OA Knee Bracing Medical Necessity Requirements

Medicare and private payers develop medical coverage policies to aid in determining whether a health service, drug or device is medically necessary and, therefore, a payable benefit. The development of medical coverage policies includes input from peer-reviewed, published medical journals, expert opinions, and guidelines from nationally recognized health organizations. The majority of payers, Medicare included, publish the coverage policies on their websites.

Local Coverage Determination

Medicare is typically the baseline standard for coverage criteria. According to the Local Coverage Determination, the following must be included in the medical record:

• Patient is ambulatory.
• Patient has knee instability.
• There is objective documentation of the knee instability. (Subjective notes, such as knee pain, do not support coverage)
• Documentation of patient's recent injury or surgery.

Certain add-on codes, such as L2397, may also be considered medically necessary if the brace is also considered medically necessary. You can find a list of appropriate add-on codes in the LCD.

Custom braces  (L1844, L1846) may be considered medically necessary if the physician's medical records document one or more of these conditions:

• Deformity of the leg or knee.
• Abnormal limb shape.
• Minimal muscle mass upon which to suspend an orthosis.
• Chronic condition requiring long-term use of the brace.

*In the case of a custom brace, the Detailed Written Order (DWO) must indicate custom brace.

You may review the Knee Orthoses LCD and Policy Article here.