Medical Policy Ankle-Foot/Knee-Ankle-Foot Orthosis

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Medical PolicyAnkle-Foot/Knee-Ankle-Foot OrthosisDescriptionFor an orthotic item to be considered for coverage, it must be a rigid or semi-rigid devicewhich is used for the purpose of supporting a weak or deformed body member orrestricting or eliminating motion in a diseased or injured part of the body. It must providesufficient support to the limb or body part for which it is designed to brace. Items that donot meet the definition of a brace are considered not reasonable and necessary.PolicyAn ankle-foot orthoses (AFO) and knee-ankle-foot orthoses (KAFO) are reasonable andnecessary for Members who meet the coverage criteria outlined below.Policy GuidelinesAFOs NOT USED DURING AMBULATION OR MINIMALLY AMBULATORY:An L4396 or L4397 (Static or dynamic positioning ankle-foot orthosis) is covered ifeither all of criteria 1 - 4 or criterion 5 is met:1. Plantar flexion contracture of the ankle (see Diagnosis Codes That SupportMedical Necessity Group 1 Codes section) with dorsiflexion on passive range ofmotion testing of at least 10 degrees (i.e., a non-fixed contracture); and,2. Reasonable expectation of the ability to correct the contracture; and,3. Contracture is interfering or expected to interfere significantly with the member'sfunctional abilities; and,4. Used as a component of a therapy program which includes active stretching of theinvolved muscles and/or tendons.5. The member has plantar fasciitis (see Diagnosis Codes That Support MedicalNecessity Group 1 Codes section)If an L4396 or L4397 is used for the treatment of a plantar flexion contracture, the pretreatment passive range of motion must be measured with a goniometer and documentedin the medical record. There must be documentation of an appropriate stretching programcarried out by professional staff (in a nursing facility) or caregiver (at home).An L4396 or L4397 and replacement interface (L4392) will be denied as not reasonableand necessary if the contracture is fixed. Codes L4396, L4397 and L4392 will be deniedas not reasonable and necessary for a member with a foot drop but without an ankle)DMEPOS Standard Medical PolicyPage 1 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot Orthosisflexion contracture. A component of a static/dynamic AFO that is used to addresspositioning of the knee or hip will be denied as not reasonable and necessary because theeffectiveness of this type of component is not established.If code L4396 or L4397 is covered, a replacement interface (L4392) is covered as long asthe member continues to meet indications and other coverage rules for the splint.Coverage of a replacement interface is limited to a maximum of one (1) per 6 months.Additional interfaces will be denied as not reasonable and necessary.A foot drop splint/recumbent positioning device (L4398) and replacement interface(L4394) will be denied as not reasonable and necessary. A foot drop splint/recumbentpositioning device and replacement interface will be denied as not reasonable andnecessary in a member with foot drop who is non-ambulatory because there are othermore appropriate treatment modalities.AFOs AND KAFOs USED DURING AMBULATION:Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116,L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory memberswith weakness or deformity of the foot and ankle, who:1. Require stabilization for medical reasons, and,2. Have the potential to benefit functionally.Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, andL4370 are covered for ambulatory members for whom an ankle-foot orthosis is coveredand for whom additional knee stability is required.If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will bedenied as not reasonable and necessary.Prefabricated walking boots are coded using codes L4360, L4361, L4386 orL4387. These codes describe complete products. Claims for add-on codes used withwalking boots coded L4360, L4361, L4386 or L4387 will be denied as unbundling.Custom fitted orthotics are: They may or may not be supplied as a kit that requires some assembly. Assemblyof the item and/or installation of add-on components and/or the use of some basicmaterials in preparation of the item does not change classification from OTS tocustom fitted.)DMEPOS Standard Medical PolicyPage 2 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot Orthosis Classification as custom fitted requires more than minimal self-adjustment forfitting at the time of delivery in order to provide an individualized fit, i.e., theitem must be trimmed, bent, molded (with or without heat), or otherwise modifiedresulting in alterations beyond minimal self-adjustment. This fitting at delivery does require expertise of a certified