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.