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 circumstances may warrant individual consideration, based on review of applicable medical records.

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.

Ankle-Foot Orthoses Not Used During Ambulation

A static or dynamic positioning ankle-foot orthosis (L4396 or L4397) may be covered if either ALL of criteria 1-4 OR criterion 5 is met:

1. Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and
2. Reasonable expectation of the ability to correct the contracture; and
3. Contracture is interfering or expected to interfere significantly with the patient’s functional abilities; and
4. Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.
5. The patient has plantar fasciitis.

If a static or dynamic positioning ankle-foot orthosis (L4396 or L4397) 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 (in a nursing facility) or caregiver (at home).

If code L4396 or L4397 is covered, a replacement interface (L4392) is covered as long as the patient 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 months.  Additional interfaces will be denied as not medically necessary.

Ankle-Foot Orthoses and Knee-Ankle-Foot Orthoses Used During Ambulation

Ankle-foot orthoses described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386, and L4631 may be covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.

Knee-ankle-foot orthoses described by codes L2000-L2038, L2126-L2136, and L4370 may be covered for ambulatory patients for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

Ankle-foot orthoses and knee-ankle-foot orthoses that are custom-fabricated, are covered for ambulatory patients when the basic coverage criteria listed above and ANY ONE of the following criteria are met:

1. The patient could not be fit with a prefabricated ankle-foot orthosis, or
2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than six months), or
3. There is a need to control the knee, ankle or foot in more than one plane, or
4. The patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury, or
5. The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria 1-5 for a custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Concentric adjustable torsion style mechanisms used to assist knee joint extension are coded as L2999 and are covered; and therefore medically necessary for members 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 are coded as L2999 and are covered for members who require ankle plantar or dorsiflexion assist in the absence of any co-existing joint contracture.

Concentric adjustable torsion style mechanisms used for the treatment of contractures, regardless of any co-existing condition(s), are coded as E1810 and/or E1815 and are covered.

Claims for devices incorporating concentric adjustable torsion style mechanisms used for the treatment of any joint contracture and coded as L2999 will be denied as incorrect coding. A participating, preferred, or network provider can bill the member for the denied service.

Replacement of a complete orthosis or component of an orthosis due to loss, significant change in the patient’s condition, or irreparable accidental damage may be covered if the device is still medically necessary.  The reason for the replacement must be documented in the supplier’s record. Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are denied as not medically necessary.

Please reference Medical Policy Bulletin E-15 for diabetic orthosis.

Reasons for Noncoverage

A static ankle-foot orthosis (L4396 or L4397) and replacement interface (4392) will be denied as not medically necessary if the contracture is fixed. A static ankle-foot orthosis and replacement interface will be denied as not medically necessary for a patient with a foot drop but without an ankle flexion contracture.  A component of a static ankle-foot orthotic that is used to address positioning of the knee or hip will be denied as not medically necessary because the effectiveness of this type of component is not established.

A static ankle-foot orthosis (L4396 or L4397) and replacement interface (L4392) is non-covered when it is used solely for the prevention or treatment of a heel pressure ulcer because for these indications it is not used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace). A participating, preferred, or network provider can bill the member for the non-covered service.

A foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394) is not reimbursable.  A foot drop splint/recumbent positioning device and replacement interface will be denied as not medically necessary in a patient with foot drop who is nonambulatory because there are other more appropriate treatment modalities.

A foot drop splint/recumbent positioning device (L4398) and replacement interface (L4394) are denied as non-covered when it is used solely for the prevention or treatment of a pressure ulcer because for these indications it is not used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace).  A participating, preferred, or network provider can bill the member for the non-covered device.

If the basic coverage criteria for an ankle-foot orthosis or knee-ankle-foot orthosis are not met, the orthosis will be denied as not medically necessary.

L- coded additions to ankle-foot orthoses and knee-ankle-foot orthoses (L2180-L2550, L2750-L2768, L2780-L2830) will be denied as not medically necessary if either the base orthosis is not medically necessary or the specific addition is not medically necessary.

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 member 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.  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. A participating, preferred, or network provider can bill the member for the non-covered service.

Correct coding of prefabricated AFO and KAFO (L1902, L1906, L1910, L1930, L1932, L1951, L1971, L2035, L2112-L2116, L2132-L2136, L4350, L4360, L4361, L4370, L4386, L4387 and L4396-L4398) is dependent upon whether or not there is a need for “minimal self-adjustment” at the time of fitting by the member, caretaker for the member, or supplier that does not require the services of a qualified practitioner (see definitions below).

When using code A9283, there is no separate billing using addition codes.  Replacement liners for devices billed with A9283 must be billed with code A9270 (non-covered item or service).  A participating, preferred or network provider can bill the member for the non-covered device.

Elastic support garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices.  Devices that are not rigid or semi-rigid must be coded A4467.  Code A4467 will be denied as non-covered.  A participating, preferred, or network provider can bill the member for the non-covered service.

A foot pressure off-loading/supportive device (A9283) is denied as non-covered because it does not support a weak or deformed body member or restrict or eliminate motion in a diseased or injured part of the body. A participating, preferred, or network provider can bill the member for the non-covered service.

Socks (L2840, L2850) used in conjunction with orthoses are non-covered. The provider can bill the member for the non-covered service.

Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are not covered. A participating, preferred, or network provider can bill the member for the non-covered service.

NOTE: 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 circumstances may warrant individual consideration, based on review of applicable medical records.

Ankle-Foot/Knee-Ankle-Foot Orthosis is typically an outpatient procedure which is only eligible for coverage as an inpatient procedure in special circumstances, including, but not limited to, the presence of a co-morbid condition that would require monitoring in a more controlled environment such as the inpatient setting.

Services that do not meet the criteria of this policy will not be considered medically necessary. A network provider cannot bill the member for the denied service unless: (a) the provider has given advance written notice, informing the member that the service may be deemed not medically necessary; (b) the member is provided with an estimate of the cost; and (c) the member agrees in writing to assume financial responsibility in advance of receiving the service. The signed agreement must be maintained in the provider’s records.

• Link to Diagnosis Codes

• Link to References