Orthopedic Casts, Braces and Splints
Number: 0009
Table Of Contents
PolicyApplicable CPT / HCPCS / ICD-10 Codes
Background
References
Policy
Scope of Policy
This Clinical Policy Bulletin addresses orthopedic casts, braces, and splints. Knee braces are addressed in a separate CPB on knee braces.
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Medical Necessity
Aetna considers the following orthopedic casts, braces and splints medically necessary (unless otherwise stated) for the listed indications when they are used to treat disease or injury:
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Orthosis (Orthopedic Brace) and/or Prosthesis
Aetna considers an orthosis (orthopedic brace) and/or prosthesis medically necessary when:
- Care is prescribed by a physician, nurse practitioner, podiatrist or other health professional who is qualified to prescribe orthotics and/or prosthetics according to State law; and
- The orthosis or prosthesis will significantly improve or restore physical functions required for mobility related activities of daily living (MRADL's); and
- The member’s participating physician or licensed health care practitioner has determined that the orthosis or prosthesis will allow the member to perform ADLs based on physical examination of the member; and
- The orthosis or prosthesis is provided within six months of the date of prescription; and
- The orthotic or prosthetic services are performed by a duly licensed and/or certified, if applicable, orthotic and/or prosthetic provider. (All services provided must be within the applicable scope of practice for the provider in their licensed jurisdiction where the services are provided); and
- The services provided are of the complexity and nature to require being provided by a licensed or certified professional orthotist and/or prosthetist or provided under their direct supervision by a licensed ancillary person as permitted under state laws. (Services may be provided personally by physicians and performed by personnel under their direct supervision as permitted under state laws, as physicians are not licensed as orthotists and/or prosthetists); and
- The certified professional orthotist or prosthetist must be in good standing with one or more of the following:
- American Board for Certification (orthotics, prosthetics, pedorthics) (ABC); or
- Board of Certification/Accreditation (prosthetics, orthotics) (BOC); or
- Licensed by the state in which services are provided (where legally required);
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Back Braces
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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:
- To facilitate healing following an injury to the spine or related soft tissues; or
- To facilitate healing following a surgical procedure on the spine or related soft tissue (see section on Post-operative Back Braces below); or
- To reduce pain by restricting mobility of the trunk; or
- To support weak spinal muscles and/or a deformed spine.
Supportive lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis are considered experimental, investigational, or unproven 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:
- 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;
- A custom-fitted back brace is considered medically necessary as the initial brace after surgical stabilization of the spine following traumatic injury;
- 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;
- Custom-fitted and custom-fabricated back braces are considered experimental, investigational, or unproven when these criteria are not met.
Note: Back braces are considered DME, except when used as a post-operative brace (see Post-operative back braces below).
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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, investigational, or unproven for other indications because their effectiveness or indications other than the one listed above has not been established.
Note: Post-operative back braces are considered part of the surgical protocol for certain back operations.
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Cast-Braces (also called Fracture Braces)
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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, investigational, or unproven 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
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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, investigational, or unproven 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.
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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.Footnote1*
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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, investigational, or unproven 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
Abduction splint (e.g., the Pavlik harness and the Tubingen splint) is considered medically necessary for the treatment of infants with hip dislocation or persistently dislocatable or subluxatable hips.Note: Childhood hip braces are considered integral to the management of hip disorders in children.
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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.
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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.
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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, investigational, or unproven for other indications because its effectiveness for indications other than the one listed above has not been established.
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Scoliosis braces
For Aetna's policy on scoliosis braces, see CPB 0398 - Idiopathic Scoliosis.
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Prefabricated Volar Wrist Brace
Aetna considers prefabricated volar wrist brace (cock up non-molded) medically necessary for the treatment of carpal tunnel syndrome.
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Splints and Immobilizers
Certain orthopedic problems are routinely treated with splints or splint-like devices. The following are considered medically necessary:
- Acromio-clavicular splint (also called a Zimmer splint)
- Carpal tunnel splints
- Clavicle splint (also called a figure-8 splint)
- Denis Browne Splint for children with clubfoot or metatarsus valgus to maintain and correct abduction
- Dynasplints under circumstances specified in CPB 0405 (See CPB 0405 - Mechanical Stretching Devices for Contracture and Joint Stiffness)
- Finger splints
- Shoulder immobilizer
- Splints or splint-like devices for moderate-to-severe acute or subacute wrist sprains.
