An orthosis is an orthopedic appliance or apparatus used to support, align, prevent, or correct deformities or to improve function of movable parts of the body. Ankle-Foot Orthosis (AFO’s) and Knee-Ankle-Foot Orthosis (KAFO’s) are designed to control knee and ankle motion.
The purpose of a brace is to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body.
For an item to be considered for coverage under the brace benefit category, it must be a rigid or semi-rigid device which is used for the purpose of supporting a weak or deformed body extremity or restricting or eliminating motion in a diseased or injured part of the body. It must provide support and counterforce (i.e., a force in a defined direction of a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that it is being used to brace.
Elastic support garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices and are non-covered.
An orthosis can be classified as either prefabricated (off-the-shelf or custom fitted) or custom-fabricated. Items that do not meet the definition of a brace are non-covered.
AFO or KAFO Non-Ambulatory/Minimally Ambulatory
Treatment with a static or dynamic positioning AFO may be considered medically necessary for ONE or more of the following conditions:
If a static or dynamic positioning AFO is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff or caregiver.
If a static or dynamic positioning AFO is considered medically necessary, a replacement interface is considered medically necessary as long as the individual continues to meet indications and other coverage rules for the splint. Coverage of a replacement interface is limited to a maximum of one (1) per six (6) months. Additional interfaces will be denied as not medically necessary.
An AFO or KAFO may be considered medically necessary for the following indications:
AFO or KAFO Ambulatory
An AFO may be considered medically necessary for ambulatory individuals with weakness or deformity of the foot and ankle, who require stabilization for medical reasons (including required support for standing transfers), and have the potential to benefit functionally.
A KAFO may be considered medically necessary for ambulatory individuals for whom an ankle-foot orthosis is considered medically necessary and additional knee stability is required.
An AFO or KAFO that is custom-fabricated may be considered medically necessary for ambulatory individuals when the basic coverage criteria listed above and ONE of the following criteria are met:
If a custom fabricated orthosis is provided but ALL of the coverage criteria above including the additional criteria for a custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not medically necessary.
Concentric adjustable torsion style mechanisms used to assist knee joint extension may be considered medically necessary for individuals who require knee extension assist in the absence of any co-existing joint contracture.
Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion may be considered medically necessary for individuals who require ankle plantar or dorsiflexion assist in the absence of any co-existing joint contracture.
Concentric adjustable torsion style mechanisms may be considered medically necessary when used for the treatment of contractures, regardless of any co-existing condition(s).
Replacement of a complete orthosis or component of an orthosis due to loss, significant change in the individual’s condition, or irreparable accidental damage may be considered medically necessary if the device is still medically necessary. The reason for the replacement must be documented in the supplier’s record. Replacements not meeting criteria will be considered not medically necessary.
If the specific AFO or KAFO criteria are not met, the orthosis will be considered not medically necessary.
A4467 |
A9283 |
A9285 |
E1810 |
E1815 |
L1900 |
L1902 |
L1904 |
L1906 |
L1907 |
L1910 |
L1920 |
L1930 |
L1932 |
L1940 |
L1945 |
L1950 |
L1951 |
L1960 |
L1970 |
L1971 |
L1980 |
L1990 |
L2000 |
L2005 |
L2010 |
L2020 |
L2030 |
L2034 |
L2035 |
L2036 |
L2037 |
L2038 |
L2106 |
L2108 |
L2112 |
L2114 |
L2116 |
L2126 |
L2128 |
L2132 |
L2134 |
L2136 |
L2180 |
L2182 |
L2184 |
L2186 |
L2188 |
L2190 |
L2192 |
L2200 |
L2210 |
L2220 |
L2230 |
L2232 |
L2240 |
L2250 |
L2260 |
L2265 |
L2270 |
L2275 |
L2280 |
L2300 |
L2310 |
L2320 |
L2330 |
L2335 |
L2340 |
L2350 |
L2360 |
L2370 |
L2375 |
L2380 |
L2385 |
L2387 |
L2390 |
L2395 |
L2397 |
L2405 |
L2415 |
L2425 |
L2430 |
L2492 |
L2500 |
L2510 |
L2520 |
L2525 |
L2526 |
L2530 |
L2540 |
L2550 |
L2750 |
L2755 |
L2760 |
L2768 |
L2780 |
L2785 |
L2795 |
L2800 |
L2810 |
L2820 |
L2830 |
L2840 |
L2850 |
L2861 |