orthotist or anindividual who has specialized training in the provision of orthosis to fit the itemto the individual beneficiary.In contrast to “minimal self-adjustment,” “more than minimal self-adjustment” is definedas changes made to achieve an individualized fit during the final fitting at the time ofdelivery of the item that requires the expertise of a certified orthotist or an individual whohas equivalent specialized training in the provision of orthotics in compliance with allapplicable Federal and State licensure and regulatory requirements. A certified orthotist isdefined as an individual who is certified by the American Board for Certification inOrthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.AFOs and KAFOs that are custom-fabricated are covered for ambulatory members whenthe basic coverage criteria listed above and one of the following criteria are met:1. The member could not be fit with a prefabricated AFO; or,2. The condition necessitating the orthosis is expected to be permanent or oflongstanding duration (more than 6 months); or,3. There is a need to control the knee, ankle or foot in more than one plane; or,4. The member has a documented neurological, circulatory, or orthopedic status thatrequires custom fabricating over a model to prevent tissue injury; or,5. The member has a healing fracture which lacks normal anatomical integrity oranthropometric proportions.If a custom fabricated orthosis is provided but basic coverage criteria above and theadditional criteria 1-5 for a custom fabricated orthosis are not met, the custom fabricatedorthosis will be denied as not reasonable and necessary.L coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2768, L2780-L2830)will be denied as not reasonable and necessary if either the base orthosis is not reasonableand necessary or the specific addition is not reasonable and necessary.)DMEPOS Standard Medical PolicyPage 3 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot OrthosisConcentric adjustable torsion style mechanisms used to assist knee joint extension arecoded as L2999 and are covered for members who require knee extension assist in theabsence of any co-existing joint contracture.Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexionor dorsiflexion are coded as L2999 and are covered for members who require ankleplantar or dorsiflexion assist in the absence of any co-existing joint contracture.Concentric adjustable torsion style mechanisms used for the treatment of contractures,regardless of any co-existing condition(s), are coded as E1810 and/or E1815 and arecovered under the Durable Medical Equipment benefit (see related Policy Article CodingGuidelines for additional information).Claims for devices incorporating concentric adjustable torsion style mechanisms used forthe treatment of any joint contracture and coded as L2999 will be denied as incorrectcoding.Elastic or other fabric support garments A4467 (Belt, Strap, Sleeve, Garment orCovering, Any Type) with or without stays or panels do not meet the definition of a bracebecause they are not rigid or semi-rigid devices. Code A4467 is denied as noncovered.An inversion/eversion correction device (A9285) is denied as noncovered, because itdoes not act as a brace; that is, it does not support a weak or deformed body member orrestrict or eliminate motion in a diseased or injured part of the body.Socks (L2840, L2850) used in conjunction with orthoses are denied as noncovered.Refer to the Orthopedic Footwear policy for information on coverage of shoes and relateditems which are an integral part of a brace.MISCELLANEOUS:Replacement of a complete orthosis or component of an orthosis due to loss, significantchange in the member’s condition, or irreparable accidental damage is covered if thedevice is still reasonable and necessary. The reason for the replacement must bedocumented in the supplier's record.Replacement components (e.g., soft interfaces) that are provided on a routine basis,without regard to whether the original item is worn out, are denied as not reasonable andnecessary.The right (RT) and left (LT) modifiers must be used with orthosis base codes, additions,and replacement parts. Effective for claims with dates of service (DOS) on or after3/1/2019, when the same code for bilateral items (left and right) is billed on the same dateof service, bill each item on two separate claim lines using the RT and LT modifiers and)DMEPOS Standard Medical PolicyPage 4 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot Orthosis1 unit of service (UOS) on each claim line. Do not use the RTLT modifier on the sameclaim line and billed with 2 UOS. Claims billed without modifiers RT and/or LT, or withRTLT on the same claim line and 2 UOS, will be rejected as incorrect coding.HCPCS