Orthopedic Casts, Braces and Splints

Number: 0009

Policy

Note: Most Aetna traditional plans cover durable medical equipment (DME) as a standard benefit.  Standard Aetna HMO plans do not cover DME without a policy rider.  Please check benefit plan descriptions for details.  Certain orthopedic casts, braces and splints are covered under HMO plans without the DME rider because their use is integral to the treatment of certain orthopedic fractures and recovery after certain orthopedic procedures.

The following braces may be considered medically necessary for the listed indications when they are used to treat disease or injury.

1. Back Braces

   1. Lumbar Orthosis, Lumbar-Sacral Orthosis, and Thoracic-Lumbar-Sacral Orthosis

      Aetna considers a lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis medically necessary for any of the following indications:

      1. To facilitate healing following an injury to the spine or related soft tissues; or
      2. To facilitate healing following a surgical procedure on the spine or related soft tissue (see section on Post-operative Back Braces below); or
      3. To reduce pain by restricting mobility of the trunk; or
      4. To support weak spinal muscles and/or a deformed spine.

      Supportive lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis are considered experimental and investigational for other indications because their effectiveness for indications other than the ones listed above has not been established.  Following a strain/sprain, supportive lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis (back supports, lumbo-sacral supports, support vests) are used to render support to an injured site of the back.  The main effect is to support the injured muscle and reduce discomfort.  The following additional criteria apply to custom-fitted and custom-fabricated back braces.

      1. A custom-fitted back brace (a prefabricated back brace modified to fit a specific member) is considered medically necessary where there is a failure, contraindication or intolerance to an unmodified, prefabricated (off-the-shelf) back brace.
      2. A custom-fitted back brace is considered medically necessary as the initial brace after surgical stabilization of the spine following traumatic injury.
      3. A custom-fabricated back brace (individually constructed to fit a specific member from component materials) is considered medically necessary if there is a failure, contraindication, or intolerance to a custom-fitted back brace.
      4. Custom-fitted and custom-fabricated back braces are considered experimental and investigational when these criteria are not met.

      Note: Back braces are considered DME, except when used as a post-operative brace (see section I, B).

   2. Post-Operative Back Braces

      Aetna considers post-operative back braces medically necessary to facilitate healing when applied within 6 weeks following a surgical procedure on the spine or related soft tissue.

      A post-operative back brace is used to immobilize the spine following laminectomy with or without fusion and metal screw fixation is considered medically necessary.  This brace promotes healing of the operative site by maintaining proper alignment and immobilization of the spine.  Post-operative back braces are considered experimental and investigational for other indications because their effectiveness or indications other than the one listed above has not been estalbished.

      Note: Post-operative back braces are considered part of the surgical protocol for certain back operations.

   3. Prophylactic Lumbar Supports

      Prophylactic lumbar supports (Tech Belts, air belts, tool belts, elastic or inflatable lumbar supports, back rest supports) are considered experimental and investigational supplies because they have not been proven to be effective treatments for back injuries.

      Note: Prophylactic inflatable or elastic lumbar supports do not meet Aetna's definition of covered DME because they are not durable (not made to withstand prolonged use) and because they are not mainly used in the treatment of disease or injury or to improve body function lost as the result of a disease or injury.Footnotes^*

   4. Protective Body Socks

      Note: Protective body socks do not meet Aetna's definition of covered DME because they are not made to withstand prolonged use.

2. Knee Braces

   1. A prefabricated knee orthosis with joints or knee orthosis with condylar pads and joints with or without patellar control

      is considered medically necessary for ambulatory members who have weakness or deformity of the knee and require stabilization.
      
      

   2. A prefabricated knee orthosis with a locking knee joint (i.e., joints that lock a knee into a particular position) or a rigid knee orthosis (knee immobilizer)

      is considered medically necessary for members with flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture).
      
      

   3. A prefabricated knee orthosis, double upright with adjustable joint, with inflatable air support chambers

      is considered experimental and investigational because there is no proven clinical benefit to the inflatable air bladder incorporated into their design.
      
      

   4. A prefabricated knee immobilizer without joints, or a knee orthosis with adjustable knee joints, or a knee orthosis with an adjustable flexion and extension joint that provides both medial-lateral and rotation control,

      are considered medically necessary if the member has had recent injury to or a surgical procedure on the knees (within 6 weeks prior to brace application) requiring range of motion limitations. These braces are considered experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established. Note: When used for this indication, the knee brace is considered a rehabilitation brace (also known as a post-operative or post-injury brace) and is considered an integral part of the orthopedic surgical or fracture care protocol.  Examples include: Bledsoe Postop Brace, DonJoy IROM Brace.
      
      

   5. A prefabricated knee orthosis with double uprights and adjustable knee joints or adjustable flexion and extension joints that provides both medial-lateral and rotation control,

      are also considered medically necessary for members who are ambulatory and have knee instability due to any of the following: neurologic disorders (e.g., multiple sclerosis, cerebral palsy, hemiplegia, paraplegia); immunologic condition (e.g., rheumatoid arthritis, juvenile idiopathic arthritis); knee arthritis (e.g., osteoarthritis, chondromalacia patellae); aseptic necrosis of the tibia/fibula; knee osteonecrosis; dislocations and subluxations affecting the knee; congenital disorders and malformations of the knee; disruptions of the knee ligaments, articular cartilage and meniscus; strains of muscles and tendons of the lower leg; disorders of knee joint prostheses or internal fixation devices; failed total knee arthroplasty; and knee fractures (e.g., tibial plateau fracture). Knee instability must be documented by examination of the member and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). For persons with these indications, valgus or varus bracing alleviates pressure on the medial or lateral compartment of the knee. 
      
      

   6. A prefabricated knee orthosis, Swedish type (i.e., knee orthoses with double uprights and thigh and calf pads) 

      is considered medically necessary for a member who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee. Knee instability must be documented by examination of the member and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).
      
      

   7. Prefabricated knee orthoses

      are considered experimental and investigational for other indications because their effectiveness for indications other than the ones listed above has not been established.
      
      

   8. Knee braces may be custom-fitted prefabricated or custom-made.  Custom-made functional braces (also known as "custom-fabricated" or "molded" knee orthoses)

      are considered medically necessary if the member meets criteria for a prefabricated knee brace above but is unable to be fitted with a custom-fitted prefabricated knee brace.  Examples of situations in which a person may meet criteria for a custom-made knee brace include, but are not limited to:

      1. a deformity of the knee or leg that interferes with fitting;
      2. disproportionate size of thigh and calf;
      3. minimal muscle mass upon which to suspend an orthosis. 

      Exceptionally tall or short stature or obesity does not, by itself, establish the medical necessity for custom-made functional knee braces.  Exceptionally tall persons can usually be fitted with a prefabricated brace with extensions, short persons can usually be fitted with a pediatric prefabricated brace, and obese persons can usually be fitted with a prefabricated knee brace with extra large straps.  Custom-fabricated orthoses are not considered medically necessary for treatment of knee contractures in cases where the member is nonambulatory. Custom-fabricated orthoses are considered experimental and investigational when criteria are not met.
      
      

   9. A custom fabricated knee immobilizer without joints

      is considered medically necessary if criteria a and b are met:
      1. medical necessity criteria for the prefabricated knee orthosis without joints is met; and
      2. The general criterion defined above for a custom fabricated orthosis is met.
         
         

   10. A custom fabricated derotation knee orthosis

       is considered medically necessary for instability due to internal ligamentous disruption of the knee (such as due to ligament deficiency/insufficiency or reconstruction). Note: When used for this indication, the knee brace is considered a functional (derotational) knee brace and is considered DME.  Examples include: Lenox Hill Brace, Boston Knee Brace, DonJoy CI Brace.
       
       

   11. A custom fabricated knee orthosis with an adjustable flexion and extension joint

       is considered medically necessary if criteria a and b are met:
       1. The medical necessity criteria for the knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control are met; and
       2. The general criterion defined above for a custom fabricated orthosis is met.
          
          

   12. A custom fabricated knee orthosis with a modified supracondylar prosthetic socket

       is considered medically necessary for a member who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee.
       
       

   13. Heavy duty knee joints

       are considered medically necessary for persons who weigh more than 300 pounds.
       
       

   14. Up to two removable soft interfaces

       are considered medically necessary per year beginning one year after the date of service for initial issuance of the orthosis.
       
       

   15. Concentric adjustable torsion style mechanisms used to assist knee joint extension

       are considered medically necessary for members who require knee extension assist in the absence of any co-existing joint contracture. For the use of concentric adjustable torsion style mechanisms used for joint contracture, see CPB 405 - Mechanical Stretching Devices for Contracture and Joint Stiffness.
       
       

   16. Knee braces composed of high-strength, lightweight material

       are considered medically necessary for persons who meet criteria for a knee orthosis and whose weight is greater than 250 lbs.  Knee braces composed of high-strength, lightweight material are considered experimental and investigational for other indications.
       
       

   17. Prophylactic Knee Braces

       Prophylactic knee braces are designed to reduce the likelihood or severity of knee ligament injuries in a relatively normal (stable) knee.

       Prophylactic knee braces are considered experimental and investigational.  The American Academy of Orthopedic Surgeons has concluded that prophylactic bracing has not been proven to be effective and, in some cases, may actually contribute to knee injury.

