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Linda Collins Blogger

OA Bracing: Coverage

Posted by Linda Collins | June 23, 2014

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 polices on their websites.

What does this mean when evaluating whether or not the insurance will cover an OA Brace? You and your staff have access to basic criteria by payer that helps you determine if the product is the right fit for the patient and what information needs to be included in your documentation. Let us look at some of the major payers’medical coverage policies for OA Braces.


(Region A L27263; Region B L27262: Region C L22664; Region D L27058)

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

L1832, L1833, L1843 and L1845 Coverage Criteria

  • 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.
    • One or more of the following conditions:715.16 Osteoarthrosis localized primary involving lower leg
    • 715.26 Osteoarthrosis localized secondary involving lower leg
    • 715.36 Osteoarthrosis localized not specified whether primary secondary involving lower leg
    • 715.96 Osteoarthrosis unspecificed whether generalized or localized involving lower leg

Private payers may follow these exact coverage guidelines or request additional information. Here are examples of some of the larger payers’ coverage criteria for OA bracing:


Clinical Policy Bulletin: Orthopedic Casts, Braces and Splints 0009

  • The brace is an alternative to surgery
  • The patient has failed to respond to other treatment modalities and use of a neoprene sleeve.
  • Documentation of patient’s progressive limitation in activities of daily living
  • A diagnosis of OA
  • Patient has not had knee surgery in previous six weeks
  • Patient is ambulatory and able to apply and use the brace


Prefabricated and Prophylactic Knee Braces #CG-OR-PR-02

The patient has Osteoarthritis of the knee and at least one of the following criteria is present:

  • High tibial osteotomy or total knee arthroplasty (TKA) (replacement) candidate that may elect nonsurgical treatment; or
  • To predict the success of high tibial osteotomy versus TKA; or
  • Severe patellofemoral arthrosis in conjunction with medial or lateral compartment arthrosis.

Blue Cross/Blue Shield (Healthcare Services Corporation)

Knee Braces: DME103.002

  • Painful osteoarthritis involving the medial compartment of the knee


Knee Braces 0362

Medically necessary for the treatment of moderate to severe osteoarthritis of the knee with ALL of the following criteria:

  • unicompartmental disease that requires load reduction to an affected compartment
  • documented failure of prior medical treatment modalities (e.g., nonsteroidal anti-inflammatory medications, steroid injections, viscoelastic supplementation)
  • radiographic documentation of single-compartment osteoarthritis with or without varus/valgus deformity
  • persistent knee pain limiting activities of daily living

Most private payers list the coverage policies on their websites. Be sure to check for specific criteria prior to submitting a claim and document the diganosis, symptoms, and previous Medical treatments.

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