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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.
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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, investigational, or unproven for other indications because their effectiveness for indications other than the one listed above has not been established.
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Miscellaneous Covered Services
- Casting of a sprain is considered medically necessary.
- Casting following surgical procedures is considered medically necessary.
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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.
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Experimental, Investigational, or Unproven
The following DME and supplies are considered experimental, investigational, or unproven because the effectiveness for the specified indication(s) has not been established (not an all-inclusive list):
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Prophylactic Lumbar Supports
Prophylactic lumbar supports (Tech Belts, air belts, tool belts, elastic or inflatable lumbar supports, back rest supports) are considered experimental, investigational, or unproven 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.Footnote1*
- Hip brace for acetabular labral tears / femoro-acetabular impingement
- The Spine and Scapula Stabilizing Brace (the S3 Brace)
- Adjustable click systems (e.g., Revo and Boa click systems).
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Policy Limitations and Exclusions
- Protective body socks do not meet Aetna's definition of covered DME because they are not made to withstand prolonged use.
- 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: 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.
Consistent with DME MAC policy:
Treating practitioner means physician (MD or DO) or physician assistant, nurse practitioner, or clinical nurse specialist. A prosthetist, orthotist, orthotic fitter, pedorthotist, physical therapist, or occupational therapist is not considered a treating practitioner.
A new prescription from the treating practitioner is required each time a new device or repair is requisitioned.
There must be sufficient medical information included in the medical record to demonstrate that all applicable coverage criteria are met.
Consistent with DME MAC policy:
Supplier prepared statements and physician attestations by themselves do not provide sufficient documentation of medical necessity, even if signed by the ordering physician.
"Neither a practitioner’s order, nor a supplier-prepared statement, nor a practitioner’s attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating practitioner or supplier. There must be information in the member’s medical record that supports the medical necessity for the item and substantiates the information on a supplier-prepared statement or treating practitioner’s attestation (if applicable)."
"Forms are subject to corroboration with information in the medical record."
Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary.
Consistent with DME MAC policy:
A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not medically necessary.
The SWO must contain all the following elements:
- Member's name or identification number
- Order date
- General description of the item
- The description can be either a HCPCS code, a HCPCS code narrative, or a brand name/model number
- In addition to the description of the base item, the SWO must include all concurrently ordered options, accessories or additional features that are separately billed or require an upgraded code (List each separately).
- For supplies -- In addition to the description of the base item, the order/prescription must include all concurrently ordered supplies that are separately billed (List each separately)
- Each item or service requested must individually list the HCPCS code (Procedure code) and quantity to be dispensed
- Treating Practitioner Name and national provider identifier (NPI)
- Treating practitioner's signature.
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Note on Code Verification Review
Consistent with CMS policy, the only products which may be billed using the following list of HCPCS codes are those for which a written coding verification review (CVR) has been made by the Pricing, Data Analysis, and Coding (PDAC) contractor and subsequently published on the appropriate Product Classification List:
- L1832
- L1833
- L1845
- L1851
- L1852
Information concerning the documentation that must be submitted to the PDAC for a CVR can be found on the PDAC website or by contacting the PDAC. A Product Classification List with products which have received a coding verification can be found on the PDAC website.
Product information such as manufacturer, part number or part name must be recorded in the medical records.
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Related Policies
- CPB 0398 - Idiopathic Scoliosis
- CPB 0399 - Upper Limb Prostheses
- CPB 0405 - Mechanical Stretching Devices for Contracture and Joint Stiffness
- CPB 0451 - Foot Orthotics
- CPB 0565 - Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs)
- CPB 0578 - Lower Limb Prostheses
- CPB 1094 - Knee Braces
Footnote1*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.
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.
- 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
- 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.
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 non-elastic 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
- compression shirt with no strap tension (S) and
- 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.
Spine and Scapula Stabilizing Brace (S3 Brace)
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.
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.