   18. Osteoarthritis Braces (Unloader Braces)

       Aetna considers prefabricated unloader braces medically necessary DME as an alternative to surgery for members with severe symptomatic osteoarthritis of the knee who have pain that has failed to respond to medical therapy and knee bracing with a neoprene sleeve, who have progressive limitation in activities of daily living, and who do not have any of the following:

       1. Arthritis other than osteoarthritis; or a recent knee operation (within the previous 6 weeks); or
       2. Diseases that would preclude use of a brace (e.g., skin disease, peripheral vascular disease, or varicose veins); or
       3. Inability to apply the brace because of physical limitations such as arthritis of the hands or inability to bend over; or
       4. Paresis or other disease that would preclude ambulation; or
       5. Severe cardiovascular deficit; or
       6. Symptomatic disease of the hip, ankle or foot.

       A custom-fabricated unloader brace is considered medically necessary for members who meet criteria for a prefabricated unloader brace and meet medical necessity criteria for a custom-made brace noted in the section on functional and rehabilitation knee braces above.  Unloader braces are considered experimental and investigational when criteria are not met.

       Examples: Generation II Unloader, Orthotech Performer, Vixie Enterprise MKSIII

   19. The Ottobock E-Mag Electronically Locking Knee Brace

       Aetna considers the Ottobock E-Mag electronically locking knee brace experimental and investigational because there is a lack of evidence regarding its effectiveness.

   20. Levitation 2 Bionic Knee Brace

       Aetna considers the Levitation 2 bionic knee brace experimental and investigational because of insufficient evidence regarding its clinical value.

   Note: Elastic support garments (e.g. made of material such as neoprene or spandex [elastane, Lycra]) do not meet Aetna's definition of covered DME because they are not durable (not made to withstand prolonged use).

   Note: Socks and braces sleeves are considered medically necessary supplies when used in conjunction with knee orthoses.

   Note: Please see Appendix for guidelines on the reasonable usable lifetime of knee orthoses. These guidelines also provide the medically necessary frequency of replacement interfaces.

3. Cast-Braces (also called Fracture Braces)

   1. Comfort, Non-Therapeutic

      Comfort, non-therapeutic cast-braces are considered medically necessary DME after a fracture or surgery.  Comfort, non-therapeutic cast-braces are considered experimental and investigational for other indications because their effectiveness for indications other than the ones listed above has not been established.  These braces are often used after the patient has been in a walking cast.  They are usually removable.  Molded casts, which allow the user to remove the cast to bathe the affected extremity, can also be used when a fracture is slow to heal or non-healing.  The use of these removable casts replaces monthly cast changes.  A removable cast of this type offers no therapeutic advantages over a non-removable cast.

      Example: Cam Walker

   2. Functional Cast-Brace

      Functional cast-braces are considered medically necessary after a fracture or surgery.  These have become the standard brace for certain fractures, including tibial-femoral fractures.  The functional cast-brace is used following a short period of standard fracture treatment using a non-weight bearing or partial weight-bearing cast, or immediately following surgery.  It allows protected weight bearing, and motion of the joints above and below the fracture.  The joints are moved earlier, contractures are prevented, and early healing is effected due to the weight bearing.  Functional cast-braces are considered experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established.

      Examples: Patellar tendon bearing (PTB) cast brace, PTB fracture brace, MAFO (molded ankle-foot orthosis) fracture brace with pelvic band, Achilles tendon hinged brace

      Note: Functional cast-braces are considered integral to the treatment of the fracture.

4. Cervical (Neck) Braces

   Cervical (neck) braces are considered medically necessary DME for members with neck injury and other appropriate indications (e.g., torticollis).

   Example: Philadelphia Cervical Collar

   Note: Cervical foam neck collars do not meet Aetna's definition of covered DME because they are not durable, and not made to withstand prolonged use. Footnotes^*

5. Childhood Hip Braces

   Specialized hip braces are considered medically necessary for children with hip disorders to stabilize the hip and/or to correct and maintain hip abduction.  These hip braces are considered experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established.

   Example: Pavlik Harness, Frejka Pillow Splint, Friedman Strap

   Note: Childhood hip braces are considered integral to the management of hip disorders in children.

6. Braces for Congenital Defects

   Aetna considers orthopedic braces medically necessary in the treatment of congenital defects.  Aetna also considers replacement braces medically necessary when the member has outgrown the previous brace or because his/her condition has changed such as to make the previous brace unusable.  This includes scoliosis braces.

   1. Plastic Braces (MAFOs)

      Increasing use is made of plastic braces.  These devices have various names and are often called molded ankle-foot orthoses (AFOs) or molded ankle-foot orthoses (MAFOs).  They may also be called orthotics.  For information on ankle-foot orthotics, see CPB 0565 - Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs).  Orthotics of this type should not be confused with simple, removable orthotic arch supports or shoe inserts.  For information on foot orthotics, see CPB 0451 - Foot Orthotics.

   2. Wheaton Brace

      A Wheaton Brace is considered medically necessary DME to treat metatarsus adductus in infants replacing the need for serial casting.  A Wheaton Brace is considered experimental and investigational for other indications because its effectiveness for indications other than the one listed above has not been established.

   3. Scoliosis Braces

      For Aetna's policy on scoliosis braces, see CPB 0398 - Idiopathic Scoliosis.

7. Splints and Immobilizers

   Certain orthopedic problems are routinely treated with splints or splint-like devices.  The following are considered medically necessary:

   1. Acromio-clavicular splint (also called a Zimmer splint)
   2. Carpal tunnel splints
   3. Clavicle splint (also called a figure-8 splint)
   4. Denis Browne Splint for children with clubfoot or metatarsus valgus to maintain and correct abduction
   5. Dynasplints under circumstances specified in CPB 0405 (See CPB 0405 - Mechanical Stretching Devices for Contracture and Joint Stiffness)
   6. Finger splints
   7. Shoulder immobilizer.

8. Unna Boots

   Unna boots are considered medically necessary only for non-fracture care.  Unna boots have no proven value when used in conjunction with fracture treatment.  They can be used to treat sprains and torn ligaments, provide protection for other soft tissue injuries and may be used after certain surgical procedures as a protective cover to promote healing.  Occasionally they are used in the first days after a fracture before a cast is put on.  Their use in this regard is controversial.

9. Air Casts

   Air Casts are considered medically necessary for treatment of fractures or other injuries (i.e., sprains, torn ligaments).  Air Casts (air splints) are used as an alternative to plaster casts to immobilize an elbow, ankle, or knee.  Air Casts are considered experimental and investigational for other indications because their effectiveness for indications other than the one listed above has not been established.

10. Miscellaneous Covered Services

    1. Casting of a sprain is considered medically necessary.
    2. Casting following surgical procedures is considered medically necessary.

11. Fiberglass versus Plaster Casts

    The casting material used in fracture care can be either fiberglass or plaster.  The choice of material is dictated by the individual situation and is left to the discretion of the treating doctor.

12. The Spine and Scapula Stabilizing Brace (the S3 Brace)

    The Spine and Scapula Stabilizing brace (the S3 brace) is considered experimental and investigational because of insufficient evidence of its effectiveness.  According to the manufacturer, the vest-type Spine and Scapula Stabilizing brace (the S3 brace) (AlignMed, Inc., Santa Ana, CA) is designed to help restore normal shoulder kinematics.  It consists of a Velcro strapping system with "propioceptive padding" and mesh vest "to allow biofeedback to patients".  According to the manufacturer, "this neural feedback, along with the vest's innate postural support, could potentially emphasize proper shoulder muscular mechanics".  Evidence for the S3 brace consists of unpublished abstracts examining the effect on shoulder kinematics in normal subjects as well as subjects with "scapular dyskinesis".  There are no published clinical outcome studies of the S3 brace.

13. Adjustable Click Systems

    Aetna considers adjustable click systems (e.g., Revo and Boa click systems) experimental and investigational because of insufficient published evidence of their effectiveness and safety.

Footnotes^*Note: Certain non-durable items (e.g., arm slings, Ace bandages, splints, foam cervical collars, etc.) may be eligible for payment in some circumstances even though they are not durable and do not fit within the definition of DME.  These non-durable items may be covered when charges are made by a hospital, surgical center, home health care agency, or doctor for necessary medical and surgical supplies used in connection with treatment rendered at the time the supply is used.  However, charges for take home supplies (i.e., extra bandages, cervical pillows, etc.) are not covered.  Please check benefit plan descriptions for details.

For Aetna's policy on orthopedic shoes, orthotics and supportive devices for the feet, see CPB 0451 - Foot Orthotics.

Background

This policy is based primarily on Medicare DME MAC criteria for spinal orthoses and knee orthoses.

Prosthetics are devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or replace all or part of the function of a permanently inoperative or malfunctioning internal body organ. This does not require a determination that there is no possibility that the patient’s condition may improve sometime in the future. If the medical record, including the judgment of the attending practitioner, indicates that the condition is of long and indefinite duration, the test of permanence is considered met.

An orthosis (brace) is a rigid or semi-rigid device which is used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. It must provide support and counterforce (i.e., a force in a defined direction of a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that it is being used to brace. An orthosis can be classified as either prefabricated (off-the-shelf or custom fitted) or custom-fabricated.

A custom fabricated item is one that is individually made for a specific patient. No other patient would be able to use this item. A custom fabricated item is a device which is fabricated based on clinically derived and rectified castings, tracings, measurements, and/or other images (such as X-rays) of the body part. The fabrication may involve using calculations, templates, and components. This process requires the use of basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of uncut or unshaped sheets, bars, or other basic forms and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling, and finishing prior to fitting on the patient.

