Anthem Post-Payment Recoupment Demands for Custom Foot Orthoses – What Members Need to Know

09/17/2026

NYSPMA is aware that some members are receiving post-payment demand letters from Anthem Blue Cross Blue Shield seeking repayment of reimbursements for custom foot orthoses, including HCPCS codes L3000, L3010 and L3020.

NYSPMA is concerned about this development and understands that the issue may extend beyond New York. APMA will be involved as we work to better understand and address the situation. NYSPMA is also seeking a meeting with Anthem to discuss the basis for these recoupment demands.

Based on the information currently available, it appears that Anthem may be conducting plan and benefit-specific post-payment reviews in which it is applying a Utilization Management guideline concerning orthopedic footwear and inserts. That plan guideline states that inserts and other shoe modifications are considered medically necessary only in certain circumstances, including when they are an integral part of a medically necessary leg brace and are required for the proper functioning of the brace.

What should members do?

1. If you receive an Anthem recoupment letter, do not ignore it. Members should preserve their right to appeal in writing before any deadline and carefully review the specific claims and dates of service identified by Anthem.

2. Request the applicable member-specific contract language. NYSPMA recommends that members, or their legal representatives, request that Anthem provide the member's contract benefits in effect at the time of service and identify the provisions applicable to the individual member that Anthem relied upon in determining coverage or non-coverage of the custom foot orthoses.

3. For future patients, obtain coverage information in writing. Providers should request written confirmation of the patient's benefits and coverage guidelines for custom foot orthoses. Members should not rely solely upon verbal assurances of prior authorization from an Anthem representative that the devices are covered.

4. Consider requesting a Pre-Determination of benefits. Even when Anthem indicates that prior authorization is not required or is granted, NYSPMA recommends that members consider requesting a written Pre-Determination of benefits for custom foot orthoses. This may require submission of clinical documentation, but a written determination can provide important documentation regarding the patient's coverage. It will also ensure that Anthem understands that the Custom Foot Orthoses will be a stand alone device utilized only in the patient's shoe gear, and not part of a brace.

NYSPMA recognizes that these letters are creating significant concern for our members. We are actively working to obtain clarification from Anthem and will continue coordinating with APMA as this issue is evaluated.

Please retain all Anthem correspondence, claim information, payment records, and appeal documentation related to these matters and ensure that appeal deadlines are met to avoid collection and enforcement action.

NYSPMA will provide additional information as it becomes available.