MEDICALLY NECESSARY
ANKLE-FOOT ORTHOSES (AFOs) AND KNEE-ANKLE-FOOT ORTHOSES (KAFOs) USED FOR AMBULATORY INDIVIDUALS
Ankle-Foot Orthoses (AFOs)
AFOs (L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387, and L4631) are considered medically necessary and, therefore, covered for ambulatory individuals with a weakness or deformity of the foot and ankle, who require stabilization for medical reasons and have the potential to benefit functionally from the orthosis.
Knee-Ankle-Foot Orthoses (KAFOs)
KAFOs (L2000-L2038, L2126-L2136, and L4370) are considered medically necessary and, therefore, covered for ambulatory individuals who meet the criteria for an AFO and require additional knee stabilization.
Custom-Fabricated AFOs/KAFOs
Custom-fabricated and molded-to-individual-model AFOs/KAFOs (L1900, L1904, L1907, L1920, L1940, L1945, L1950, L1960, L1970, L1980, L1990, L2000, L2005, L2010, L2020, L2030, L2034, L2036, L2037, L2038, L2106, L2108, L2126, L2128, and L4631) are considered medically necessary and, therefore, covered for ambulatory individuals when the medical necessity criteria for AFOs/KAFOs listed above are met, and at least one of the following additional criteria is met:
- The individual cannot be fitted with a prefabricated orthosis.
- The condition necessitating the orthosis is expected to be permanent or of long-standing duration (more than 6 months).
- There is a need to control the knee, ankle, or foot in more than one plane.
- The individual has a documented neurologic, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury.
- The individual has a healing fracture that lacks normal anatomic integrity or anthropometric proportions.
Shoes
Shoes (L3224, L3225, and L3649) are considered medically necessary and, therefore, covered if they are an integral part of a covered AFO or KAFO used during ambulation (L1900, L1920, L1980-L2030) and are medically necessary for the proper functioning of the brace.
ANKLE-FOOT ORTHOSES (AFOs) NOT USED DURING AMBULATION (NON-AMBULATORY INDIVIDUALS)Static or dynamic positioning AFOs (including ankle contracture splints/static AFOs) (L4396 or L4397) are considered medically necessary and, therefore, covered for individuals when nonambulatory to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured body part when either of the following criteria is met:
- The individual has plantar fasciitis.
- All of the following criteria are met:
- The nonfixed ankle plantar flexion contracture exhibits dorsiflexion on passive range of motion testing of at least 10 degrees (the pretreatment passive range of motion should be measured with a goniometer).
- There is reasonable expectation that the device will correct the nonfixed contracture.
- The nonfixed contracture is interfering or expected to interfere significantly with the individual's functional abilities.
- The orthosis is a component of a therapy program that includes active stretching of the involved muscles and/or tendons.
AFOS/ KAFOs USED FOR NIGHT SPLINTING IN CHILDREN WITH NEUROMUSCULAR DISORDERS/ ORTHOTIC MANAGEMENT AT REST SPLINTING
AFOs/KAFOs used for night/orthotic management at rest splinting is considered medically necessary and, therefore, covered when used in the treatment of muscle contractures in children with neuromuscular disorders (e.g., cerebral palsy [CP]).
CONCENTRIC ADJUSTABLE TORSION-STYLE MECHANISMS
Concentric adjustable torsion-style mechanisms (L2999) used to assist knee joint extension are considered medically necessary and, therefore, covered for individuals who require knee extension assist in the absence of any coexisting joint contracture.
Concentric adjustable torsion-style mechanisms (L2999) used to assist ankle joint plantar flexion or dorsiflexion are considered medically necessary and, therefore, covered for individuals who require ankle plantar or dorsiflexion assist in the absence of any coexisting joint contracture.
ADDITIONS
Additions to an AFO/KAFO are considered medically necessary and, therefore, covered when the AFO/KAFO is considered medically necessary according to the criteria listed in this policy. Refer to Attachment A for a list of corresponding codes.
EVALUATION AND FITTING
Evaluation of the individual, measurement and/or casting, and fitting of the orthosis are included in the allowance for the orthosis. There is no separate reimbursement for these services.