Bracing for Patella-Femoral Osteoarthritis
In a prospective, randomized study, Merino and colleagues (2021) compared the long-term effects of a brace designed to stabilize the patella-femoral (PF) joint in comparison to a standard neoprene sleeve for the knee with patellar hole in patients with patella-femoral osteoarthritis (PFOA). A total of 38 patients with PFOA and co-morbidities received either a functional PF brace (Study Group, SG) or a neoprene sleeve for the knee (Control Group, CG). Both groups received clinical treatment to OA and co-morbidities according to a program from the institution. Patients were examined with Western Ontario and MacMaster (WOMAC) and Lequesne questionnaires, 30-second chair stand test (30CST), Timed Up and Go (TUG), anthropometric measures and self-reported physical activity in minutes/week at inclusion, 1, 3 and 12 months after placing the brace. X-Rays were taken to measure the angles. At 1year there was more abandonment in the CG without differences in weight and body mass index (BMI) between groups during the study. The SG maintained improvements in Lequesne and WOMAC total and subsets during the year, whereas the CG returned to baseline values for pain, function and total (p < 0.01). TUG and 30CST results were always better in the study group without any clinically important improvement in both groups. The authors concluded that long-term use of functional brace added to self-management program improved pain and function in patients with PFOA. Level of Evidence = II.
In a prospective, randomized trial, Yamamoto and associates (2021) compared the effect of a brace designed to stabilize the PF joint to that of a patella-shaped neoprene sleeve with patella cut out in patients with PFOA. A total of 57 patients with PFOA were allocated to 2 groups -- patients with PF functional brace and those with a neoprene knee with a patellar orifice. Both groups underwent clinical treatment of OA and used medications daily 1 month before and up to 3 months after brace placement. They were evaluated with the WOMAC and Lequesne questionnaires and performed 5 times sit to stand test, TUG test, and six-minute walk test (6MWT) immediately before and 1 and 3 months after brace placement. Both groups had improved pain, stiffness, and function with no difference between groups. Drug use decreased in both groups in the 1st month but increased in the 3rd month; naproxen use was progressively higher in the control group. The authors concluded that both knee orthoses improved pain and function and altered drug use only in the 1st month. They stated that functional knee brace provided analgesia without increased use of naproxen. Level of Evidence IB.
Furthermore, an UpToDate review on “Patellofemoral pain” (O'Connor and Mulvaney, 2021) states that “Although the foundation of treatment for PFP remains exercise and strengthening, if a patient cannot participate fully in rehabilitation exercises due to pain or does not make progress, it is reasonable to perform taping or patellofemoral bracing if this improves symptoms”.
Hip Brace for Individuals with Acetabular Labral Tears / Femoro-Acetabular Impingement Syndrome
In a parallel, 2-arm, exploratory randomized trial, Eyles and colleagues (2022) examined if a hip brace could improve hip health QOL and is well-tolerated in individuals with symptomatic labral tears or femoro-acetabular impingement syndrome (FAIS) after 6 weeks of wear. Subjects were individuals aged 18 years with FAIS or labral tears. Patient-reported outcomes were assessed with the International Hip Outcome Tool (iHOT-33), and Copenhagen Hip and Groin Outcome Scores (HAGOS). Brace acceptability was measured using the Quebec User Evaluation of Satisfaction with Assistive Technology survey. Independent t-tests assessed between-group differences. A total of 38 subjects were recruited, 19 each group, 60 % women, mean age of 39.3 ± 11.8 years, body mass index (BMI) of 25.3 ± 4.4 kg/m2, iHOT-33 36.6 ± 24.8; 3 subjects dropped out (1 usual care, 2 braced). The mean between-group difference for iHOT-33 was 19.4 (95 % confidence interval [CI]: 1.68 to 37.06, p = 0.03) favoring the brace. There were improvements in most HAGOS subscale scores favoring the brace. Issues with brace tolerability for some subjects were perceived comfort and effectiveness; 3 brace-related adverse events (AEs) were reported. The authors concluded that between-group differences favored the braced group for hip health QOL, pain, symptoms, and function. Moreover, these researchers stated that although these findings were promising, the CIs for the estimates were wide, the small sample size (n = 35) likely a contributing factor. They stated that these findings suggested that further investigation of the brace is needed; these researchers calculated sample sizes and made recommendations for the design of a future trial.
