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Linda Collins Blogger

Knee Bracing Prior to Knee Surgery

Posted by Linda Collins | August 14, 2018

According to the Local Coverage Determination for Lower Extremity Major Joint Replacement (LCD ID L36007), Medicare will consider coverage when all the following criteria are met:

  1. X-rays or MRI indicating joint disease.
  2. Pain that interferes with activities of daily living.
  3. Three-month course of non-surgical medical management is well documented and has failed to reduce the pain.

Knee bracing is considered a possible conservative treatment modality under these guidelines.

Many private payers are following this guideline as well. Other private payers have guidelines for arthroplasties.  Summaries of a few of the major payers coverage polices are below:

 

Anthem

Knee Arthroscopy, CG-SURG-43

After a failed trial of non-operative, conservative therapy for a minimum of 6 weeks.

Conservative therapy consists of appropriate combination of:

  • NSAIDS or other appropriate medications
  • Physical therapy
  • Bracing, weight loss, activity modification

 

Aetna

Knee Arthroplasties Medical Policy 0660

At least 12 weeks of nonsurgical treatment documented in the medical record , including all of the following, unless contraindicated:

  • NSAIDs
  • Physical Therapy
  • Activity modification
  • Bracing, assistive device use
  • Therapeutic injections, as appropriate 

 

Blue Shield California

Knee Arthroscopy

Section 7.0 Surgery

Documentation of unsuccessful conservative therapy for at least six weeks or documentation of rationale if conservative management is considered inappropriate.

All of the following conservative treatments are to be documented in the medical record:

  • NSAID
  • Activity modification
  • Physical therapy
  • Weight reduction counseling
  • Bracing or other assistive devices
  • Therapeutic injections, as appropriate

 

Cigna

Musculoskeletal Knee Replacement/Arthroplasty

Failure of at least three (3) months of provider-directed non-surgical management

 

What does this mean for you?

Review, in detail, the payer policies regarding total knee replacement and educate your referral sources.The above are basic summaries only and policies may change. Download the Össur Bracing Reimbursement Guides here.


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