| Highmark Commercial Medical Policy - Pennsylvania |
| Medical Policy: | O-8-023 |
| Topic: | Braces and Supports |
| Section: | Orthotic & Prosthetic Devices |
| Effective Date: | February 1, 2016 |
| Issue Date: | February 1, 2016 |
| Last Reviewed: | October 2015 |
Braces and Supports are prosthetic or orthotic devices which steady, align, protect, or strengthen weakened, injured, or deformed body parts. Custom fitted orthotics are prefabricated, may require some assembly, and substantially modified for individual fitting at the time of delivery by a certified orthotist, or an individual with equivalent specialized training. Substantial modifications are changes by a certified orthotist or an individual with equivalent specialized training in compliance with licensure and regulatory requirements to achieve an individualized fit using CAD/CAM technology. Minimal self-adjustment can be performed by the member, and does not require expertise of a certified orthotist. Off-the-shelf (OTS) orthotics are prefabricated, may require some assembly and/or minimal self-adjustment, but not requiring expertise of a certified orthotist. |
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.
| Policy Position Coverage is subject to the specific terms of the member’s benefit plan. |
Braces and supports addressed in this medical policy may be considered medically necessary when ALL of the following general criteria are met, AND any category specific criteria:
General Criteria
Devices not meeting the above criteria are considered not medically necessary.
Purchase of more than two of the same type of device on the same day is considered not medically necessary.
Dispensing a device for post-operative use prior to the procedure is considered not medically necessary.
Hernia supports (Corset or Truss style) may be considered medically necessary when ALL of the following criteria are met:
Hernia supports (Corset or Truss style) are considered not medically necessary for all other indications.
Supportive Back Braces may be considered medically necessary when ANY ONE of the following are met:
Supportive Back Braces are considered not medically necessary for all other indications.
Custom-fitted and Custom-fabricated Back Braces may be considered medically necessary when criteria for supportive back braces AND ONE of the following are met:
Custom-fitted or Custom-fabricated Back Braces are considered not medically necessary for all other indications.
Postoperative Back Braces may be considered medically necessary when ALL of the following are met:
Postoperative Back Braces are considered not medically necessary for all other indications.
Quantity Level Limits (QLL) for all back braces
One (1) back brace per every five (5) years may be considered medically necessary as the reasonable lifetime of a back brace is no less than five (5) years.
Postoperative Hip Braces may be considered medically necessary after ANY ONE of the following procedures:
Postoperative hip braces are considered not medically necessary for all other indications.
Cast-Braces (Fracture Braces)
Comfort, non-therapeutic cast-braces (Cam Walker) may be considered medically necessary when ALL of the following criteria are met:
Comfort, non-therapeutic cast-braces are considered not medically necessary for all other indications.
Functional cast-braces (PTB cast brace, PTB fracture brace, MAFO-molded ankle-foot orthosis, fracture brace with pelvic band, Achilles tendon hinged brace) may be considered medically necessary when ALL of the following criteria are met:
Functional cast-braces are considered not medically necessary for all other indications.
Rehabilitation Braces may be considered medically necessary when ALL of the following criteria are met:
Rehabilitation Braces are considered not medically necessary for all other indications.
Cervical (Neck) Braces may be considered medically necessary when ALL of the following criteria are met:
Cervical (Neck) Braces are considered not medically necessary for all other indications.
Childhood Hip Braces (Pavlik Harness, Frejka Pillow Splint, Friedman Strap) may be considered medically necessary for children with hip disorders when ALL of the following criteria are met:
Childhood Hip Braces are considered not medically necessary for all other indications.
Braces for Congenital Defects may be considered medically necessary in the treatment of congenital defects when general criteria are met.
Replacement braces may be considered medically necessary when:
Cervical-thoracic-lumbar-sacral or Thoracic-lumbar-sacral orthoses may be considered medically necessary for the treatment of scoliosis in juvenile and adolescent patients at high-risk of progression when ALL of the following criteria are met:
Cervical-thoracic-lumbar-sacral or Thoracic-lumbar-sacral orthoses are considered not medically necessary for all other indications.
Wheaton Braces may be considered medically necessary to treat metatarsus adductus in infants, replacing the need for serial casting when general criteria are met.
Wheaton Braces are considered not medically necessary for all other indications.
Splints and Immobilizers - The following devices may be considered medically necessary when general criteria are met:
Splints and Immobilizers are considered not medically necessary for all other indications.
Unna Boots may be considered medically necessary for the following non-fracture care indications:
Unna Boots are considered not medically necessary for all other indications.
Air Casts/Air Splints may be considered medically necessary for treatment of fractures or other injuries (i.e., sprains, torn ligaments) when general criteria are met.
Air Casts are considered not medically necessary for all other indications.
Miscellaneous Covered Services
Casting of a sprain or casting following a surgical procedure may be considered medically necessary.
The following braces and supports do not meet the definition of covered durable medical equipment because they are not made to withstand long term use; and are therefore considered non-covered:
For Provider Overhead Expenses, see Medical Policy Bulletin Z-39. For Foot Orthotics for Conditions Other Than Diabetes, see Medical Policy Bulletin O-12. For Ankle-Foot/Knee- Ankle-Foot Orthosis, See Medical Policy Bulletin O-24. For Compression Stockings, see Medical Policy Bulletin E-1. For Dynamic Splinting Devices, see Medical Policy Bulletin O-10. For Rigid Immobilization, see Medical Policy Bulletin S-13. For Diabetic Services and Supplies, see Medical Policy Bulletin E-15. |
| Place of Service: Outpatient |
The use of Braces and Supports 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.
| The policy position applies to all commercial lines of business |
| FEP Guidelines |
This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
| Denial Statements |
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.
Quantity level limits or quantity of supplies that exceed the frequency guidelines listed on the policy will be denied as non-covered. A network provider cannot bill the member for the non-covered service.
A network provider can bill the member for the non-covered service.
| Links |
11/2015, Braces and Support Guidelines Added