Abduction Splint (e.g., the Pavlik Harness and the Tubingen Splint) for the Treatment of Stable and Unstable Developmental Dysplasia of the Hip
Ran et al (2020) noted that the Pavlik harness and the Tubingen hip flexion splint are 2 effective options for the early management of patients younger than 6 months of age with developmental dysplasia of the hip (DDH). These researchers examined the clinical and radiological outcomes of patients younger than 6 months of age with type IIb to IV DDH managed by Pavlik harness or Tubingen hip flexion splint. The Pavlik harness and Tubingen hip flexion splint groups were comparable regarding the affected side (p = 0.09), Graf grade (p = 0.635), and age at initial treatment (p = 0.77). Overall, failure rates were 12 % and 33 % in Pavlik harness (4/33 hips) and Tubingen hip flexion splint groups (14/43 hips), respectively (p = 0.038). No cases of avascular necrosis (AVN) were found in either group. In the Tubingen hip flexion splint group, the failure rate was significantly higher in bilateral cases (66.6 %; p = 0.004), in severe forms (Graf grade IV hips; p ≤ 0.0001), and in patients with lower age at initial treatment (67.7 ± 39.3 days; p = 0.005). The average follow-up time was 30.35 ± 3.58 months (range of 24 to 36). At the last follow-up visit, no statistically significant differences were found between the Pavlik harness and Tubingen hip flexion splint groups regarding the acetabular index (t = 0.632; p = 0.53) or center-edge angle (Z = -0.303; p = 0.762). The authors concluded that the findings of this study demonstrated that both brace treatments for DDH in children younger than 6 months of age were effective and well-tolerated; however, the Tubingen hip flexion splint should not be used in patients with severe forms of DDH (Graf grade IV hips).
In a retrospective study, Lyu et al (2021) examined the clinical and radiological outcomes of patients younger than 6 months of age with DDH managed by either a Pavlik harness or Tubingen hip flexion splint. Records of 251 consecutive infants with a mean age of 89 days (SD 47), diagnosed with DDH between January 2015 and December 2018, were reviewed. Inclusion criteria for patients with DDH were entailed younger than 180 days at the time of diagnosis; ultrasound (US) Graf classification of IIc or greater; treatment by Pavlik harness or Tubingen splint; and no prior treatment history. All patients underwent hip US every 7 days during the first 3 weeks of treatment and subsequently every 3 to 4 weeks until completion of treatment . If no signs of improvement were found after 3 weeks, the Pavlik harness or Tubingen splint was discontinued. Statistical analysis was carried out. The study included 251 patients with Graf grades IIc to IV in 18 males and 233 females with DDH. Mean follow-up time was 22 months (SD 10). A total of 116 hips were graded as Graf IIc (39.1 %), 9 as grade D (3.0 %), 100 as grade III (33.7 %), and 72 as grade IV (24.2 %). There were 109 patients (128 hips) in the Pavlik group and 142 patients (169 hips) in the Tubingen group (p = 0.227). The Tubingen group showed a 69.8 % success rate in Graf III and Graf IV hips while the success rate was significantly lower in the Pavlik group, 53.9 % (p = 0.033). For infants older than 3 months of age, the Tubingen group showed a 71.4 % success rate, and the Pavlik group a 54.4 % success rate (p = 0.047). The authors concluded that the Tubingen splint should be the preferred therapeutic option for children older than 3 months, and for those with severe forms of DDH such as Graf grade III and IV, who are younger than 6 months at time of diagnosis. The Tubingen hip flexion splint is a valid alternative to the Pavlik harness for older infants and those with more severe DDH.
