Ankle-Foot/Knee-Ankle-Foot Orthosis

Policy ID: O-24-013

Section: Orthotic & Prosthetic Devices

Effective Date: July 01, 2018

Revised Date: August 08, 2019

Last Reviewed: September 21, 2020

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	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

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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