, and the service still has to be a covered benefit on the date it’s provided.{⁶}

What You’ll Actually Pay

Out-of-pocket costs for orthotics vary widely by plan. A few real examples from Cigna plan documents show the spread:

A Cigna Connect Silver EPO plan applied 40% coinsurance to durable medical equipment after a $3,000 deductible, with out-of-network services not covered at all.{}⁷
A Cigna small-group HMO plan in Arizona covered durable medical equipment and external prosthetic appliances at 100% with no cost sharing.{}⁸
A Cigna Medicare Advantage PPO plan charged 10% coinsurance for prosthetic and orthotic devices, with a $0 copay for diabetic therapeutic shoes.{}⁹
A HealthSpring Preferred HMO Medicare Advantage plan applied 20% coinsurance to prosthetic and orthotic devices and therapeutic shoes.{}¹⁰

The only reliable way to know your number is to pull your plan’s Summary Plan Description, Evidence of Coverage, or Summary of Benefits. The medical coverage policy itself says that individual plan documents supersede the general policy whenever there’s a conflict.

Using an In-Network Provider

Cigna’s orthotic and prosthetic services run through a national network maintained by EviCore. You can find a participating provider through Cigna’s online provider directory or by calling EviCore at 800-298-4806.{⁴} In certain networks, your treating provider is required to refer you to the authorized Cigna DME vendor rather than billing Cigna directly for the device.{¹¹}

Going out of network can mean significantly higher costs or no coverage at all. EPO and HMO designs typically don’t cover out-of-network DME. PPO plans usually offer some coverage, but at a higher coinsurance and with the risk of balance billing.

If Cigna Denies Your Orthotic Claim

Denials are common for custom devices and for diagnoses like plantar fasciitis. You have 180 calendar days from the denial notice to file an internal appeal.{¹²}

Start informally. A call to Cigna customer service at the number on the back of your ID card can sometimes resolve the issue without a formal appeal.{¹³} If that doesn’t work, submit a written appeal with supporting clinical documentation. For a medical necessity dispute, the appeal is reviewed by a physician who wasn’t involved in the original denial. Your provider can also request a peer-to-peer clinical consultation with a Cigna medical director.{⁶}

Cigna notifies you in writing within 30 calendar days for pre-service or post-service medical necessity appeals. Administrative appeals can take up to 60 days. If the internal appeal is denied and the dispute involves medical judgment, you may be eligible for an independent external review; the instructions arrive with the final internal appeal decision.

For a custom orthotic appeal, the documentation should show why a prefabricated device is inadequate. That means the physical examination findings, the specific diagnosis, evidence that you tried and failed a prefabricated orthotic (or an explanation of why one is medically contraindicated), and documentation of how the custom device will improve your ability to perform daily activities.{¹}

1
Cigna. Orthotic Devices and Shoes Medical Coverage Policy 0543
2
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Cigna. Cigna Medical Exclusions – Tennessee
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Cigna. Durable Medical Equipment and Orthotics Precertification
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eviCore. Cigna Orthotics and Prosthetics DME Provider Orientation
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eviCore. Cigna eviCore DME Quick Reference Guide
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Cigna. Summary of Benefits – Cigna HMO Small Group AZ
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Fairfax County. Cigna True Choice Core Medicare PPO Summary of Benefits
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