Merchant et al (2021) stated that bracing is considered a gold standard in treating DDH in infants under 6 months of age with reducible hips. A variety of braces are available that work on similar principles of limiting hip adduction and extension. These investigators examined the current evidence regarding bracing in DDH. Most of the literature pertains to the Pavlik harness and there were few studies for other brace types. Bracing eliminates dislocating forces from the hamstrings, the block to reduction of the psoas and improves the muscle line of pull to stabilize the hip joint. Recent studies have shown no benefit in bracing for stable dysplasia. The rates of Pavlik harness treatment failure in Ortolani-positive hips have been reported to be high. Barlow positive hips have lower Graf grades and are more amenable to Pavlik harness treatment. There is consensus that the earlier the diagnosis of DDH and initiation of Pavlik harness treatment, the better the outcome. Failure rates due to unsuccessful reduction and AVN were higher with treatment initiated after age of 4 to 6 months. Studies have shown no benefits of staged weaning of braces. The authors stated that while there is no maximum time in brace, current consensus suggested a minimum of 6 weeks.
Chaibi et al (2022) stated that the Tubingen splint was initially developed for the treatment of stable DDH. Later on, some investigators expanded its use to treat unstable DDH; however, there remain some controversies regarding its effectiveness for this indication. In a retrospective study, these researchers compared the outcome between stable and unstable DDH treated with a Tubingen splint. Epidemiological data and US data of all infants diagnosed with DDH and initially treated with a Tubingen splint at the authors’ institution between May 2017 and February 2020 were assessed. These investigators divided the population into stable and unstable hips using the Graf classification. Age at treatment initiation, duration of treatment, complications, and radiological outcome between 12 and 24 months were examined. This study included a total of 45 patients (57 hips) affected by DDH treated with the Tubingen splint. Treatment has been successful in 93 % of stable hips and only 40 % of unstable hips. Radiological outcome at 1-year follow-up significantly correlated with initial Graf classification (p < 0.001). The authors concluded that the findings of this study confirmed that the Tubingen splint is a safe and effective treatment for stable hips. For unstable hips in which treatment with a Tubingen splint is initiated, very close monitoring is mandatory in order to adapt the treatment in the event of poor evolution. The treatment of choice will then be closed reduction and spica cast.
Furthermore, an UpToDate review on “Developmental dysplasia of the hip: Treatment and outcome” (Rosenfeld, 2022) states that “We recommend treatment with an abduction splint for infants younger than six months with hip dislocation or persistently dislocatable or subluxatable hips (Grade 1B). The Pavlik harness is the most thoroughly studied and most commonly used abduction splint”.
Prefabricated Volar Wrist Brace (Cock Up Non-Molded) for Carpal Tunnel Syndrome
The American Academy of Orthopedic Surgeons’ evidence-based clinical practice guideline on “Management of carpal tunnel syndrome” (AAOs, 2016) noted that “Strong evidence supports that the use of immobilization (brace/splint/orthosis) should improve patient reported outcomes. (Evidence from 2 or more “high” strength studies with consistent findings for recommending for the intervention).
Splinting for Wrist Sprains
An American College of Occupational and Environmental Medicine’s guideline on “Hand, Wrist, and Forearm Disorders” (ACOEM, 2019) recommended splinting for moderate-to-severe acute or subacute wrist sprains.
Post-Operative Bracing After Lumbar Spinal Surgeries
Yao et al (2018) stated that bracing following spinal fusion for lumbar degenerative disease is common; however, the necessity of post-operative bracing is still controversial. These investigators noted that there is a paucity of high-quality studies examining the effectiveness of bracing. In a prospective, randomized study, these researchers examined the outcome of bracing following transforaminal lumbar interbody fusion (TLIF) in patients with degenerative lumbar spine diseases. A total of 90 patients with degenerative lumbar disease receiving instrumented TLIF were randomly assigned to brace and no brace groups for post-operative care. Patients in the brace group were instructed to wear a rigid brace full-time for 12 weeks. Patients in the no brace group were instructed to wear a soft corset for 2 weeks, after which it was weaned off. In all subjects, the visual analog scale (VAS) and Oswestry Disability Index (ODI) scores were examined pre-operatively; post-operatively; and at 6 weeks, 3, 6, and 12 months of follow-up. The fusion rates, complications, and re-operation rates were recorded. A total of 44 patients were assigned to the brace group (mean age of 69.2 ± 10.7 years), and 46 were assigned to the no brace group (mean age of 68.8 ± 11.9 years). All subjects received at least 12 months of follow-up. There were no significant differences between the 2 groups with regard to patient demographic characteristics. The VAS and ODI scores at each follow-up were not significantly different between the 2 groups. The fusion rate and complications at the 12-month post-operative follow-up were not significantly different between the 2 groups. The authors concluded that the findings of this study showed that in patients with degenerative spinal disease who received TLIF, wearing a rigid brace post-operatively was unnecessary. Furthermore, the fusion rate was not related to bracing, and there were no complications or re-operations whether a brace was worn. Level of Evidence = II.
