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Linda Collins Blogger

Medically Necessary Criteria for Ankle and Knee Braces

Posted by Linda Collins | December 01, 2016

​In order for an item to be considered for coverage by Medicare, it must be “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member…” The Local Coverage Decisions (LCDs) give detailed information about medical necessity requirements for various types of braces.

Ankle-Foot Orthoses (AFOs)

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

  1. They are ambulatory, AND,
  2. There is weakness and/or deformity of the foot, AND,
  3. The beneficiary requires stabilization for medical reasons, AND,
  4. The beneficiary has the 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 (ICD-9 718.47), 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 (ICD-9 728.71)

Knee Ankle Foot Orthoses (KAFO)

Braces described by codes L2000-L2038, L2126-L2136, and L4370 are covered for patients when:

  1. They are ambulatory, AND,
  2. There is weakness and/or deformity of the foot, AND,
  3. The beneficiary requires stabilization for medical reasons, AND,
  4. The beneficiary has the potential to benefit functionally,  AND,
  5. Additional knee stability is required.

Remember, the only products which you can bill to Medicare using code L1906 are those for which a written coding verification has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and that are listed on the website at www.dmepdac.com.

You may download additional reimbursement guides under the Reimbursement Resources under Össur R&R.

Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at reimbursement411@ossur.com