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Linda Collins Blogger

OA Knee Bracing: Coverage

Posted by Linda Collins | July 05, 2016

In this second post of the three part series on OA bracing, we discuss coverage criteria for Medicare and private payers.

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.

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.


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

K0901, K0902, 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.

The LCD provides a list of ICD-10 codes which support the medical necessity of the brace. The list includes, but is not limited to:

M17.11 Unilateral primary osteoarthritis, right knee

M17.12 Unilateral primary osteoarthritis, left knee

M17.2 Bilateral post-traumatic osteoarthritis of knee

M17.31 Unilateral post-traumatic osteoarthritis, right knee

M17.32 Unilateral post-traumatic osteoarthritis, left knee

M17.4 Other bilateral secondary osteoarthritis of knee

M17.5 Other unilateral secondary osteoarthritis of knee

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.

Private Payers

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:


  • 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.


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)

  • Painful osteoarthritis involving the medial compartment of the knee.


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 diagnosis, symptoms, and previous Medical treatments.

The Össur OA Knee Bracing Reimbursement Guide and OA Knee Bracing Checklist are available from your Össur representative. These guides provide detailed information about the medical necessity requirements. Please take advantage of these free resources as you dispense and bill for OA Knee Braces. 

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