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Details on being a Medicaid Expansion provider
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.
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or
All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.
Coverage is subject to the specific terms of the member's benefit plan.
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 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.
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 covered, 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. 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.
If the specific AFO or KAFO criteria are not met, the orthosis will be considered not medically necessary.
The following conditions will be considered not medically necessary:
The following conditions are considered non-covered:
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.
Not Applicable
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
Internal Medical Policy Committee 5-14-2024 Coding - Effective July 1, 2024
Internal Medical Policy Committee 9-17-2024 Revision with Coding update- Effective November 04, 2024
Internal Medical Policy Committee 5-13-2025 Coding update - Effective April 01, 2025
References (PDF)
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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