Ankle-Foot/Knee-Ankle-Foot Orthosis

Policy ID: O-24-015

Section: Orthotic & Prosthetic Devices

Effective Date: July 01, 2018

Revised Date: August 08, 2019

Last Reviewed: March 23, 2023

Applies To: Commercial and Medicaid Expansion

Description

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 (AFO) and Knee-Ankle-Foot Orthosis (KAFO) are designed to control knee and ankle motion.

The purpose of a brace is to support a weak or deformed body extremity or to restrict or eliminate motion in a diseased or injured part of the body.

Criteria

Ankle foot orthoses (AFOs) not used during ambulation

A static or dynamic positioning ankle-foot orthosis may be considered medically necessary for the treatment of plantar fasciitis OR when ALL of the following are met.

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
Reasonable expectation of the ability to correct the contracture; and
Contracture is interfering or expected to interfere significantly with the patient's functional abilities; and
Used as a component of a therapy program; this includes active stretching of the involved muscles and/or tendons

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 (in a nursing facility) or caregiver (at home).

If a static or dynamic positioning AFO is considered medically necessary, a replacement interface may be 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.

Ankle-foot orthoses (AFO) and knee-ankle-foot orthoses (KAFO) used during ambulation

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 Knee-ankle-foot orthoses (KAFO) may be considered medically necessary for ambulatory individuals for whom an ankle-foot orthosis is covered and additional knee stability is required.

An AFOs or KAFO is custom-fabricated may be considered medically necessary for ambulatory individuals when the basic coverage criteria listed above and ANY ONE of the following criteria are met:

The individual could not be fitted with a prefabricated AFO; or
The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than six (6) months); or
There is a need to control the knee, ankle or foot in more than one plane; or
The individual has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or
The individual has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

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).

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

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 considered medically necessary 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.

Procedure Codes

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

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

Astatic AFO and replacement interface will be denied as not medically necessary if the contracture is fixed. A static AFO and replacement interface will be denied as not medically necessary for an individual with a foot drop but without an ankle flexion contracture. A component of a static AFO 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 AFO and replacement interface 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 foot drop splint/recumbent positioning device or replacement interface is considered not medically necessary. A foot drop splint/recumbent positioning device and replacement interface will be denied as not medically necessary in an individual with foot drop who is non ambulatory because there are other more appropriate treatment modalities.

A foot drop splint/recumbent positioning device and replacement interface will be considered not medically necessary when 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).

Additions to AFOs and KAFOs will be considered not medically necessary if either the base orthosis is not medically necessary, or the specific addition is not medically necessary.

A foot pressure off-loading/supportive device 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.

Socks used in conjunction with orthoses are non-covered.

Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are non-covered.

Diagnosis Codes

Diagnosis codes for Procedure Codes L4392, L4396 and L4397

M24.571

M24.572

M24.574

M24.575

M72.2

Diagnosis codes for Procedure Code L4631

A52.16

E08.610

E09.610

E10.610

E11.610

E13.610

M14.69

M14.671

M14.672

M14.69

M62.471

M62.472

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 7-22-2020 Annual Review

Internal Medical Policy Committee 9-21-2020 Removed coding from policy statements-no changes to criteria

Internal Medical Policy Committee 9-21-2021 Annual Review-no changes in criteria

Internal Medical Policy Committee 9-28-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 3-23-2023 Annual Review-no changes in criteria

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving and the Company reserves the right to review and update medical policy periodically.

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