CODES:Group 1 7L1910L1920L1930L1932L1940L1945DescriptionBELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANY TYPE,EACHFOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANYTYPE, EACHINVERSION/EVERSION CORRECTION DEVICEANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSISTCALF BAND, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED,OFF-THE-SHELFANKLE ORTHOSIS, ANKLE GAUNTLET, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT,PREFABRICATED, OFF-THE-SHELFANKLE ORTHOSIS, SUPRAMALLEOLAR WITH STRAPS, WITH ORWITHOUT INTERFACE/PADS, CUSTOM FABRICATEDANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASPATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC ORADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE), CUSTOMFABRICATEDANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTAFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBEROR EQUAL MATERIAL, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL,CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIALSECTION (FLOOR REACTION), CUSTOM-FABRICATED)DMEPOS Standard Medical PolicyPage 5 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot 000L2005L2006L2010L2020DescriptionANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OFREHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOMFABRICATEDANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OFREHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHERMATERIAL, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC,CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOMFABRICATEDANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITHANKLE JOINT, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTARDORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR'BK' ORTHOSIS), CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTARDORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (DOUBLEBAR 'BK' ORTHOSIS), CUSTOM-FABRICATEDKNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE,FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS(SINGLE BAR 'AK' ORTHOSIS), CUSTOM-FABRICATEDKNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE ORDOUBLE UPRIGHT, STANCE CONTROL, AUTOMATIC LOCK ANDSWING PHASE RELEASE, ANY TYPE ACTIVATION, INCLUDESANKLE JOINT, ANY TYPE, CUSTOM FABRICATEDKNEE ANKLE FOOT DEVICE, ANY MATERIAL, SINGLE ORDOUBLE UPRIGHT, SWING AND STANCE PHASEMICROPROCESSOR CONTROL WITH ADJUSTABILITY, INCLUDESALL COMPONENTS (E.G., SENSORS, BATTERIES, CHARGER), ANYTYPE ACTIVATION, WITH OR WITHOUT ANKLE JOINT(S),CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE,SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM-FABRICATEDKNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE,SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (DOUBLE BAR)DMEPOS Standard Medical PolicyPage 6 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot 108L2112L2114L2116L2126Description'AK' ORTHOSIS), CUSTOM-FABRICATEDKNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE,SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS, (DOUBLE BAR'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLEUPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, MEDIALLATERAL ROTATION CONTROL, WITH OR WITHOUT FREEMOTION ANKLE, CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, STATIC(PEDIATRIC SIZE), WITHOUT FREE MOTION ANKLE,PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLEUPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH ORWITHOUT FREE MOTION ANKLE, CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLEUPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH ORWITHOUT FREE MOTION ANKLE, CUSTOM FABRICATEDKNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH ORWITHOUT FREE MOTION KNEE, MULTI-AXIS ANKLE, CUSTOMFABRICATEDANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIALFRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTINGMATERIAL, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIALFRACTURE CAST ORTHOSIS, CUSTOM-FABRICATEDANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIALFRACTURE ORTHOSIS, SOFT, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIALFRACTURE ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIALFRACTURE ORTHOSIS, RIGID, PREFABRICATED, INCLUDESFITTING AND ADJUSTMENTKNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORALFRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTINGMATERIAL, CUSTOM-FABRICATED)DMEPOS Standard Medical PolicyPage 7 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot scriptionKNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORALFRACTURE CAST ORTHOSIS, CUSTOM-FABRICATEDKAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CASTORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTKAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CASTORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTINGAND ADJUSTMENTKAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CASTORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING ANDADJUSTMENTADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS,PLASTIC SHOE INSERT WITH ANKLE JOINTSADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROPLOCK KNEE JOINTADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS,LIMITED MOTION KNEE JOINTADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS,ADJUSTABLE MOTION KNEE JOINT, LERMAN TYPEADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS,QUADRILATERAL BRIMADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS,WAIST BELTADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIPJOINT, PELVIC BAND, THIGH FLANGE, AND PELVIC BELTADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION,EACH JOINTADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST(PLANTAR FLEXION RESIST), EACH JOINTADDITION TO LOWER EXTREMITY, DORSIFLEXION ANDPLANTAR FLEXION ASSIST/RESIST, EACH JOINTADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPERSTIRRUPS AND PLATE ATTACHMENTADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOMFOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOMFABRICATED ORTHOSIS ONLYADDITION TO LOWER EXTREMITY, ROUND CALIPER AND)DMEPOS Standard Medical PolicyPage 8 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot 385L2387L2390DescriptionPLATE ATTACHMENTADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TOPATIENT MODEL, STIRRUP ATTACHMENTADDITION TO LOWER EXTREMITY, REINFORCED SOLIDSTIRRUP (SCOTT-CRAIG TYPE)ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUPADDITION TO LOWER EXTREMITY, VARUS/VALGUSCORRECTION ('T') STRAP, PADDED/LINED OR MALLEOLUS PADADDITION TO LOWER EXTREMITY, VARUS/VALGUSCORRECTION, PLASTIC MODIFICATION, PADDED/LINEDADDITION TO LOWER EXTREMITY, MOLDED INNER BOOTADDITION TO LOWER EXTREMITY, ABDUCTION BAR(BILATERAL HIP INVOLVEMENT), JOINTED, ADJUSTABLEADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHTADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FORCUSTOM FABRICATED ORTHOSIS ONLYADDITION TO LOWER EXTREMITY, LACER MOLDED TOPATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLYADDITION TO LOWER EXTREMITY, ANTERIOR SWING BANDADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDEDTO PATIENT MODELADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK)SOCKET, MOLDED TO PATIENT MODEL, (USED FOR 'PTB' 'AFO'ORTHOSES)ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANKADDITION TO LOWER EXTREMITY, PATTEN BOTTOMADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLEJOINT AND HALF SOLID STIRRUPADDITION TO LOWER EXTREMITY, TORSION CONTROL,STRAIGHT KNEE JOINT, EACH JOINTADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT,HEAVY DUTY, EACH JOINTADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT,FOR CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS,EACH JOINTADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH)DMEPOS Standard Medical PolicyPage 9 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot scriptionJOINTADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVYDUTY, EACH JOINTADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSIONSLEEVEADDITION TO KNEE JOINT, DROP LOCK, EACHADDITION TO KNEE LOCK WITH INTEGRATED RELEASEMECHANISM ( BAIL, CABLE, OR EQUAL), ANY MATERIAL, EACHJOINTADDITION TO KNEE JOINT, DISC OR DIAL LOCK FORADJUSTABLE KNEE FLEXION, EACH JOINTADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE ANDPROGRESSIVE KNEE EXTENSION, EACH JOINTADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RINGADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING,GLUTEAL/ ISCHIAL WEIGHT BEARING, RINGADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING,QUADRI- LATERAL BRIM, MOLDED TO PATIENT MODELADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING,QUADRI- LATERAL BRIM, CUSTOM FITTEDADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING,ISCHIAL CONTAINMENT/NARROW M-L BRIM MOLDED TOPATIENT MODELADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING,ISCHIAL CONTAINMENT/NARROW M-L BRIM, CUSTOM FITTEDADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING,LACER, NON-MOLDEDADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING,LACER, MOLDED TO PATIENT MODELADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING,HIGH ROLL CUFFADDITION TO LOWER EXTREMITY ORTHOSIS, PLATINGCHROME OR NICKEL, PER BARADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH,LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREGCOMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED)DMEPOS Standard Medical PolicyPage 10 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot 045L4050DescriptionORTHOSIS ONLYADDITION TO LOWER EXTREMITY ORTHOSIS, EXTENSION, PEREXTENSION, PER