A custom fabricated orthosis may be covered when there is documentation in the medical record supporting the medical necessity of a custom fabricated brace.

Documenting Medical Necessity for a Custom Knee Brace. Ossur.com

Documenting Medical Necessity for a Custom Knee Brace

The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months)

A need to control the knee in more than one plane

Nature and extent of functional limitations

Other therapeutic interventions and results

Physical characteristics requiring custom brace such as:

Documented neurological, circulatory, or orthopedic status

Minimal muscle mass upon which to suspend an orthosis

The physician’s prescription must specify a custom knee brace.

All knee orthoses claims require the following modifiers:

KX - Requirements specified in the medical policy have been met

For bilateral braces billed on the same date of service, bill two separate braces, each with the base code and one with LT and one with RT modifier. This will result in a two-line claim.

A suspension sleeve may be billed separately as a component of custom fabricated knee braces.

Documenting Medical Necessity for a Custom Knee Brace

Documentation should include:

The physician’s prescription must specify a custom knee brace.

Suspension Sleeve