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/Knee-Ankle-Foot Orthosis is designed to control knee and ankle motion; extends from the upper portion of the thigh, crossing the knee and ankle, and terminating at the toes.

The purpose of a brace is to support a weak or deformed body member 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 (L4396 or L4397) may be considered medically necessary for the treatment of plantar faciitis 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 (L4396 or L4397) 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 code L4396 or L4397 is covered, a replacement interface (L4392) 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 and knee-ankle-foot orthoses used during ambulation

AFOs described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386, and L4631 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.

Knee-ankle-foot orthoses (KAFOs) described by codes L2000-L2038, L2126-L2136, and L4370 may be considered medically necessary for ambulatory individuals for whom an ankle-foot orthosis is covered and additional knee stability is required.

AFOs and KAFOs that are 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 are coded as L2999 and 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 are coded as L2999 and 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), are coded as E1810 and/or E1815.

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

Reasons for non-coverage

A static AFO (L4396 or L4397) and replacement interface (L4392) 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 a patient 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 (L4396 or L4397) and replacement interface (L4392) 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 (L4398) or replacement interface (L4394) is not reimbursable.  A foot drop splint/recumbent positioning device and replacement interface will be denied as not medically necessary in a patient with foot drop who is nonambulatory because there are other more appropriate treatment modalities.

A foot drop splint/recumbent positioning device (L4398) and replacement interface (L4394) are denied as non-covered when it is 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).

If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not medically necessary.

L- coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2768, L2780-L2830) will be denied as not medically necessary if either the base orthosis is not medically necessary or the specific addition is not medically necessary.

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 member 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.  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.

Correct coding of prefabricated AFO and KAFO (L1902, L1906, L1910, L1930, L1932, L1951, L1971, L2035, L2112-L2116, L2132-L2136, L4350, L4360, L4361, L4370, L4386, L4387 and L4396-L4398) is dependent upon whether or not there is a need for “minimal self-adjustment” at the time of fitting by the, individual, caretaker for the individual, or supplier that does not require the services of a qualified practitioner (see definitions below).

When using code A9283, there is no separate billing using addition codes.  Replacement liners for devices billed with A9283 must be billed with code A9270 (non-covered item or service).

Elastic support garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Devices that are not rigid or semi-rigid must be coded A4467. Code A4467 will be denied as non-covered.

A foot pressure off-loading/supportive device (A9283) 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 (L2840, L2850) 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 not covered.

Procedure Codes

Diagnosis Codes

Diagnosis codes for procedure codes L4392, L4396 and L4397

Diagnosis codes for procedure code L4631

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