REPAIR AND REPLACEMENT
Repair and replacement for AFOs/KAFOs are considered medically necessary and, therefore, covered when the criteria listed in this policy are met for the specific orthosis. In addition, the requirements listed in the Repair and Replacement of Durable Medical Equipment (DME) policy must be met.
If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no reimbursement will be made for the excess expense.
The allowance for the labor involved for the replacement for an orthotic component that is coded with a specific Healthcare Common Procedure Coding System (HCPCS) L-code is included in the reimbursement for that component. The allowance for the labor involved in replacing an orthotic component that is coded with the miscellaneous HCPCS code L4210 is separately reimbursable in addition to the allowance for that component.
The reason for the repair or replacement must be documented in the supplier's record.
NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT
Orthotic training may include teaching the individual regarding a wearing schedule, placing and removing the orthosis, skin care, and performing tasks while wearing the device. It is not appropriate to include the time spent assessing, measuring or fitting, fabricating or modifying, or making the orthotic in the time spent providing orthotic training. Only the time spent actually training the individual should be included in the orthotic training service.
Evaluation of the individual, 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.
NOT MEDICALLY NECESSARY
The following items are considered not medically necessary and, therefore, not covered because the available published peer-reviewed literature does not support its use in the treatment of illness or injury:
- A KAFO for a nonambulatory individual.
- An AFO/KAFO that does not meet medical necessity criteria.
- Additions to the orthosis when an AFO/KAFO is considered not medically necessary.
- A static or dynamic AFO and replacement interface for an individual who has a fixed ankle plantar flexion contracture.
- A static or dynamic AFO and replacement interface for an individual who has foot drop without a nonfixed ankle flexion contracture.
- Components of a static/dynamic AFO that are used to position the knee or hip because the effectiveness of these components has not been established.
- Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out.
- Replacement components (e.g., soft interfaces) in excess of one every 6 months.
- Foot drop splints/recumbent positioning devices, and related replacement interfaces for ambulatory and nonambulatory individuals with foot drop because there are other more appropriate treatment modalities.
Ankle-Foot/Knee-Ankle-Foot Orthoses of any type worn to facilitate participation in sports are considered not medically necessary and, therefore, not covered.
NOT COVERED
Items that are not primarily medical in nature (e.g., femoral and tibial fracture socks) are not covered by the Company because they are a benefit contract exclusion. Therefore, they are not eligible for reimbursement consideration.
The following items are not covered by the Company because it is not used to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace). Therefore it is not eligible for reimbursement consideration:
- Elastic support garments (A4467)
- Inversion/eversion correction device (A9285)
FACE-TO-FACE REQUIREMENTS
As a condition for payment, a professional provider must have a face-to-face encounter with the individual for whom the item is ordered that meets all of the following requirements:
- The treating professional provider must have an in-person encounter with the individual within the six (6) months prior to the date of the written order prior to delivery.
- This encounter must document that the individual was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.
A new face-to-face encounter is required each time a new standard written order for one of the specified items is ordered. A new standard written order is required:
- For all claims for purchases or initial rentals
- When there is a change in the standard written order for the accessory, supply, drug, etc.
- If periodic standard written order renewal required per medical policy
- When an item is replaced
- When there is a change in the supplier
- When required by state law
In this policy the specified items are:
| Code | Narrative |
L1932
| Ankle-foot orthosis (AFO), Rigid Anterior Tibial Section, Total Carbon Fiber Or Equal Material, Prefabricated, Includes Fitting And Adjustment
|
L1940
| Ankle-Foot orthosis (AFO), plastic or other material, custom fabricated
|
L1951
| Ankle-Foot Orthosis (AFO), Spiral, (Institute Of Rehabilitative Medicine Type), Plastic Or Other Material, Prefabricated, Includes Fitting And Adjustment
|
| L1960 | Ankle-Foot Orthosis (AFO), Posterior Solid Ankle, Plastic, Custom-Fabricated
|
L1970
| Ankle-Foot Orthosis (AFO), Plastic With Ankle Joint, Custom-Fabricated
|
L2005
| Knee-Ankle-Foot Orthosis (KAFO), Any Material, Single Or Double Upright, Stance Control, Automatic Lock And Swing Phase Release, Any Type Activation, Includes Ankle Joint, Any Type, Custom Fabricated
|
L2036
| Knee-Ankle-Foot Orthosis (KAFO), Full Plastic, Double Upright, With Or Without Free Motion Knee, With Or Without Free Motion Ankle, Custom Fabricated
|
REQUIRED DOCUMENTATION
- Provide the product that is specified by the ordering professional provider (i.e., type of orthosis and method of fitting [OTS or custom fitted]).
- Be sure that the medical record justifies the need for the type of product and method of fitting.
- Be sure only to use the code that accurately reflects both the type of orthosis and the appropriate level of fitting.
- Have detailed documentation that justifies the code selected for custom fitted versus OTS.
When providing custom-fabricated orthotics, there must be documentation in the supplier's records to support the medical necessity of that type device rather than a prefabricated orthosis.
If an ankle contracture splint/static or dynamic AFO is used for the treatment of a nonfixed ankle plantar flexion contracture, the pretreatment passive range of motion should be measured with a goniometer and documented in the medical record. There should also be documentation that an appropriate stretching program is being overseen by professional staff (in a nursing facility) or a caregiver (at home).
The Company may conduct reviews and audits of services to our members regardless of the participation status of the provider. Medical record documentation must be maintained on file to reflect the medical necessity of the care and services provided. These medical records may include but are not limited to: records from the professional provider’s office, hospital, nursing home, home health agencies, therapies, and test reports.
STANDARD WRITTEN ORDER REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete standard written order for each item billed that is signed and dated by the professional provider who is treating the member. Requesting a provider to sign a retrospective standard written order at the time of an audit or after an audit for submission as an original standard written order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.
PROOF OF DELIVERY REQUIREMENTS
Medical record documentation must include a contemporaneously prepared delivery confirmation or member’s receipt of supplies and equipment. The medical record documentation must include a copy of delivery confirmation if delivered by a commercial carrier and a signed copy of delivery confirmation by member/caregiver if delivered by the DME supplier/provider. All documentation is to be prepared contemporaneous with delivery and be available to the Company upon request.
CONSUMABLE SUPPLIES (WHEN APPLICABLE)
The DME supplier must monitor the quantity of accessories and supplies an individual is actually using. Contacting the individual regarding replenishment of supplies should not be done earlier than approximately 7 days prior to the delivery/shipping date. Dated documentation of this contact with the individual is required in the individual’s medical record. Delivery of the supplies should not be done earlier than approximately 5 days before the individual would exhaust their on-hand supply.
For specified DME items, documentation of a face-to-face encounter between the treating professional provider and the individual meeting the above requirements, including an assessment of the individual’s clinical condition supporting the need for the prescribed DME item(s), must be provided to and kept on file by the DME supplier.
If required documentation is not available on file to support a claim at the time of an audit or record request, the DME supplier may be required to reimburse the Company for overpayments.
BILLING REQUIREMENTS
It is not appropriate to report L2999 for devices incorporating concentric adjustable torsion-style mechanisms used for the treatment of any joint contracture.
Replacement components that do not have a unique HCPCS code must be billed with a “not otherwise specified” code (L2999). The claim must include a description of the component provided, the reason for replacement, and the HCPCS code or narrative description of the base orthosis.
HCPCS code L4205 may only be billed for time involved with the actual repair of an orthotic, or for medically necessary adjustments.
HCPCS code L4205 must not be used to bill for time involved with other professional services including those listed below. Reimbursement for these services is included in the allowance for the HCPCS codes that describe the orthosis.
- Evaluating the individual
- Taking measurements, making a cast, making a model, use of CAD/CAM
- Making modifications to a prefabricated item to fit it to the individual
- Follow-up visits
- Making adjustments at the time of or within 90 days after delivery
HCPCS code L4210 must not be used for casting supplies or other materials used in the fitting or fabrication of an orthosis.
Addition codes L4002-L4130, and L4392 are for billing of replacement components and are not payable at initial issue of a base orthosis.