A molded-to-patient-model is a particular type of custom fabricated device in which either:

1. An impression (usually by means of a plaster or fiberglass cast) of the specific body part is made directly on the patient, and this impression is then used to make a positive model of the body part from which the final product is crafted; or
2. A digital image of the patient’s body part is made using Computer-Aided Design-Computer-Aided Manufacturing (CAD-CAM) systems software. This technology includes specialized probes/digitizers and scanners that create a computerized positive model, and then direct milling equipment to carve a positive model. The device is then individually fabricated and molded over the positive model of the patient.

Positive Model of the Patient: A molded-to-patient-model is a negative impression taken of the patient’s body member and a positive model rectification is constructed. In positive models, a CAD-CAM system, by use of digitizers, transmits surface contour data to software that the practitioner uses to rectify or modify the model on the computer screen. The data depicting the modified shape is electronically transmitted to a commercial milling machine that carves the rectified model. Alternatively, a direct formed model is one in which the patient serves as the positive model. The device is constructed over the model of the patient and is then fabricated to the patient. The completed custom fabrication is checked and all necessary adjustments are made. There is no separate billing if CAD-CAM technology is used to fabricate an orthosis.

Custom fitted orthotics are defined as devices that are prefabricated. They may or may not be supplied as a kit that requires some assembly. They all require fitting and adjustment (for example, the item must be trimmed, bent, molded [with or without heat], or otherwise modified by an individual with expertise in customizing the fit in order for it to be used by a specific patient). Custom fitted requires modification of the item in order to provide an individualized fit. Modifications must result in alterations in the item beyond simple adjustments made by bending, trimming, and/or molding of the item, installation of add-on components or assembly of the item. Custom fitted orthotics are:

• Devices that are prefabricated.
• They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
• Classification as custom fitted requires substantial modification for fitting at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment.
• This fitting at delivery does require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthosis to fit the item to the individual member.

Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient may be considered as custom fitted if the final fitting upon delivery to the patient requires substantial modification requiring expertise as described in this section.

Off-the-shelf (OTS) orthotics are defined as those prefabricated items which require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit to the individual. Off-the-shelf (OTS) orthotics are:

• Items that are prefabricated.
• They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.
• OTS items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit an individual.
• This fitting does not require expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthoses to fit the item to the individual member. 

Fabrication of an orthosis using CAD/CAM or similar technology without the creation of a positive model with minimal self-adjustment at delivery is considered as OTS. There is no separate payment if CAD-CAM technology is used to fabricate an orthosis. Reimbursement is included in the allowance of the codes for custom fabricated orthoses.

Substantial modification is defined as changes made to achieve an individualized fit of the item that requires the expertise of a certified orthotist or an individual who has equivalent specialized training in the provision of orthotics such as a physician, treating practitioner, an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements. A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification. 

Minimal self-adjustment is defined as an adjustment the member, caretaker for the member, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotics/Prosthetist Certification) or an individual who has specialized training. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category. 

Specialized Training: Individuals with specialized training necessary to provide custom fitting services for patients with a medical need for orthotics include: a physician, a treating practitioner (a physician assistant, nurse practitioner, or clinical nurse specialist), an occupational therapist, or physical therapist in compliance with all applicable Federal and State licensure and regulatory requirements.

Kits are a collection of components, materials and parts that require further assembly before delivery of the final product. The elements of a kit may be packaged and complete from a single source or may be an assemblage of separate components from multiple sources by the supplier.

Evaluation of the member, measurement and/or casting, and fitting/adjustments of the orthosis are included in the allowance for the orthosis. There is no separate payment for these services.

For prefabricated orthoses, there is no physical difference between orthoses coded as custom fitted versus those coded as off-the-shelf. The differentiating factor for proper coding is the need for "minimal self-adjustment" at the time of fitting by the member, caretaker for the member, or supplier. This minimal self-adjustment does not require the services of a certified orthotist or an individual who has specialized training. Items requiring minimal self-adjustment are coded as off-the-shelf orthoses. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category. Fabrication of an orthosis using CAD/CAM or similar technology without the creation of a positive model with minimal self-adjustment at delivery is considered as OTS. Items requiring substantial modification by a qualified practitioner are coded as custom fitted. For custom fabricated orthoses, there must be detailed documentation in the supplier’s records to support the medical necessity of that type device rather than a prefabricated orthosis.

Knee orthoses

A prefabricated elastic knee orthosis with joints describes a prefabricated knee orthoses constructed of latex, neoprene, spandex or other elastic material. There are no condylar pads. There are hinges or joints. 

A prefabricated elastic knee orthosis with condylar pads and joints describes a prefabricated knee orthosis with hinges or joints, constructed of latex, neoprene, spandex or other elastic material. There are medial and lateral condylar pads. 

A prefabricated canvas longitudinal knee immobilizer orthosis describes a prefabricated knee orthosis immobilizer, with rigid metal or plastic stays placed laterally and posteriorly. The interface material is constructed of canvas, closed cell foam or equal. The thigh and calf cuffs are one-piece construction held in place by velcro straps or equal. The orthosis immobilizes the knee joint and prevents flexion or extension. There are no hinges or joints. 

A prefabricated, locking knee joint, positional knee orthosis describes a prefabricated knee orthoses with joint(s) which lock the knee into a particular position. A prefabricated knee orthosis, double upright with adjustable joint, with inflatable air support chambers also have joints which lock the knee into a particular position; in addition, they have an air bladder in the space behind the knee. These orthoses are designed for members who are nonambulatory. They are typically used to treat flexion/extension contractures of the knee. 

An adjustable flexion and extension joint is one which enables the practitioner to set limits on flexion and extension but allows the member free motion of the knee within those limits. The increments of adjustability must be, at a minimum, 15 degrees. The joint may be either unicentric or polycentric. 

A rigid prefabricated positional knee orthosis with adjustable knee joints (unicentric or polycentric) describes prefabricated knee orthoses that have double uprights and adjustable flexion and extension joints. Medial-lateral control of the knee is accomplished by the solid metal (or similar material) structure of the double uprights. They may have condylar pads. These orthoses are designed for a member who can bear weight on the knee and is capable of ambulation. They are typically used for early rehabilitation following knee surgery. 

Rigid knee orthoses without a knee joints are designed to prevent knee motion. These orthoses are designed for members who can bear weight on the knee, are capable of ambulating, and need additional support provided through immobilization of the knee joint. They may be custom fabricated or prefabricated. 

A custom-fabricated knee orthosis, derotation, medial-lateral, anterior cruciate ligament describes a custom fabricated knee orthosis with knee joints designed to protect the ligaments of the knee through medial-lateral torsion, providing stability and preventing rotation. 

A knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotational control, with or without varus/valgus adjustment, describes knee orthoses which are constructed of rigid thigh and calf cuffs and a single upright with an adjustable flexion and extension knee joint. It must have condylar pads. They may be prefabricated or custom-fabricated. It must have condylar pads. Through a series of straps/supports that cross over and around the knee joint, rotational control and varus or valgus force is exerted on the knee joint. These orthoses are designed to open the medial or lateral compartment of the knee to provide pain relief due to osteoarthritis. These orthoses are designed for persons who are fully ambulatory. 

A knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric, medial-lateral and rotation control, with or without varus/valgus adjustment, describes knee orthoses that have double uprights, condylar pads, and an adjustable flexion and extension joint and provide both medial-lateral and rotation control. They may be prefabricated or custom-fabricated. Medial-lateral control of the knee is accomplished by the solid metal (or similar material) structure of the double uprights. Rotation control is accomplished by the combination of (i) solid metal (or similar material) in the anterior portion of the thigh and calf cuffs and (ii) the condylar pads.  These orthoses are designed for members who are fully ambulatory.

A prefabricated, off-the-shelf, Swedish type knee orthosis describes a prefabricated orthosis with double uprights and thigh and calf pads. It may or may not have joints. These orthoses are used to prevent hyperextension of the knee joint in ambulatory members. 

A custom-fabricated knee orthosis, modification of supracondylar prosthetic socket describes a custom fabricated orthosis without joints, constructed of plastic or other similar material. These orthoses are used to prevent hyperextension of the knee joint in ambulatory members. 

An addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom-fabricated orthoses describes an addition to a lower extremity orthosis composed of high strength and/or lightweight material such as kevlar, carbon fiber or other laminated or impregnated composite material.

Knee braces may be custom-fitted or custom-made.  A custom-fitted prefabricated brace is one which only measurements and a sizing chart are needed for fitting.  A custom-made (custom-fabricated or made-to-order) knee brace is one that requires an initial impression of the knee for fitting.  Knee orthoses that are custom-fitted require the assistance of an orthotist in adjusting the brace to the correct size, but do not require an initial impression of the knee for fitting.  Custom-made functional knee braces have not been shown to be medically superior to custom-fitted prefabricated functional knee braces.  Therefore, use of custom-made functional knee braces is reserved for those patients who are hard to fit because of a deformity of the knee or leg that interferes with fitting.  Exceptionally tall persons can be fitted into an custom-fitted prefabricated brace with extensions, short persons can be fitted with a pediatric custom-fitted prefabricated brace, and obese persons can be fitted into an custom-fitted prefabricated knee brace with extra large straps. 

A classification scheme devised by the American Academy of Orthopedic Surgeons (AAOS) divides knee braces into 3 categories:

1. Prophylactic knee braces are designed to reduce the likelihood of severity of knee ligament injuries in a relatively normal knee.
2. Functional knee braces are designed to improve stability for an unstable or postoperative knee in activities of daily living and sports.
3. Rehabilitative (or Rehabilitation) knee braces are designed to allow protected motion of an injured knee treated operatively or nonoperatively early after the injury.

Each of these types of braces will be discussed in turn below.