L2999 |
L4002 |
L4010 |
L4020 |
L4030 |
L4040 |
L4045 |
L4050 |
L4055 |
L4060 |
L4070 |
L4080 |
L4090 |
L4100 |
L4110 |
L4130 |
L4205 |
L4210 |
L4350 |
L4360 |
L4361 |
L4370 |
L4386 |
L4387 |
L4392 |
L4394 |
L4396 |
L4397 |
L4398 |
L4631 |
|
|
|
|
|
The following conditions will be considered not medically necessary:
The following conditions are considered non-covered:
A4467 |
A9283 |
A9285 |
E1810 |
E1815 |
L1900 |
L1902 |
L1904 |
L1906 |
L1907 |
L1910 |
L1920 |
L1930 |
L1932 |
L1940 |
L1945 |
L1950 |
L1951 |
L1960 |
L1970 |
L1971 |
L1980 |
L1990 |
L2000 |
L2005 |
L2010 |
L2020 |
L2030 |
L2034 |
L2035 |
L2036 |
L2037 |
L2038 |
L2106 |
L2108 |
L2112 |
L2114 |
L2116 |
L2126 |
L2128 |
L2132 |
L2134 |
L2136 |
L2180 |
L2182 |
L2184 |
L2186 |
L2188 |
L2190 |
L2192 |
L2200 |
L2210 |
L2220 |
L2230 |
L2232 |
L2240 |
L2250 |
L2260 |
L2265 |
L2270 |
L2275 |
L2280 |
L2300 |
L2310 |
L2320 |
L2330 |
L2335 |
L2340 |
L2350 |
L2360 |
L2370 |
L2375 |
L2380 |
L2385 |
L2387 |
L2390 |
L2395 |
L2397 |
L2405 |
L2415 |
L2425 |
L2430 |
L2492 |
L2500 |
L2510 |
L2520 |
L2525 |
L2526 |
L2530 |
L2540 |
L2550 |
L2750 |
L2755 |
L2760 |
L2768 |
L2780 |
L2785 |
L2795 |
L2800 |
L2810 |
L2820 |
L2830 |
L2840 |
L2850 |
L2861 |
L2999 |
L4002 |
L4010 |
L4020 |
L4030 |
L4040 |
L4045 |
L4050 |
L4055 |
L4060 |
L4070 |
L4080 |
L4090 |
L4100 |
L4110 |
L4130 |
L4205 |
L4210 |
L4350 |
L4360 |
L4361 |
L4370 |
L4386 |
L4387 |
L4392 |
L4394 |
L4396 |
L4397 |
L4398 |
L4631 |
|
|
|
|
|
Microprocessor Controlled KAF/KAFO
Microprocessor controlled KAF/KAFO are considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
L2006 |
|
Refer to Medical Policy O-8, Braces and Supports, for additional information.
Refer to Medical Policy E-15, Diabetic Services and Supplies, for additional information.
Covered Diagnosis Codes for Procedure Codes L4392, L4396 and L4397
M24.571 |
M24.572 |
M24.574 |
M24.575 |
M72.2 |
|
|
Covered Diagnosis Codes for Procedure code L4631
A52.16 |
E08.610 |
E09.610 |
E10.610 |
E11.610 |
E13.610 |
M14.671 |
M14.672 |
M14.69 |
M62.471 |
M62.472 |
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|
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This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical or other circumstances may warrant individual consideration, based on review of applicable medical records, as well as other regulatory, contractual and/or legal requirements.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect Highmark's reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Highmark retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you need these services, contact the Civil Rights Coordinator.
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475
, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697
(TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
This information is issued by Highmark Blue Shield on behalf of its affiliated Blue companies, which are independent licensees of the Blue Cross Blue Shield Association. Highmark Inc. d/b/a Highmark Blue Shield and certain of its affiliated Blue companies serve Blue Shield members in the 21 counties of central Pennsylvania. As a partner in joint operating agreements, Highmark Blue Shield also provides services in conjunction with a separate health plan in southeastern Pennsylvania. Highmark Inc. or certain of its affiliated Blue companies also serve Blue Cross Blue Shield members in 29 counties in western Pennsylvania, 13 counties in northeastern Pennsylvania, the state of West Virginia plus Washington County, Ohio, the state of Delaware[ and [8] counties in western New York and Blue Shield members in [13] counties in northeastern New York]. All references to Highmark in this document are references to Highmark Inc. d/b/a Highmark Blue Shield and/or to one or more of its affiliated Blue companies.
Medical policies do not constitute medical advice, nor are they intended to govern the practice of medicine. They are intended to reflect reimbursement and coverage guidelines. Coverage for services may vary for individual members, based on the terms of the benefit contract.
Discrimination is Against the Law
The Claims Administrator/Insurer complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Claims Administrator/Insurer does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Claims Administrator/ Insurer:
If you believe that the Claims Administrator/Insurer has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: 1-866-286-8295, TTY: 711, Fax: 412-544-2475, email: CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights Coordinator is available to help you.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.