Custom Made Knee Braces: New Criteria from Anthem

One of the largest private payers, Anthem, released new criteria for medical necessity of custom made knee braces. According to the policy, Custom Made Knee Braces CG-OR-PR-03, custom made unloader braces have unique criteria.

Specifically, the policy states that for a custom unloader brace to be considered medically necessary, there must be a diagnosis of unicompartmental osteoarthritis, with or without valgus/varus and any of the following must be documented:

• Individual is a candidate for high tibial osteotomy or total knee arthroplasty (replacement) and may elect nonsurgical treatment; or
• To predict the success of high tibial osteotomy versus total knee arthroplasty; or
• Individual has severe patellofemoral arthrosis in conjunction with medial or lateral compartment arthrosis.

This criteria differs from the criteria listed for custom- made functional knee braces (e.g. post surgical braces.) A custom made functional brace may be considered medically necessary when any of the

• Abnormal limb contour (disproportionate size of thigh and calf);or
• Knee deformity that interferes with fitting (valgus or varus limb);or
• Minimal muscle mass upon which to suspend an orthosis.

Review the full policy here.