Prophylactic Knee Braces

Prophylactic knee braces and other protective gear (such as helmets, elbow pads, gloves, eye goggles, etc.) are considered safety items and are therefore not covered under terms of Aetna’s policies.  Please check benefit plan descriptions.

The common occurrence of medial collateral sprains in football and other sports led to the fabrication of prophylactic hinge braces designed to prevent or attenuate this injury.  These braces have lateral or sometimes medial and lateral hinges designed to absorb valgus impact to the knee.  Prophylactic knee braces are available custom-fitted prefabricated (not custom-made) and without a prescription. 

The effectiveness of prophylactic knee braces for collateral ligament injury to the knee is controversial.  Prophylactic knee braces have not been shown to be effective.  Indeed, some studies have shown that the risk of knee injury may be increased with use of prophylactic knee braces.  Hald and Fandel (1996) explained that recent research has raised questions about the possibility of such braces "preloading" knee structures and predisposing the wearer to an increased risk of ligament injuries.  These investigators concluded that "[w]e now feel that time and money might be better spent on preventive conditioning than for braces."

Functional Knee Braces

Functional knee braces are considered medically necessary if they are needed for activities of daily living, such as standing, walking, and climbing stairs, and thus are worn throughout the day.  Functional knee braces are considered not medically necessary when used primarily for sports, because participation in sports is considered an elective activity.

Functional knee braces are designed to provide support to the knees made unstable by injury or to provide additional protection following surgery to correct such instabilities.  They are usually recommended in the postoperative period and after completion of rehabilitation when full activity is resumed, or for the patient with a diagnosis of anterior cruciate ligament insufficiency in whom a nonoperative approach is used.

Some of these braces are ready-made in sizes to provide for immediate fit (so-called custom-fitted prefabricated braces).  Others require custom construction based on some form of cast molding or measurement of the person’s leg (so called custom-made or custom-fabricated braces).  Functional braces usually involve some form of hyperextension stop, as well as straps or fitted shells to control rotation.  There is no clear-cut advantage of shell braces over strap braces.

Functional knee braces are fabricated from a variety of materials, including carbon composites, aluminum, and kevlar.  Despite their relatively high cost, knee braces composed of carbon composites (also known as carbon fiber or graphite) are favored by competitive athletes because of their lightness.  There are, however, no medical advantages of carbon fiber braces over braces composed of materials that are heavier, but equally as strong, such as steel or aluminum.  A variety of suspension systems and knee joint designs are used in functional knee braces.  There is, however, no evidence of medical benefits from one knee joint design over another.  Therefore, custom-made braces is considered medically necessary only for persons who cannot be fit into off the shelf braces because deformity.  Even persons who are very tall or markedly obese, however, can be fitted with custom-fitted prefabricated functional braces that have been modified with attachments, such as extensions and extra long straps.

Functional knee braces are most commonly used in persons with prior ligamentous knee injuries.  The ligaments of the knee include the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the lateral collateral ligament (LCL), and the medial collateral ligament (MCL).  The use of functional braces for injuries involving each of these ligaments is described below:

Up to 70 % of acute ACL injuries occur during sports.  Episodes occur during sports requiring quick turns, sudden stopping, jumping, or lateral movements (such as football, volleyball, basketball, and racquetball).  The diagnosis of an acutely torn anterior cruciate ligament (ACL) is based on the circumstance of the injury as reported by the patient and the stability assessment during the physical examination.  Lachman’s test of assessing the anterior translation of the tibia on the femur with the knee in 20 to 30 degrees of flexion is the most accurate diagnostic examination.  For patients treated conservatively, optional bracing has been used after rehabilitation to assist patients in returning to low-demand activity.  However, neuromuscular rehabilitation and activity modification are far more important.

The use of the functional brace for the ACL-deficient knee remains controversial.  Laboratory studies have shown that functional braces do not prevent abnormal tibial displacement, even at physiologic loads.  However, persons with prior cruciate ligament injuries subjectively feel more secure in these devices.

Loss of the anterior cruciate ligament has been associated with a loss of ability to detect knee joint motion due to disruption of normal efferent pathways.  Some have conjectured that knee braces can substitute for this lost pathway, and that subjective improvements while wearing the brace are due to heightened propioception (position sense), although the evidence supporting this hypothesis is inconclusive.  Others feel that psychological support may be the greatest benefit of functional braces.  Despite the subject’s subjective improvement, giving away episodes can occur in spite of wearing the functional brace.  The AAOS concluded that the “scientific rationale for this ‘security’ is not clear, but perhaps related to the fact that the devices do provide warmth and increased knee awareness” (AAOS, 1991).

No study has demonstrated medically significant advantages of custom-made functional knee braces over custom-fitted prefabricated functional knee braces in patients with knee ligament injuries.  Because the benefits of functional knee braces are due to their ability to effect heightened propioception and to the sense of security the impart, the precise fitting of the brace, as through custom-fabrication or custom-molding, is not essential to its effectiveness.

More than 50 functional braces are on the market, with no clear-cut advantage for any brand.  “[B]eing aware of the growing number of ‘off the shelf’ functional braces on the market, physicians and clinicians must decide whether the custom-made brace is worth the extra cost to the athlete or patient if the protection offered is propioceptive in nature” (Harrelson, 1991).  Reider explained that “[w]e currently favor the new generation of custom-fitted prefabricated braces for economic reasons, saving the more expensive custom-molded types for the harder-to-fit athlete” (Reider et al, 1996).

In proving that one brace is superior to another, the manufacturer must demonstrate brace efficacy in studies designed to approximate the in vivo situation.  Current studies do not provide adequate evidence to conclude that custom-made functional knee braces result in medical benefits beyond those provided by custom-fitted prefabricated braces.  The manufacturer claiming superiority of their brace must be asked to verify claims and to provide documentation of efficacy.

The medial collateral ligament is the most commonly injured knee ligament in sports.  Persons with a first-degree MCL sprain need only wear a knee immobilizer for a few days, and no functional brace is necessary.

A first-degree sprain is, by definition, an injury to the ligament in which there is no increased laxity of that ligament.  If there is laxity present, then there is either a second- or third-degree sprain.  A second-degree sprain is differentiated clinically from a third degree sprain by the feel of the "end-point" on examination and the amount of laxity.  A second-degree sprain has a "firm" end point on stressing, as the ligament fibers that were not torn in the injury become taut.  A third-degree sprain has a "soft" end point, as translation is gradually stopped when other ligaments and tendon fibers (secondary restraints) become taut.

For the patient with a second-degree MCL sprain (partial tear), it is appropriate to prescribe an custom-fitted prefabricated functional knee brace after the rehabilitative knee brace is removed, and have the patient use this brace for up to 8 weeks after injury.

Isolated third-degree MCL injuries (complete tear) may be treated with a hinged rehabilitative brace, rather than a knee immobilizer, for the first 6 weeks after injury.  (An isolated MCL sprain is one where the ACL and PCL (posterior cruciate ligament) have been proven intact by MRI and instrumented laxity testing.)  It is recommended that following the acute injury, a functional brace be worn for 4 to 6 months.

The posterior cruciate ligament is infrequently injured.  Functional bracing has little role in PCL injuries because there is no clinical benefit or biomechanical evidence for the use of a functional brace in the PCL-injured knee.

The lateral collateral ligament is the least frequently injured of all the knee ligaments in sports because the knee is usually protected from a blow to the medial side by the person's other leg.  Treatment for first- and second-degree sprains follows the same program and a very similar time frame that was used for MCL injuries.  A custom-fitted prefabricated functional brace is appropriate for the patient that desires early return to activity.  Operative referral is necessary for patients with third-degree sprains.

Evidence is insufficient to support the use of knee braces as a treatment for patellofemoral pain syndrome.  In a Cochrane review on orthotic devices for treating patello-femoral pain syndrome, D'hondt et al (2002) concluded that the evidence from randomized controlled trials is currently too limited to draw definitive conclusions about the use of knee and foot orthotics for the treatment of patellofemoral pain.  The authors stated that future high quality trials in this field are warranted. An earlier systematic evidence review of treatments for patellofemoral pain similarly concluded that, "[d]ue to the low quality and quantity of the current evidence, the use of patellofemoral orthoses ... cannot be supported or refuted" (Crossley et al, 2001).  In a review on the management of patients with patello-femoral pain syndrome, Dixit and colleagues (2007) stated that there is little evidence to support the routine use of knee braces or non-steroidal anti-inflammatory drugs. 

Rehabilitative (or Rehabilitation) Knee Braces

Rehabilitative (or rehabilitation) braces are used as alternatives to knee immobilizers used immediately after surgery or injury to both control knee motion and protect the knee during rehabilitation.  Rehabilitative knee orthoses offer the patient early limited mobility to improve recovery time and decrease the effects of disuse on the graft or reconstructed ligament.

Rehabilitative knee orthoses are custom-fitted prefabricated, and can be ordered either as small, medium, or large, or by a size chart.  Most of them can be adjusted within each size to allow for edema or atrophy, and thus can be conveniently stocked in a hospital or clinic for quick fittings.

In collateral ligament injuries that do not involve a complete tear (second degree injuries), the torn fibers are internally splinted from excessive stress by the intact ligament fibers, and the use of the knee immobilizer or rehabilitative brace is only for comfort.

There are few objective studies offering objective data about the stabilizing effects of various types, and no guidelines for choosing any particular rehabilitative knee brace over another.  Choice of rehabilitation brace is usually based on availability, ancillary features, and ease of use.

Rehabilitative knee braces do not require precise fitting (and, hence, are never custom-made) because their size must be repeatedly readjusted throughout the course of rehabilitation to accommodate changes in swelling that occur following injury or surgery to the knee.