BAR (FOR LINEAL ADJUSTMENT FORGROWTH)ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BARADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVEFINISH, PER BARADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCKRETAINER, EACHADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL,FULL KNEECAPADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL,KNEE CAP, MEDIAL OR LATERAL PULL, FOR USE WITH CUSTOMFABRICATED ORTHOSIS ONLYADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL,CONDYLAR PADADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACEFOR MOLDED PLASTIC, BELOW KNEE SECTIONADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACEFOR MOLDED PLASTIC, ABOVE KNEE SECTIONADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTHSOCK, FRACTURE OR EQUAL, EACHADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORALLENGTH SOCK, FRACTURE OR EQUAL, EACHLOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIEDREPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALLCOMPONENTS, ANY LENGTH, ANY TYPEREPLACE TRILATERAL SOCKET BRIMREPLACE QUADRILATERAL SOCKET BRIM, MOLDED TOPATIENT MODELREPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTEDREPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATEDORTHOSIS ONLYREPLACE NON-MOLDED THIGH LACER, FOR CUSTOMFABRICATED ORTHOSIS ONLYREPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED)DMEPOS Standard Medical PolicyPage 11 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot scriptionORTHOSIS ONLYREPLACE NON-MOLDED CALF LACER, FOR CUSTOMFABRICATED ORTHOSIS ONLYREPLACE HIGH ROLL CUFFREPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFOREPLACE METAL BANDS KAFO, PROXIMAL THIGHREPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGHREPLACE LEATHER CUFF KAFO, PROXIMAL THIGHREPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGHREPLACE PRETIBIAL SHELLREPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15MINUTESREPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINORPARTSANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDESANY TYPE INTERFACE (E.G., PNEUMATIC, GEL),PREFABRICATED, OFF-THE-SHELFWALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH ORWITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL,PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT,MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT ASPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISEWALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH ORWITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL,PREFABRICATED, OFF-THE-SHELFPNEUMATIC FULL LEG SPLINT, PREFABRICATED, OFF-THESHELFWALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS,WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATEDITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED,OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BYAN INDIVIDUAL WITH EXPERTISEWALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS,WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED,OFF-THE-SHELFREPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO)DMEPOS Standard Medical PolicyPage 12 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot EPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINTSTATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDINGSOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FORPOSITIONING, MAY BE USED FOR MINIMAL AMBULATION,PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT,MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT ASPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISESTATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDINGSOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FORPOSITIONING, MAY BE USED FOR MINIMAL AMBULATION,PREFABRICATED, OFF-THE-SHELFFOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE,PREFABRICATED, OFF-THE-SHELFANKLE FOOT ORTHOSIS, WALKING BOOT TYPE,VARUS/VALGUS CORRECTION, ROCKER BOTTOM, ANTERIORTIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT,PLASTIC OR OTHER MATERIAL, INCLUDES STRAPS ANDCLOSURES, CUSTOM FABRICATEDICD-10 Codes that Support Medical NecessityGroup 1 Paragraph: The presence of an ICD-10 code listed in this section is notsufficient by itself to assure coverage. Refer to the section on “Coverage Indications,Limitations and/or Medical Necessity” for other coverage criteria and paymentinformation.For HCPCS codes L4392, L4396 and L4397:Group 1 escriptionContracture, right ankleContracture, left ankleContracture, right footContracture, left footPlantar fascial fibromatosis)DMEPOS Standard Medical PolicyPage 13 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot OrthosisGroup 2 Paragraph: For HCPCS code L4631:Group 2 Codes:ICD-10CodeA52.16DescriptionCharcot's arthropathy (tabetic)E10.610E11.610Diabetes mellitus due to underlying