Aetna Hammertoe Correction prior authorization requirements (2026)
What Aetna generally requires to approve Hammertoe Correction (CPT 28285, 28286). Yes. Aetna generally requires prior authorization for Hammertoe Correction (CPT 28285, 28286).
Medical-necessity criteria Aetna generally applies
Medically necessary for skeletally mature individuals (18 or older) when ALL are met: (1) radiographic confirmation on AP and lateral views of the affected foot documenting the deformity; (2) persistent pain and difficulty walking following at least 3 months of conservative treatment (corticosteroid injections, callus/corn debridement, foot orthotics or shoe modifications, NSAIDs or analgesics, protective padding, taping or adhesive devices); AND (3) at least ONE clinical indication: adventitious bursitis on the dorsal surface, joint ankylosis (DIP or PIP), interdigital neuroma caused by the deformity, MTP capsular tear from the deformity, painful nail conditions from trauma, tendon contracture requiring repair, MTP joint subluxation or dislocation, MTP synovitis or capsulitis, or ulceration of the toe apices. Repeat surgery is medically necessary after failure of a previous surgical procedure.
Diagnoses that commonly support medical necessity
ICD-10-CM diagnoses frequently associated with medical necessity for Hammertoe Correction. Confirm the covered diagnosis list against the current Aetna policy.
Commonly required documentation
- AP and lateral radiographs of the affected foot
- documentation of persistent pain and difficulty walking
- record of at least 3 months of conservative treatment
- documentation of at least one qualifying clinical indication
- skeletal-maturity documentation.
Situations to verify before submitting
Aetna may not cover Hammertoe Correction in these situations. Verify against the current policy rather than assuming a denial:
- Cosmetic correction without meeting the medical-necessity criteria.
- Certain hammertoe fixation implants are considered experimental/unproven (insufficient evidence).
- Plantar plate repair for MTP instability is considered not established.
Source
Source: Aetna Clinical Policy Bulletin 0636, Hammertoe Repair, last reviewed 12/11/2025 (). View the source policy. Last verified 2026-06-16.
Frequently asked questions
Does Aetna require prior authorization for Hammertoe Correction?
Yes. Aetna generally requires prior authorization for Hammertoe Correction (CPT 28285, 28286).
What does Aetna require to approve Hammertoe Correction?
Medically necessary for skeletally mature individuals (18 or older) when ALL are met: (1) radiographic confirmation on AP and lateral views of the affected foot documenting the deformity; (2) persistent pain and difficulty walking following at least 3 months of conservative treatment (corticosteroid injections, callus/corn debridement, foot orthotics or shoe modifications, NSAIDs or analgesics, pr… Always confirm against the current Aetna policy.
How long does a Aetna prior authorization take?
Turnaround varies by plan and submission method. Check the Aetna portal for current timeframes.
Submitting Hammertoe Correction to Aetna?
Praxigen checks your clinical note against these criteria before you submit and drafts a policy-cited appeal if it is denied. You review and submit; nothing is sent automatically.