The Ottobock E-Mag Electronically Locking Knee Brace

The Ottobock E-Mag electronically locking knee brace supposedly offers wearers increased stability when standing and helps patients achieve a more active lifestyle. It features an electronically controlled lock that is activated by a small remote control to provide absolute stability in the stance phase.  The lock is activated with the touch of a button, allowing the wearer to support themselves with both arms and stand safely at all times.  The Ottobock E-Mag's special feedback system also informs the wearer when the joint is opening.

The WorkSafeBC Evidence-Based Practice Group’s report on the “E-MAG Active” (Edeer and Martin, 2010) stated that “E-MAG Active has recently been introduced by Otto Bock as a SCKAFO [Stance Control Knee Ankle Foot Orthoses] that utilizes an electromagnetic technique (hence, the name E-MAG which refers to this Electronic Magnet).  It became available in the market in North America in December 2008 …. To use E-MAG Active the patient is required to have both functional extensors and flexors of the hip with a strength of 3 to 5 (based on the Kendall and Kendall scale).  The patient must also have the capacity for full extension of the knee, both prior to the initial contact and at the terminal stance (to lock and unlock the knee) …. Otto Bock recommends E-MAG Active for “patients that present with flaccid paralysis/paresis of the knee extensors coupled with limited ankle ROM” …. Currently, there are no review articles, or any other study papers (case reports, comparative studies, or cost effectiveness studies) specifically about E-MAG Active …. There is no specific coverage policy regarding E-MAG Active at WorkSafeBC …. The policy manual of the US Department of Veterans Affairs contains a section on “orthotics” but does not include a specific policy regarding E-MAG Active or SCKAFOs in general …. We did not come across any specific coverage policy on E-MAG Active from any of the searched workers compensation organizations or health insurance companies”.

Spinal Orthoses

Spinal orthoses have the following characteristics:

• Used to immobilize the specified areas of the spine; and 
• Intimate fit and generally designed to be worn under clothing; and
• Not specifically designed for persons in wheelchairs.

In addition, the body jacket type spinal orthoses are characterized by a rigid plastic shell that encircles the trunk with overlapping edges and stabilizing closures and provides a high degree of immobility. The entire circumference of the plastic shell must be the same rigid material.

A rigid or semi rigid spinal orthotic device eliminates or restricts motion in the planes being controlled by an orthosis.

A spinal orthosis is designed to control gross movement of the trunk and intersegmental motion of the vertebrae in one or more planes of motion:

• Lateral/flexion (side bending) in the coronal/frontal plane. Control of this plane is achieved by a rigid panel in the mid-axillary line, which is either an integral part of a posterior or anterior panel, or a separate panel
• Anterior flexion (forward bending) or posterior extension (backward bending) in the sagittal plane. Control of this plane is achieved by a rigid posterior panel.
• Axial rotation (twisting) viewed in the transverse plane. Straps over the shoulders attaching to a posterior panel alone do not provide transverse spinal control.

Lumbar Sacral Orthoses (LSO) and Thoracic Lumbar Sacral Orthoses (TLSO) are considered braces. Elastic support garments (e.g. made of material such as neoprene or spandex [elastane, Lycra]) are not considered braces because they are not rigid or semi-rigid devices. Flexible spinal orthoses that are made primarily of nonelastic material (e.g., canvas, cotton or nylon) or that have a rigid posterior panel are considered braces.

The purpose of a rigid or semi-rigid LSO and TLSO spinal orthosis is to restrict the effect of the forces within a three point pressure system. The posterior panel must encompass the paraspinal muscle bodies from one lateral border to another in order to provide sufficient surface area to enhance the three point pressure system. The posterior panel must provide coverage to meet the minimum height requirements as described in the individual HCPCS codes.

For an item to be classified as a TLSO the posterior portion of the brace must extend from the sacrococcygeal junction to just inferior to the scapular spine. This excludes elastic or equal shoulder straps or other strapping methods. The anterior portion of the orthosis must at a minimum extend from the symphysis pubis to the xiphoid. Some TLSOs may require the anterior portion of the orthosis to extend up to the sternal notch.

A custom fabricated spinal orthosis is one which is individually made for a specific member (no other member would be able to use this orthosis) starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves substantial work such as vacuum forming, cutting, bending, molding, sewing, etc. It requires more than trimming, bending, or making other modifications to a substantially prefabricated item.

A molded-to-member-model spinal orthosis is a particular type of custom fabricated orthosis in which either:

• An impression of the specific body part is made (usually by means of a plaster or fiberglass cast) and this impression is then used to make a positive model (usually of plaster) of the body part; or
• Detailed measurements are taken of the member’s torso and are used to modify a positive model (which has been selected from a large library of models) to make it conform to the member’s body shape and dimensions; or
• A digital image of the member’s torso is made using computer (CAD-CAM) software which then directs the carving of a positive model.

The spinal orthosis is then individually fabricated and molded over the positive model of the member.

Scapular Bracing

Cole et al (2013) noted that overhead athletes commonly have poor posture.  Commercial braces are used to improve posture and function, but few researchers have examined the effects of shoulder or scapular bracing on posture and scapular muscle activity.  These researchers examined if a scapular stabilization brace acutely alters posture and scapular muscle activity in healthy overhead athletes with forward-head, rounded-shoulder posture (FHRSP).  A total of 38 healthy overhead athletes with FHRSP were included in this study.  Participants were assigned randomly to 2 groups:

1. compression shirt with no strap tension (S) and
2. compression shirt with the straps fully tensioned (S + T). 

Posture was measured using lateral-view photography with retro-reflective markers.  Electromyography (EMG) of the upper trapezius (UT), middle trapezius (MT), lower trapezius (LT), and serratus anterior (SA) in the dominant upper extremity was measured during 4 exercises (scapular punches, W's, Y's, T's) and 2 gleno-humeral motions (forward flexion, shoulder extension).  Posture and exercise EMG measurements were taken with and without the brace applied.  Head and shoulder angles were measured from lateral-view digital photographs.  Normalized surface EMG was used to assess mean muscle activation of the UT, MT, LT, and SA.  Application of the brace decreased forward shoulder angle in the S + T condition.  Brace application also caused a small increase in LT EMG during forward flexion and Y's and a small decrease in UT and MT EMG during shoulder extension.  Brace application in the S + T group decreased UT EMG during W's, whereas UT EMG increased during W's in the S group.  The authors concluded that application of the scapular brace improved shoulder posture and scapular muscle activity, but EMG changes were highly variable.  They stated that the use of a scapular brace might improve shoulder posture and muscle activity in overhead athletes with poor posture.  One important drawback of this study was the variable fit of the scapular brace on each participant.  Braces were provided in 6 sizes to fit the participants, and the investigators involved in the application of the braces were trained by a representative from the manufacturer on how to fit each brace for each participant.  However, the material of the compression top often gathered during movement, and the participants with short torsos had more difficulty with fit than did other participants.  Other drawbacks included: (a) 1 type of brace application was used – different brace applications might affect posture and EMG differently, and using a different method might be more beneficial; and (b) although every effort was made to blind the participants and the primary investigators to ensure the validity of the results, it cannot be ruled out that the subjects might have altered their posture and muscle activity simply because of research participation.

Levitation 2 Bionic Knee Brace

Budarick et al (2020) noted that knee osteoarthritis (OA) is a significant problem in the aging population, causing pain, impaired mobility, and decreased quality of life (QOL).  Conservative treatment methods are necessary to reduce rapidly increasing rates of knee joint surgery.  Recommended strategies include weight loss and knee bracing to unload knee joint forces.  Although weight loss can be beneficial for joint unloading, knee OA patients often find it difficult to lose weight or exercise due to knee pain, and not all patients are over-weight.  Uni-compartment off-loader braces can re-distribute joint forces away from 1 tibio-femoral (TF) compartment, however, less than 5 % of patients have uni-compartmental TFOA, while isolated patella-femoral (PF) or multi-compartmental OA are much more common.  By absorbing body weight and aiding the knee extension moment using a spring-loaded hinge, sufficiently powerful knee-extension-assist (KEA) braces could be useful for unloading the whole knee.  These researchers described the design of a spring-loaded tri-compartment unloader (TCU) knee brace intended to provide unloading in all 3 knee compartments while weight-bearing, measured and compared the force output of the TCU against the only published and commercially available KEA brace, and calculated the static unloading capacity of each device.  The TCU and KEA braces delivered maximum assistive moments equivalent to reducing body weight by 45 and 6 lbs, respectively.  The authors concluded that sufficiently powerful spring-loaded knee braces showed promise in a new class of multi-compartment unloader knee orthoses, capable of providing a clinically meaningful unloading effect across all 3 knee compartments.

Appendix

The following chart reflects the reasonable useful lifetime of prefabricated knee orthoses:

Table: Reasonable Useful Lifetime of Prefabricated Knee Orthoses

Knee orthosis	Reasonable useful lifetime
K0901	3 years
K0902	3 years
L1810	1 year
L1812	1 year
L1820	1 year
L1830	1 year
L1831	2 years
L1832	2 years
L1833	2 years
L1836	3 years
L1843	3 years
L1845	3 years
L1850	2 years

The reasonable useful lifetime of custom fabricated orthoses is 3 years.

Source: Noridian (2015).