condition with diabetic neuropathicarthropathyDrug or chemical induced diabetes mellitus with diabetic neuropathicarthropathyType 1 diabetes mellitus with diabetic neuropathic arthropathyType 2 diabetes mellitus with diabetic neuropathic arthropathyM14.671M14.672Charcot's joint, right ankle and footCharcot's joint, left ankle and footE08.610E09.610Important Note:Northwood’s Medical Policies are developed to assist Northwood in administering planbenefits and determining whether a particular DMEPOS product or service is reasonableand necessary. Equipment that is used primarily and customarily for a non-medicalpurpose is not considered durable medical equipment.Coverage determinations are made on a case-by-case basis and are subject to all of theterms, conditions, limitations, and exclusions of the member’s contract including medicalnecessity requirements.The conclusion that a DMEPOS product or service is reasonable and necessary does notconstitute coverage. The member’s contract defines which DMEPOS product or serviceis covered, excluded or limited. The policies provide for clearly written, reasonable andcurrent criteria that have been approved by Northwood’s Medical Director.The clinical criteria and medical policies provide guidelines for determining the medicalnecessity for specific DMEPOS products or services. In all cases, final benefitdeterminations are based on the applicable contract language. To the extent there are anyconflicts between medical policy guidelines and applicable contract language, thecontract language prevails. Medical policy is not intended to override the policy thatdefines the member’s benefits, nor is it intended to dictate to providers how to direct care.Northwood Medical policies shall not be interpreted to limit the benefits afforded to)DMEPOS Standard Medical PolicyPage 14 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot OrthosisMedicare or Medicaid members by law and regulation and Northwood will use theapplicable state requirements to determine required quantity limit guidelines.Northwood’s policies do not constitute medical advice. Northwood does not provide orrecommend treatment to members. Members should consult with their treatingpractitioner in connection with diagnosis and treatment decisions.References1. Aetna: Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-FootOrthosis (KAFOs) http://www.aetna.com/cpb/medical/data/500 599/0565.htmlAccessed December 5, 2018, December 9, 2019.2. CGS Administrators, LLC. Jurisdiction B DME MAC, Ankle-Foot/Knee-AnkleFoot Orthosis. Local Coverage Determination No. L33686 revised date January 1,2020. Accessed December 8, 2017. Reviewed December 5, 2018, December 9,2019, December 2020.3. Noridian Healthcare Solutions, LLC. Ankle-Foot/Knee-Ankle-Foot Orthosis.Local Coverage Determination No. L33686. Durable Medical EquipmentMedicare Administrative Carrier Jurisdiction A; revised January 1, 2020.Reviewed December 5, 2018, December 2020.4. Centers for Medicare and Medicaid Services, Medicare Coverage Database,National Coverage Documents; October 2015.5. Buschbacher RM. Ankle sprain evaluation and bracing. In Physical Rehabilitationof the Injured Athlete. JR Andrews, GL Harrelson, eds. Philadelphia, PA: WBSaunders Co.; 1991:221-239.6. Barringer WJ. Principles of orthotic management of athletic injury. In ClinicalSports Medicine. WA Grana, A Kalenak, eds. Philadelphia, PA: WB SaundersCo.; 1991:315-331.7. Reider B, Belniak R, Miller DW. Football. In Sports Medicine: The School-AgeAthlete. 2nd ed. B Reider, ed. Philadelphia, PA: WB Saunders Co.; 1996:613645.8. American Academy of Orthopedic Surgeons. Athletic Training and SportsMedicine. 2nd ed. Rosemont, IL: American Academy of Orthopedic Surgeons;1991:705-715.)DMEPOS Standard Medical PolicyPage 15 of 22Ankle-Foot/Knee-Ankle-Foot Orthosis (Commercial/Medicare/NH Medicaid)Confidential and Proprietary

Medical PolicyAnkle-Foot/Knee-Ankle-Foot Orthosis9. Hald RD, Fandel DM. Taping and bracing. In Sports Medicine and Rehabilitation:A Sports-Specific Approach. RM Buschbacher, RL Braddom, eds. Philadelphia,PA: Hanley & Belfus, Inc; 1994:337-354.10. Handoll HH, Rowe BH, Quinn KM, et al. Interventions for preventing ankleligament injuries. Cochrane Database Syst Rev. 2001;(3):CD000018.11. Bono CM, Berberian WS. Orthotic devices. Degenerative disorders of the footand ankle. Foot Ankle Clin. 2001;6(2):329-340.12. Buonomo LJ, Klein JS, Keiper TL. Orthotic devices. Custom-made,prefabricated, and material selection. Foot Ankle Clin

ankle foot orthosis, multiligamentus ankle support, prefabricated, off-the-shelf l1907 ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated l1910 ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes

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