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Linda Collins Blogger

Ankle Braces: What is and is not covered

Posted by Linda Collins | April 19, 2017

What is Covered:

According to this LCD, AFOs billed with L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386, L4387, and L4631 are when:

  1. The patient is ambulatory, AND,
  2. There is weakness and/or deformity of the foot, AND,
  3. Stabilization is required for medical reasons, AND,
  4. There is a potential to benefit functionally.

The only AFOs covered for non-ambulatory patients are those products described by HCPCPS L4396 or L4397. The coverage requirements include:

  1. A documented diagnosis of plantar flexion contracture AND,
  2. Documented passive range of motion testing with at least 10 degrees dorsiflexion, AND,
  3. A reasonable expectation of the ability to correct the contracture with the AFO, AND,
  4. The contracture is significantly interfering with the beneficiary's functional abilities, AND,
  5. The brace is used as part of a therapy program, which includes active stretching of the muscles and tendons,

OR

  1. The beneficiary has a documented diagnosis of plantar fasciitis

What is NOT Covered:

A walking boot used solely for treatment of a lower extremity ulcer or pressure reduction must be coded A9283. This is a non-covered benefit under Medicare. 

Medicare does not reimburse for a foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394).

What does this mean for you?

Make sure your documentation details the medical necessity of the brace. If the brace is being used for treatment of lower extremity ulcers or pressure reduction, you may charge the patient for the full cost.  Learn more about the coverage criteria by reviewing the Local Coverage Determination L33686.

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