The following table lists addition codes which describe components or features that can be and frequently are physically incorporated in the specified prefabricated base orthosis. Addition codes may be separately payable if both the base orthosis and the addition are medically necessary:

Table: Add-on Codes for Prefabricated Orthoses

Base Code	Additional codes eligible for separate reimbursement
L1810	None
L1812	None
L1820	None
L1830	None
L1831	None
L1832	L2397, L2795, L2810
L1833	L2397, L2795, L2810
L1836	None
L1843	L2385, L2395, L2397
L1845	L2385, L2395, L2397, L2795
L1847	None
L1848	None
L1850	L2397
L1851	L2385, L2395, L2397
L1852	L2385, L2395, L2397, L2795

Source: Noridian, 2019.

The following table lists addition codes which describe components or features that can be and frequently are physically incorporated in the specified custom fabricated base orthosis. Addition codes may be separately payable if both the base orthosis and the addition are medically necessary:

Table: Add-on Codes for Custom Fabricated Orthoses

Base Code	Additional codes eligible for separate reimbursement
L1834	L2795
L1840	L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2755, L2785, L2795
L1844	L2385, L2390, L2395, L2397, L2405, L2492, L2755, L2785
L1846	L2385, L2390, L2395, L2397, L2405, L2415, L2492, L2755, L2785, L2795, L2800
L1860	None

Source: Noridian, 2019.

Medically Necessary Quantity of Orthotics

The Coverage Table in the following link provides the medically necessary numbers of orthotics (Washington State Health Care Authority, 2016):

Prosthetic and orthotic device quantity limits

The table limits durable orthotics to 1 per limb per year.

