Custom Fabricated Knee Orthoses
General Criteria for Custom Fabricated Knee Orthoses:
-
A custom fabricated orthosis may be considered medically necessary when there is a documented physical characteristic which requires the use of a custom fabricated orthosis instead of a prefabricated orthosis. Examples of situations which meet the criterion for a custom fabricated orthosis include, but are not limited to:
- Deformity of the leg or knee; or
- Size of thigh and calf; or
- Minimal muscle mass upon which to suspend an orthosis.
- Although these are examples of potential situations where a custom fabricated orthosis may be appropriate, suppliers must consider prefabricated alternatives such as pediatric knee orthoses in individuals with small limbs, straps with additional length for large limbs, etc.
- If a custom fabricated orthosis is provided but the medical record does not document why that item is medically necessary instead of a prefabricated orthosis, the custom fabricated orthosis is considered not medically necessary.
- Custom fabricated orthoses are considered not medically necessary in the treatment of knee contractures in cases where the individual is not ambulatory.
A custom fabricated knee immobilizer without joints may be considered medically necessary when
BOTH
of the following criteria are met:
-
The coverage criteria for the prefabricated orthosis, knee immobilizer without joints as mentioned above are met;
and
- The general criteria for a custom fabricated orthosis is met.
Custom fabricated knee orthosis may be considered medically necessary in non-ambulatory individuals with severe spastic conditions such as, but not limited to cerebral palsy.
Custom fabricated knee orthosis in non-ambulatory individuals for indications other than severe spastic conditions is considered not medically necessary.
If a custom fabricated knee immobilizer without joints is provided and both criteria above are not met, the orthosis is considered not medically necessary.
A custom fabricated derotation knee orthosis may be considered medically necessary for instability due to internal ligamentous disruption of the knee.
A custom fabricated knee orthosis with an adjustable flexion and extension joint may be considered medically necessary if
ALL
the following are met:
-
The coverage criteria for the prefabricated orthosis, and knee orthosis with an adjustable flexion and extension joint are met;
and
- The general criteria for a custom fabricated orthosis are met.
If a custom fabricated knee orthosis with an adjustable flexion and extension joint is provided and both criteria above are not met, the orthosis is considered not medically necessary.
A custom fabricated knee orthosis with a modified supracondylar prosthetic socket may be considered medically necessary for an individual who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee.
A custom fabricated orthosis for any other condition not stated above is considered not medically necessary.
Procedure Codes
| L1834 | L1840 | L1844 | L1846 | L1860 |