Soliman et al (2018) noted that braces are often prescribed following posterior spinal instrumented fusion (PSIF) in patients with lumbar degenerative conditions with the aim of improving pain relief and QOL; however, there is a lack of evidence on the indication for post-operative bracing, as surgeons use braces mainly based on their experience and training. In a randomized controlled trial (RCT), these researchers examined if bracing following PSIF could improve pain relief and QOL 6 weeks and 3 months post-operatively. This trial included a total of 43 patients with PSIF for lumbar degenerative conditions; the care-givers were blinded but not the orthotist. There were 25 patients in the brace group, and 18 patients in the control group with similar baseline characteristics. All patients completed the ODI, the short form (SF)-12v2 General Health Survey and VAS for LBP pre-operatively, at 6 weeks, and 3 months follow-up. Wilcoxon-Mann-Whitney test and a level of significance of 0.05 were used for statistical analyses. Both groups had comparable demographic characteristics, and pre-operative SF-12v2, ODI, and VAS scores. The ODI, SF-12v2, and VAS for LBP improved in comparison to pre-operative scores. The improvement was significant at 3 months follow-up regarding ODI and VAS for both groups, and significant only for the control group regarding SF-12v2 scores. The improvement in ODI, SF-12v2, and VAS was significantly greater for control group at 3 months post-operatively. Moreover, larger proportion of patients in the control group reached minimum clinically important difference (MCID) as compared to brace group at 6 weeks and 3 months. The authors concluded that post-operative bracing did not result in better improvement in QOL or pain relief up to 3 months following PSIF in patients with lumbar degenerative conditions. Level of Evidence = I.
Fujiwara et al (2019) noted that although the effectiveness of lumbo-sacral orthoses (LSOs) is unclear, these devices are used as standard of care (SOC) following lumbar fusion surgery. In a prospective RCT, these investigators examined the clinical and radiographic effectiveness of LSO treatment in patients who underwent posterior LIF (PLIF) of less than 3 segments. A total of 73 patients who underwent PLIF were randomly allocated to 3 groups: 1 with custom-made LSO with metallic stays (C group); 1 with ready-made LSO without metallic stays (R group), and 1 without LSO (N group). The patients in the C and R groups were instructed to wear LSO post-operatively for 3 months. Clinical outcomes were evaluated using the Japanese Orthopedic Association (JOA) score, JOA-back pain evaluation questionnaire (JOABPEQ), Roland-Morris Disability Questionnaire, and 100-mm VAS for low back pain (LBP). Radiographic evaluation included intervertebral fusion rates and loss of correction post-operatively at 2 years. A significant difference in the clinical outcomes was observed only for the lumbar dysfunction domain of JOABPEQ post-operatively at 1 month (N versus C groups; 45 % versus 10 %, p = 0.03). Radiographic outcomes were not different between the groups. The authors concluded that no effect of orthosis treatment for less than 3 segments in PLIF was observed on clinical and radiographic outcomes. The type of orthosis also did not influence the outcomes. These researchers stated that the findings of this RCT suggested that the use of LSO for PLIF could be simplified or was omissible except in patients with severe osteoporosis.
Nasi et al (2020) stated that post-operative bracing treatment is often used following surgery for lumbar degenerative diseases; however, guidelines are lacking in this regard, and its use is primarily driven by individual surgeon preferences. In a systematic review, these investigators examined the available evidence on the use of post-operative bracing following surgery for lumbar degenerative disease. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed while carrying out a systematic search of the PubMed/Medline, Scopus, and Cochrane databases from January 1990 to January 2019. High-quality studies were included that evaluated disability, pain, QOL, the rate of fusion, complications, and rate of re-operations in patients who had surgery for lumbar degenerative disease, with and without post-operative bracing. The overall strength of evidence across the studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Of the 391 citations screened, 4 RCTs fulfilled the inclusion criteria and were included in the review. Based on low-to-moderate quality evidence, post-operative bracing in patients with lumbar degenerative disease did not result in improved disability, pain, and QOL compared to no bracing patients. Low-quality evidence also suggested that there was no significant difference between the 2 groups in terms of the rate of fusion, complications, and the need for re-operation. The authors concluded that there was a lack of evidence to support the use of bracing following surgery for lumbar degenerative disease.
Pathak et al (2021) stated that there is limited evidence on the use of orthoses across varying elective spine surgeries. When previously studied in 2009, inconsistent lumbar post-operative bracing practices were reported. These researchers provided a 10-year update regarding post-operative bracing practices following elective lumbar surgery among U.S. spine surgeons. A questionnaire was distributed to attendees of the Lumbar Spine Research Society Annual Meeting (April 2019). The questionnaire collected demographic information, and asked surgeons to identify if they used orthoses post-operatively after 10 elective lumbar surgeries. Information regarding type of brace, duration of use, and reason for bracing was also collected. Chi-square tests and 1-way analysis of variance (ANOVA) were used for comparisons. A total of 73 of 88 U.S. attending surgeons completed the questionnaire (response rate: 83 %). The majority of respondents were orthopedic surgery-trained (78 %), fellowship-trained (84 %), and academic surgeons (73 %). The majority of respondents (60 %) did not use orthoses following any lumbar surgery. Among the surgeons who braced, the overall bracing frequency was 26 %. This rate was significantly lower than that reported in the literature 10 years earlier (p < 0.0001). Respondents tended to use orthoses most often after stand-alone lateral interbody fusions (43 %) (p < 0.0001). The average bracing frequency following lumbar fusions (34 %) was higher than the average bracing frequency after non-fusion surgeries (16 %) (p < 0.0001). The most frequently used brace was an off-the-shelf lumbar sacral orthosis (66 %), and most surgeons braced patients to improve pain relief (42 %). Of surgeons who braced, most commonly did so for 2 to 4 months (57 %). The authors concluded that most surgeon respondents did not prescribe orthoses following various elective lumbar surgeries, and the frequency overall was lower than a similar study conducted in 2009. These investigators stated that there continues to be inconsistencies in post-operative bracing practices; they stated that in an era striving for evidence-based medicine, this is an area that requires further evaluation.
Dimentberg et al (2021) noted that clinical practice in post-operative bracing following posterior lumbar spine fusion (PLF) is inconsistent between providers. In a retrospective analysis, these investigators examined the effect of bracing on short-term outcomes related to safety, quality of care, and direct costs. This study included consecutive patients undergoing multi-level PLF with or without bracing (n = 980; 2013 to 2017). Patient demographics and co-morbidities were analyzed. Outcome measures included length of stay (LOS), discharge disposition, quality-adjusted life years (QALY), surgical-site infection (SSI), total cost, re-admission within 30 days, and emergency department (ED) evaluation within 30 days. Among the study population, 936 were braced and 44 were not braced. There was no difference between the braced and unbraced cohorts regarding LOS (p = 0.106), discharge disposition (p = 0.898), 30-day re-admission (p = 0.434), and 30-day ED evaluation (p = 1.000). There was also no difference in total cost (p = 0.230) or QALY gain (p = 0.740). The results indicated a significantly lower likelihood of SSI in the braced population (1.50 % versus 6.82 %, odds ratio [OR] = 0.208, 95 % CI: 0.057 to 0.751, p = 0.037). There was no difference in relevant co-morbidities (p = 0.259 to 1.000), although the braced cohort was older than the unbraced cohort (63 versus 56 years of age, p = 0.003). The authors concluded that bracing following multi-level PLF did not alter short-term post-operative course or reduce the risk for early AEs. Cost-analysis showed no difference in direct costs between the 2 therapeutic approaches. These investigators stated that short-term data suggested that removal of bracing from the post-operative regimen for PLF will not result in increased adverse outcomes.
Appendix
The following chart reflects the 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:
| 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:
| 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, 2022):
Prosthetic and orthotic device quantity limits
The table limits durable orthotics to generally 1 per limb per year.
References
The above policy is based on the following references:
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