Table: CPT Codes / HCPCS Codes / ICD-10 Codes

Code	Code Description
Information in the [brackets] below has been added for clarification purposes.   Codes requiring a 7th character are represented by "+":
Back Braces:
Other CPT codes related to the CPB:
22548 - 22812	Arthrodesis
22840 - 22855	Spinal instrumentation
63001 - 63051, 63170 - 63200, 63250 - 63290	Laminectomy
HCPCS codes covered if selection criteria are met:
L0450, L0454 - L0472, L0488 - L0621, L0623, L0625 - L0628, L0630 - L0631, L0633, L0635, L0637, L0639, L0641, L0642, L0643, L0648, L0649, L0650, L0651	Orthotic devices, spinal [prefabricated]
L0452, L0480, L0482, L0484, L0486, L0622, L0624, L0629, L0632, L0634, L0636, L0638, L0640	Orthotic devices, spinal [custom fabricated]
L0970 - L0999	Additions to spinal orthoses
L1000 - L1499	Orthotic devices - scoliosis procedures
HCPCS codes not covered for indications listed in the CPB:
L0210	Thoracic, rib belt
L0220	Thoracic rib belt, custom fabricated
ICD-10 codes covered if selection criteria are met:
A18.01	Tuberculosis of spine
G90.1	Familial dysautonomia [Riley-Day]
M08.1	Juvenile ankylosing spondylitis
M25.78	Osteophyte, vertebrae
M40.00 - M41.9, M43.20 - M43.28, M43.6 - M46.1, M46.40 - M48.38, M48.8x1 - M48.9, M49.80 - M53.1, M53.2x7 - M53.2x8, M53.3 - M54.09, M54.11 - M54.17, M54.2 - M54.9	Deforming dorsopathies, spondylopathies and other dorsopathies
M62.830	Muscle spasm of back
M67.88	Other specified disorders of synovium and tendon, other site [spine]
M81.0 - M81.8	Osteoporosis without current pathological fracture
M96.1 - M96.5	Postlaminectomy syndrome and postprocedural kyphosis, lordosis and scoliosis
M99.10 - M99.15	Subluxation complex (vertebral)
M99.20 - M99.79	Biomechanical lesions: stenosis of neural canal and intervertebral foramina
M99.83 - M99.84	Other biomechanical lesions of lumbar and sacral region
Q04.9 - Q07.9	Congenital malformations of the nervous system
Q67.5 Q76.0 - Q76.49	Congenital malformations of spine
S12.000+ - S12.9xx+	Fracture of cervical vertebra and other parts of neck [code also any associated spinal cord injury]
S13.0xx+ - S13.4xx+ S13.8xx+ - S13.9xx+	Dislocation and sprain of joints and ligaments at neck level
S14.0xx+ - S14.9xx+	Injury of nerves and spinal cord at neck level [code also any associated fracture of cervical vertebra]
S16.1xx+	Strain of muscle, fascia and tendon at neck level
S22.000+ - S22.089+	Fracture of thoracic spine [code first any associated spinal cord injury]
S23.0xx+ - S23.3xx+ S23.8xx+ - S23.9xx+	Dislocation and sprain of joints and ligaments of thorax [code also any associated spinal cord injury]
S24.0xx+ - S24.9xx+	Injury of nerves and spinal cord at thorax level [code also any associated fracture of thoracic vertebra]
S32.000+ - S32.2xx+	Fracture of lumbar spine [code first any associated spinal cord and spinal nerve injury]
S33.0xx+ - S33.39x+ S33.5xx+ - S33.9xx+	Dislocation and sprain of joints and ligaments of lumbar spine and pelvis [code also any associated spinal cord injury]
S34.01x+ - S34.4xx+	Injury of lumbar and sacral spinal cord and nerves at lower back level [code also any associated fracture of vertebra]
Z46.89	Encounter for fitting and adjustment of other specified devices
Z48.89	Encounter for other specified surgical aftercare
Numerous options	Subsequent encounter for healing traumatic fracture of vertebrae [Codes not listed due to expanded specificity]
Numerous options	Subsequent encounter for healing pathologic fracture of vertebrae [Codes not listed due to expanded specificity]
Knee Braces:
Other CPT codes related to the CPB:
29358	Application of long leg cast brace
Other HCPCS codes related to the CPB:
L1810 - L1860	Knee orthosis
Custom - made functional braces (custom-fabricated or molded knee orthoses):
HCPCS codes covered if selection criteria are met:
L1834	Knee orthosis (KO); without knee joint, rigid, custom fabricated
L1840	Knee orthosis, rigid, without joint(s), includes soft interface material, includes fitting and adjustment, derotation, medial-lateral, anterior cruciate ligament, custom fabricated
L1844	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment; custom fabricated
L1846	Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint, (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
L1860	Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (SK)
L2126	Knee-ankle-foot-orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis; thermoplastic type casting material, custom fabricated
L2128	Knee-ankle-foot-orthosis (KAFO), custom fabricated
L2800	Addition to lower extremity orthosis; knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only
Examples of additional medical necessity criteria for custom-made knee brace:
ICD-10 codes covered if selection criteria are met:
M23.601 - M23.679	Other spontaneous disruption of ligament(s) of knee
M25.361 - M25.369	Other instability, knee
Q65.81 - Q65.9	Other and unspecified congenital deformities of hip
Q66.8	Other congenital deformities of feet
Q68.2	Congenital deformity of knee
Q72.00 - Q72.93	Reduction defects of lower limb
Q74.1 - Q74.2	Congenital malformation of knee and lower limb(s), including pelvic girdle
R68.89	Other general symptoms and signs
ICD-10 codes not covered for indications listed in the CPB:
M24.561 - M24.569	Contracture of knee
Knee braces composed of high-strength, lightweight material:
HCPCS codes covered if selection criteria are met:
L2755	Addition to lower extremity orthosis; high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only
Prefabricated functional braces (Knee orthosis with joints or knee orthosis with condylar pads and joints with or without patellar control):
HCPCS codes covered if selection criteria are met:
L1810	Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L1812	Knee orthosis, elastic with joints, prefabricated, off-the-shelf
L1820	Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment
ICD-10 codes covered if selection criteria are met:
M21.061 - M21.069	Valgus deformity, not elsewhere classified, knee
M21.161 - M21.169	Varus deformity, not elsewhere classified, knee
M21.261 - M21.269	Flexion deformity, knee
M24.561 - M24.569	Contracture, knee
Prefabricated rigid knee orthoses without joints and knee orthoses with joints that lock a knee into a particular position:
HCPCS codes covered if selection criteria are met:
L1831	Knee orthosis (KO); locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment
L1832	Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustment
L1833	Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf
L1836	Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, includes fitting and adjustment
ICD-10 codes covered if selection criteria are met:
M24.561 - M24.569	Contracture of knee
M25.361 - M25.369	Other instability, knee
Prefabricated knee orthosis with locking joints and inflatable air support chambers:
HCPCS codes not covered for indications listed in the CPB:
L1847	Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L1848	Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf
Knee orthoses with varus or valgus adjustment:
HCPCS codes covered if selection criteria are met:
L1843	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L1851 - L1852	Knee orthosis (KO), single or double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
ICD-10 codes covered if selection criteria are met:
M17.0 - M17.9	Osteoarthritis of knee
M22.2x1 - M22.3x9 M22.8x1 - M22.92	Patellofemoral disorders and other derangements of patella
M23.000 - M23.369 M23.50 - M23.92	Internal derangement of knee
M80.061+ - M80.079+ M80.861+ - M80.879+	Age-related and other osteoporosis with current pathological fracture, lower leg
M84.361+ - M84.369+	Stress fracture, tibia and fibula
M84.461+ - M84.473+ M84.561+ - M84.573+ M84.661+ - M84.673+	Pathological fracture, tibia, fibula and ankle
M87.031 - M87.050, M87.061 - M87.073, M87.077 - M87.119, M87.131 - M87.146, M87.161 - M87.173, M87.177 - M87.179, M87.188 - M87.19,   M87.211 - M87.219, M87.231 - M87.250, M87.261 - M87.273, M87.277 - M87.29,   M87.311 - M87.319, M87.331 - M87.346, M87.361 - M87.373, M87.377 - M87.39,   M87.811 - M87.819, M87.831 - M87.849, M87.861 - M87.873, M87.877 - M87.89,   M90.521 - M90.549, M90.561 - M90.59	Osteonecrosis
S82.101A [S82.831A also required] S82.102A [S82.832A also required] S82.109A [S82.839A also required]	Fracture of fibula with tibia, upper end, closed
S82.101B [S82.831A also required] S82.102B [S82.832A also required] S82.109B [S82.839A also required] S82.101C [S82.831A also required] S82.102C [S82.832A also required] S82.109C [S82.839A also required]	Fracture of fibula with tibia, upper end, open
S83.401+ - S83.92x+, S86.011+ - S86.019+, S86.111+ - S86.119+, S86.211+ - S86.219+, S86.311+ - S86.319+, S86.811+ - S86.819+, S86.911+ - S86.919+	Sprain and strain of knee and lower leg
T84.010+ - T84.9xx+	Complications of internal orthopedic prosthetic devices, implants and grafts
Z96.651 - Z96.659	Presence of artificial knee joint
Numerous options	Fracture of upper end of tibia, closed [Codes not listed due to expanded specificity]
Numerous options	Fracture of upper end of tibia, open [Codes not listed due to expanded specificity]
Knee immobilizer:
HCPCS codes covered if selection criteria are met:
L1830	Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf
Knee orthosis with double uprights and adjustable flexion and extension joints:
HCPCS codes covered if selection criteria are met:
L1845	Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
ICD-10 codes covered if selection criteria are met:
M25.361 - M25.369	Other instability, knee
Q68.2	Congenital dislocation of knee
Knee orthosis with double uprights, adjustable flexion and extension joint, and medial-lateral and rotational control:
HCPCS codes covered if selection criteria are met:
L1846	Knee orthosis; double upright, thigh and calf, with adjustable flexion and extension joint(unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
ICD-10 codes covered if selection criteria are met:
M25.361 - M25.369	Other instability, knee
Knee orthoses with double uprights and thigh and calf pads (Swedish-type knee orthosis):
HCPCS codes covered if selection criteria are met:
L1850	Knee orthosis, swedish type, prefabricated, off-the-shelf
ICD-10 codes covered if selection criteria are met:
M22.2x1 - M22.3x9, M22.8x1 - M22.92	Patellofemoral disorders and other derangements of patella
M23.000 - M23.369, M23.50 - M23.92	Internal derangement of knee
M25.261 - M25.269, M25.361 - M25.369	Flail joint and other instability, knee
Socks and brace sleeves:
HCPCS codes covered if selection criteria are met:
L2840	Addition to lower extremity orthosis; tibial length sock, fracture or equal, each
L2850	femoral length sock, fracture or equal, each
Osteoarthritis Braces (Unloader Braces):
ICD-10 codes covered if selection criteria are met:
M17.0 - M17.9	Osteoarthritis of knee
M22.2x1 - M22.3x9, M22.8x1 - M22.92	Patellofemoral disorders and other derangements of patella
M23.000 - M23.369, M23.50 - M23.92	Internal derangement of knee
M80.061+ - M80.079+ M80.861+ - M80.879+	Age-related and other osteoporosis with current pathological fracture, lower leg
M84.361+ - M84.369+	Stress fracture, tibia and fibula
M84.461+ - M84.473+ M84.561+ - M84.573+ M84.661+ - M84.673+	Pathological fracture, tibia, fibula and ankle
M87.031 - M87.050, M87.061 - M87.073 M87.077 - M87.119, M87.131 - M87.146 M87.161 - M87.173, M87.177 - M87.179 M87.188 - M87.19,   M87.211 - M87.219 M87.231 - M87.250, M87.261 - M87.273 M87.277 - M87.29,   M87.311 - M87.319 M87.331 - M87.346, M87.361 - M87.373 M87.377 - M87.39,   M87.811 - M87.819 M87.831 - M87.849, M87.861 - M87.873 M87.877 - M87.89,   M90.521 - M90.549 M90.561 - M90.59	Osteonecrosis
S82.101A [S82.831A also required] S82.102A [S82.832A also required] S82.109A [S82.839A also required]	Fracture of fibula with tibia, upper end, closed
S82.101B [S82.831A also required] S82.102B [S82.832A also required] S82.109B [S82.839A also required] S82.101C [S82.831A also required] S82.102C [S82.832A also required] S82.109C [S82.839A also required]	Fracture of fibula with tibia, upper end, open
S83.401+ - S83.92x+, S86.011+ - S86.019+, S86.111+ - S86.119+, S86.211+ - S86.219+, S86.311+ - S86.319+, S86.811+ - S86.819+, S86.911+ - S86.919+	Sprain and strain of knee and lower leg
T84.010+ - T84.9xx+	Complications of internal orthopedic prosthetic devices, implants and grafts
Z96.651 - Z96.659	Presence of artificial knee joint
Numerous options	Fracture of upper end of tibia, closed [Codes not listed due to expanded specificity]
Numerous options	Fracture of upper end of tibia, open [Codes not listed due to expanded specificity]
Prefabricated unloader brace:
HCPCS codes covered if selection criteria are met:
L1843	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
ICD-10 codes not covered for indications listed in the CPB:
M17.0 - M17.9	Osteoarthritis of knee
For custom-fabricated unloader brace:
HCPCS codes covered if selection criteria are met:
L1844	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment; custom fabricated
ICD-10 codes not covered for indications listed in the CPB:
M17.0 - M17.9	Osteoarthritis of knee
Examples of medical necessity criteria for custom-made knee brace:
ICD-10 codes covered if selection criteria are met:
M25.361 - M25.369	Other instability, knee
Q65.8 - Q65.9	Other and unspecified congenital deformities of hip
Q66.8	Other congenital deformities of feet
Q68.2	Congenital deformity of knee
Q72.00 - Q72.93	Reduction defects of lower limb
Q74.1 - Q74.2	Congenital malformation of knee and lower limb(s), including pelvic girdle
R68.89	Other general symptoms and signs
Ottobock E-Mag Electronically Locking Knee Brace:
HCPCS codes covered if selection criteria are met:
L2390	Addition to lower extremity, offset knee joint, each joint
L2492	Addition to knee joint, lift loop for drop lock ring
Other HCPCS codes related to the CPB:
L2005	Knee-ankle-foot orthotic (KAFO), any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated
L2220	Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
L2250	Addition to lower extremity, foot plate, molded to patient model, stirrup attachment
L2755	Addition to lower extremity orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthotic only
L2820	Addition to lower extremity orthotic, soft interface for molded plastic, below knee section
L2830	Addition to lower extremity orthotic, soft interface for molded plastic, above knee section
L7360	Six volt battery, each
L7362	Battery charger, 6 volt, each
Addition codes for components or features that can be incorporated in base knee orthoses:
HCPCS codes covered if selection criteria are met:
L2397	Addition to lower extremity orthosis, suspension sleeve
L2405	Addition to knee joint, lock; drop, stance or swing phase, each joint
L2415	Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each joint
L2425	Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint
L2430	Addition to knee joint, ratchet lock for active and progressive knee extension, each joint
L2785	Addition to lower extremity orthosis, drop lock retainer, each
L2795	Addition to lower extremity orthosis, knee control, full kneecap
L2810	Addition to lower extremity orthosis, knee control, condylar pad
Levitation 2 Bionic Knee Brace:
HCPCS codes not covered for indications listed in the CPB:
Levitation 2 Bionic Knee Brace – no specific code:
Cast-Braces (also called Fracture Braces):
HCPCS codes covered if selection criteria are met:
L2106 - L2192	Fracture orthoses, lower limb
L3980 - L3995	Fracture orthoses, upper limb
L4360	Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L4386	Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
ICD-10 codes covered if selection criteria are met:
Numerous options	Fracture of upper limb [Codes not listed due to expanded specificity]
Numerous options	Fracture of lower limb [Codes not listed due to expanded specificity]
Heavy duty knee joints:
HCPCS codes covered if selection criteria are met:
L2385	Addition to lower extremity, straight knee joint, heavy duty, each joint
L2395	Addition to lower extremity, offset knee joint, heavy duty, each joint
ICD-10 codes covered if selection criteria are met:
E66.01 - E66.9	Overweight and obesity
Removable soft interface:
HCPCS codes covered if selection criteria are met:
K0672	Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each
Concentric adjustable torsion style mechanisms - no specific code:
ICD-10 codes not covered for indications listed in the CPB:
M24.561 - M24.569	Contracture of knee
Elastic support garments:
HCPCS codes not covered for indications listed in the CPB:
A4467	Belt, strap, sleeve, garment, or covering, any type
Rehabilitation Braces:
HCPCS codes related to the CPB:
E1800 - E1840	Other orthopedic devices
L1600 - L2999	Orthotic devices - lower limb
L3650 - L4398	Orthotic devices-upper limb
Cervical (Neck) Braces:
HCPCS codes covered if selection criteria are met:
L0112	Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated
L0113	Cranial cervical orthosis, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment
HCPCS codes not covered for indications listed in the CPB:
L0120	Cervical, flexible, nonadjustable, prefabricated, off-the-shelf (foam collar)
HCPCS codes related to the CPB:
L0130 - L0200	Orthotic devices, cervical
ICD-10 codes covered if selection criteria are met:
F44.4	Conversion disorder with motor symptom or deficit
F45.8	Other somatoform disorders
G24.3	Spasmodic torticollis
M06.88	Other specified rheumatoid arthritis, vertebrae
M43.6	Torticollis
P15.8	Other specified birth injuries
Q68.0	Congenital deformity of sternocleidomastoid muscle
R29.891	Ocular torticollis
S10.0XXA - S19.9XXS	Injuries to the neck
Childhood Hip Braces:
Other HCPCS codes related to the CPB:
L1600 - L1690	Orthotic devices, lower limb-hip
ICD-10 codes covered if selection criteria are met:
Q65.00 - Q65.9	Congenital deformities of hip
Braces for Congenital Defects:
Other HCPCS codes related to the CPB:
E1800 - E1840	Other orthopedic devices
L1000 - L1499	Orthotic devices, scoliosis procedures
L1900 - L1990	Orthotic devices, ankle-foot
L2000 - L2038	Orthotic devices, hip-knee-ankle-foot (or any combination)
L3650 - L4398	Orthotic
ICD-10 codes covered if selection criteria are met:
A18.01	Tuberculosis of spine
M40.00 - M41.9	Kyphosis, lordosis and scoliosis
M43.8x1 - M43.9	Other and unspecified deforming dorsopathies
M96.2 - M96.5	Postprocedural kyphosis, lordosis and scoliosis
Q65.00 - Q65.6, Q66.0 - Q68.5 Q68.8 - Q79.9	Congenital malformations and deformations of the musculoskeletal system
Q87.0	Congenital malformation syndromes predominantly affecting facial appearance
Splints and Immobilizers:
HCPCS codes covered if selection criteria are met:
E1800	Dynamic adjustable elbow extension/flexion device, includes soft interface material
E1802	Dynamic adjustable forearm pronation/flexion device, includes soft interface material
E1805	Dynamic adjustable wrist extension/flexion device, includes soft interface material
E1810	Dynamic adjustable knee extension/flexion device, includes soft interface material
E1825	Dynamic adjustable finger flexion/abduction/rotation device, includes soft interface material
Q4049	Finger splint, static
S8450 - S8452	Splint, prefabricated, digit, wrist or ankle, or elbow
Other HCPCS codes related to the CPB:
A4570	Splint
Q4051	Splint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and other supplies)
ICD-10 codes covered if selection criteria are met:
E08.40, E08.42, E09.40, E09.42, E10.40, E10.42, E11.40, E11.42, E13.40, E13.42	Diabetic polyneuropathy
G13.0 - G13.1, G54.0 - G73.7	Nerve root and plexus disorders, polyneuropathies and other disorders of peripheral nervous system and diseases of myoneural junction and muscle
M00.00 - M99.9	Diseases of the musculoskeletal system and connective tissue
S03.1xx+, S03.40x+ - S03.9xx+	Dislocation of septal cartilage of nose and sprain of jaw and joints other and unspecified parts of head
S11.90x+ - S11.95x+	Open wound of unspecified part of neck [code also any associated dislocation of cervical vertebrae]
S13.0xx+ - S13.29x+	Dislocation of joints at neck level [code also any associated open wound of neck]
S13.4xx+ - S13.9xx+	Sprain of ligaments at neck level
S23.0xx+ - S23.29x+	Dislocation of joints of thorax [code also any associated open wound of back wall of thorax]
S23.3xx+ - S23.9xx+	Sprain of ligaments of thorax
S29.011+ - S29.019+	Strain of muscle and tendon of thorax
S33.0xx+ - S33.39x+	Dislocation of joints of lumbar spine and pelvis [code also any associated open wound of lower back and pelvis]
S33.4xx+ - S33.9xx+	Sprain of ligaments of lumbar spine and pelvis
S39.011+ - S39.013+	Strain of muscle, fascia and tendon of abdomen, lower back and pelvis
S43.001+ - S43.396+	Dislocation of joints of shoulder girdle [code also any associated open wound of front wall of thorax, shoulder or upper arm]
S43.401+ - S43.92x+	Sprain of ligaments of shoulder girdle
S46.011+ - S46.019+, S46.111 - S46.119, S46.211+ - S46.219+, S46.311+ - S46.319+, S46.811+ - S46.819+, S46.911+ - S46.919+	Sprain of muscle, fascia and tendon at shoulder and upper arm level
S53.001+ - S53.196+	Dislocation of joints of elbow [code also any associated open wound of elbow]
S53.20x+ - S53.499+	Sprain of joints of elbow
S63.001+ - S63.299+	Dislocation of joints at wrist and hand level [code also any associated open wound of hand and wrist]
S63.301+ - S63.92x+	Sprain of ligaments at wrist and hand level
S66.011+ - S66.019+, S66.110+ - S66.119+, S66.211+ - S66.219+, S66.310+ - S66.319+, S66.411+ - S66.419+, S66.510+ - S66.519+, S66.811+ - S66.819+, S66.911+ - S66.919+	Strain of muscle, fascia and tendon at wrist and hand level
S73.001+ - S73.046+	Dislocation of joint of hip [code also any associated open wound of hip]
S73.101+ - S73.199+	Sprain of ligaments of hip
S76.011+ - S76.019+, S76.111+ - S76.119+, S76.211+ - S76.219+, S76.311+ - S76.319+, S76.811+ - S76.819+, S76.911+ - S76.919+	Strain of muscle, fascia and tendon at hip and thigh level
S83.001+ - S83.32x+	Dislocation of joints of knee [code also any associated open wound of knee]
S83.401+ - S83.92x+	Sprain of ligaments of knee
S86.011+ - S86.019+, S86.111+ - S86.119+, S86.211+ - S86.219+, S86.311+ - S86.319+, S86.811+ - S86.819+, S86.911+ - S86.919+	Strain of muscle, fascia and tendon at lower leg level
S93.01x+ - S93.336+	Dislocation of joints at ankle, foot and toe level [code also any associated open wound of ankle and foot]
S93.401+ - S93.699+	Sprain of ligaments at ankle, foot and toe level
S96.011+ - S96.019+, S96.111+ - S96.119+, S96.211+ - S96.219+, S96.811+ - S96.819+, S96.911+ - S96.919+	Strain of muscle and tendon at ankle and foot level
Unna Boots:
CPT codes covered if selection criteria are met:
29580	Strapping: Unna boot
ICD-10 codes covered if selection criteria are met:
S93.401+ - S93.699+, S96.011+ - S96.019+, S96.111+ - S96.119+, S96.211+ - S96.219+, S96.811+ - S96.819+, S96.911+ - S96.919+	Sprain and strain of ankle and foot
ICD-10 codes not covered for indications listed in the CPB:
Numerous options	Fracture of ankle or foot [Codes not listed due to expanded specificity]
Air Casts:
HCPCS codes covered if selection criteria are met:
L4360	Walking boot, pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment
L4361	Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf
L4386	Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment
L4387	Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf
ICD-10 codes covered if selection criteria are met:
S43.401+ - S43.92x+, S46.011+ - S46.019+, S46.111+ - S46.119+, S46.211+ - S46.219+, S46.311+ - S46.319+, S46.811+ - S46.819+, S46.911+ - S46.919+	Sprain and strain of shoulder and upper arm
S53.20x+ - S53.499+, S56.011+ - S56.019+, S56.111+ - S56.119+, S56.211+ - S56.219+, S56.311+ - S56.319+, S56.411+ - S56.419+, S56.511+ - S56.519+, S56.811+ - S56.819+, S56.911+ - S56.919+	Sprain and strain of elbow and forearm
S63.301+ - S63.92x+, S66.011+ - S66.019+, S66.110+ - S66.119+, S66.211+ - S66.219+, S66.310+ - S66.319+, S66.411+ - S66.419+, S66.510+ - S66.519+, S66.811+ - S66.819+, S66.911+ - S66.919+	Sprain and strain of wrist and hand
S73.111+ - S73.199+, S76.011+ - S76.019+, S76.111+ - S76.119+, S76.211+ - S76.219+, S76.311+ - S76.319+, S76.811+ - S76.819+	Sprain and strain of hip and thigh
S83.401+ - S83.92x+, S86.011+ - S86.019+, S86.111+ - S86.119+, S86.211+ - S86.219+, S86.311+ - S86.319+, S86.811+ - S86.819+, S86.911+ - S86.919+	Sprain and strain of knee and lower leg
S93.401+ - S93.699+, S96.011+ - S96.019+, S96.111+ - S96.119+, S96.211+ - S96.219+, S96.811+ - S96.819+, S96.911+ - S96.919+	Sprain and strain of ankle and foot
Numerous options	Fracture of upper and lower limb [Codes not listed due to expanded specificity]
Miscellaneous Covered Services & Fiberglass vs. Plaster casts:
CPT codes covered if selection criteria are met:
29000 - 29584	Application of casts and strapping
HCPCS codes covered if selection criteria are met:
A4580	Cast supplies
A4590	Special casting material
Q4001 - Q4051	Cast and splint supplies
ICD-10 codes covered if selection criteria are met:
R68.89	Other general symptoms and signs
Z46.89	Encounter for fitting and adjustment of other specified devices
Z48.89	Encounter for other specified surgical aftercare
Z96.60 - Z96.698	Presence of artificial joint implants
Z97.10 - Z97.16	Presence of artificial limb (complete) (partial)
Z98.1	Arthrodesis status
Numerous options	Subsequent encounter for healing traumatic fracture, pathologic fracture, or other and unspecified orthopedic aftercare [Codes not listed due to expanded specificity]
The Spine and Scapula Stabilizing Brace (S3 Brace):
HCPCS codes not covered for indications listed in the CPB:
The Spine and Scapula Stabilizing Brace (S3 Brace) - no specific code:
Adjustable Click Systems:
HCPCS codes not covered for indications listed in the CPB:
Adjustable click systems (e.g., Revo and Boa click systems) - no specific code:

The above policy is based on the following references: