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Knee Orthoses
MA05.013k

Policy

State mandates do not automatically apply to all plans; therefore, individual benefits must be verified.​

MEDICALLY NECESSARY

PREFABRICATED KNEE ORTHOSES (L1810, L1812, L1820, L1821, L1830, L1831, L1832, L1833, L1836, L1843, L1845, L1850 L1851, L1852)

A knee orthosis with joints (L1810, L1812) or a knee orthosis with condylar pads and joints, with or without patellar control (L1820, L1821), is considered medically necessary and, therefore, covered for an ambulatory individual to provide stability to a documented unstable knee due to weakness or deformity of the knee.

A knee orthosis with a locking knee joint (L1831) or a rigid knee orthosis (L1836) is considered medically necessary and, therefore, covered for individuals who have flexion or extension contractures of the knee with movement on passive range-of-motion testing of at least 10 degrees, i.e., a nonfixed contracture.

​An immobilizer knee orthosis without joints (L1830) is considered medically necessary and, therefore, covered for an individual who has had a recent injury to or a surgical procedure on the knee(s).


A knee orthosis with adjustable knee joints (L1832, L1833) is considered medically necessary and, therefore, covered when one of the following criteria are met:

  • The individual has had a recent injury to, or a surgical procedure on, the knee.
  • The individual is ambulatory and has knee instability.​​
A knee orthosis, Swedish type, prefabricated (L1850), is considered medically necessary and, therefore, covered for an individual who is ambulatory and has knee instability due to genu recurvatum (hyperextended knee/​bends backwards), ​congenital or acquired and has either of the following indications:
  • Specified acquired deformities of the lower leg
  • Congenital deformity of the knee
For a knee orthosis with adjustable knee joints or a prefabricated Swedish type knee orthosis (L1832, L1833, L1850), objective knee instability must be documented by examination of the individual and an objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior drawer test).

A knee orthosis with single or double upright, adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment (L1843, L1845, L1851, L1852) is considered medically necessary and, therefore, covered when one of the following criteria are met: 
  • The individual is ambulatory and has objective knee instability that must be supported by documentation of a physical examination including the joint laxity test(s) performed.
  • The individual has had a recent injury to, or a surgical procedure on, the knee(s).
  • The individual has a diagnosis of medial or lateral tibiofemoral osteoarthritis and all of the following criteria are met:​
    • The individual is ambulatory.
    • The individual is experiencing pain or reduction in their mobility and/or function secondary to the medial or lateral tibiofemoral osteoarthritis.
    • The knee orthosis provides either varus or valgus adjustment.
    • ​The individual expresses a willingness to use the knee orthosis​.
CUSTOM-FABRICATED KNEE ORTHOSES (L1834, L1840, L1844, L1846, L1860)
A custom-fabricated knee orthosis (including molded-to-patient-model) is considered medically necessary and, therefore, covered for an ambulatory individual who has a documented physical characteristic that requires the use of a custom-fabricated orthosis instead of a prefabricated orthosis. Examples of these indications include, but are not limited to:
  • Size of the thigh and calf
  • Deformity of the leg or knee
  • Minimal muscle mass upon which to suspend an orthosis
NOTE: Although these are examples of potential situations in which a custom-fabricated orthosis may be appropriate, consideration must be given to prefabricated alternatives such as pediatric knee orthoses in individuals with small limbs, straps with additional length for individuals with large limbs, etc. The need for a custom-fabricated orthosis must be supported by a written order as required documentation.

A custom-fabricated knee orthosis without joints (L1834) is considered m​edically necessary and, therefore, covered when both of the following criteria are met:
  • The criteria defined above for a custom-fabricated orthosis are met.
  • The above-listed coverage criteria for the prefabricated knee orthosis (L1830) are also met.
A custom-fabricated derotation knee orthosis (L1840) for instability due to internal ligamentous disruption of the knee is considered medically necessary and, therefore, covered. ​​Examples include but are not limited to:
  • Derangement/disorders of the patella
  • Chronic instability of the knee
  • Spontaneous disruption of ligaments of the knee
A custom-fabricated knee orthosis with an adjustable flexion and extension joint (L1844, L1846) is considered medically necessary and, therefore, covered for an individual when both of the following criteria are met:
  • The coverage criteria for the prefabricated orthosis codes L1843, L1845, L1851, and L1852 are met.
  • The general criteria defined above for a custom-fabricated orthosis is met.​​
A custom-fabricated knee orthosis with a modified supracondylar prosthetic socket (L1860) for an ambulatory individual with knee instability due to genu recurvatum (hyperextended knee) is considered medically necessary and, therefore, covered when the coverage criteria for a custom-fabricated orthosis are met, with either of the following indications:
  • Specified acquired deformities of the lower leg
  • Congenital deformity of the knee
Custom-fabricated knee orthoses are purchased rather than rented. All required fitting and labor are included in the reimbursement for the purchase.

A heavy-duty knee joint addition (L2385, L2395) to a knee orthosis is considered medically necessary and, therefore, covered for an individual weighing more than 300 pounds.

A removable soft interface (K0672) is considered medically necessary and, therefore, covered for a maximum of two per year after the date of service for initial issuance of the orthosis. Additional replacement soft interfaces are considered not medically necessary and, therefore, not covered. 

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.

REPAIR AND REPLACEMENT
Repair and replacement for knee orthoses are considered medically necessary and, therefore, covered when the criteria listed in this policy are met for the specific orthosis.

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/repair for an orthotic component that is coded with a specific Healthcare Common Procedure Coding System (HCPCS) code is included in the reimbursement for that component. The allowance for the labor (L4205) involved in the replacement/repair of 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 about a wearing schedule, placing and removing the orthosis, and 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

Knee orthoses for all conditions not listed above are considered not medically necessary and, therefore, not covered.

Custom-fabricated functional knee orthoses are considered not medically necessary and, therefore, not covered for the treatment of knee contractures for individuals who are nonambulatory.

Prophylactic knee orthoses are considered not medically necessary and, therefore, not covered.

Knee orthoses of any type worn to facilitate participation in sports are considered not medically necessary and, therefore, not covered.

Knee orthoses with an inflatable air bladder incorporated into the design (L1847 and L1848) are considered not medically necessary and, therefore, not covered, because the available published peer-reviewed literature does not support their use in the diagnosis or treatment of illness or injury.

NOT COVERED

Garments, belts, sleeves, or other coverings, composed of elastic or similar stretchable material (e.g., A4467), are not covered by the Company, because they are not rigid or semirigid devices. Therefore, they are not eligible for reimbursement consideration.

Under-sleeves used in conjunction with an orthosis (L9900) are not covered by the Company because they are 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., they do not meet the definition of a brace). Therefore, they are not eligible for reimbursement consideration.

ADDITION CODES

PREFABRICATED KNEE ORTHOSES
The following table lists addition codes that describe components or features that can be, and frequently are, physically incorporated into the specified prefabricated base orthosis. Addition codes may be separately payable when all of the following criteria are met:
  • They are provided with the related base code orthosis.
  • The base orthosis is medically necessary.
  • The addition is medically necessary.
Addition codes are considered not medically necessary and, therefore, not covered if the base orthosis is not medically necessary or the addition is not medically necessary.

Base Code
Addition Codes - Eligible for Separate Payment
L1810There are no addition codes that are eligible for separate payment
L1812There are no addition codes that are eligible for separate payment
L1820There are no addition codes that are eligible for separate payment
​L1821
​There are no addition codes that are eligible for separate payment​
L1830There are no addition codes that are eligible for separate payment
L1831There are no addition codes that are eligible for separate payment
L1832L2397, L2795, L2810
L1833L2397, L2795, L2810
L1836There are no addition codes that are eligible for separate payment
L1843L2385, L2395, L2397
L1845L2385, L2395, L2397, L2795
L1847There are no addition codes that are eligible for separate payment
L1848There are no addition codes that are eligible for separate payment
L1850L2397
L1851L2385, L2395, L2397
L1852L2385, L2395, L2397, L2795

The following table lists addition codes that describe components or features that can be physically incorporated into the specified prefabricated base orthosis but are considered not medically necessary and, therefore, not covered:

Base Code
Addition Codes - Not Medically Necessary
L1810L2397
L1812L2397
L1820L2397
​L1821​
​L2397
L1830L2397
L1831L2397, L2795
L1832L2405, L2415, L2492, L2785
L1833L2405, L2415, L2492, L2785
L1836L2397
L1843L2405, L2492, L2785
L1845L2405, L2415, L2492, L2785
L1847L2397, L2795
L1848L2397, L2795
L1850L2275
L1851L2405, L2492, L2785
L1852L2405, L2415, L2492, L2785

The following table lists addition codes that describe components or features that can be physically incorporated into the specified prefabricated base orthosis but are considered to be included in the allowance for the orthosis. The addition codes are considered not separately payable if they are billed with the related base code:

Base Code
Addition Codes - Not Separately Payable But Included in the Allowance of the Base Orthosis
L1810L2390, L2750, L2780,L4002
L1812L2390, L2750, L2780, L4002
L1820L2390, L2750, L2780, L2810, L4002
L1830K0672, L4002
L1831K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002
L1832K0672, L2390, L2425, L2430, L2750, L2780, L2820, L2830, L4002
L1833K0672, L2390, L2425, L2430, L2750, L2780, L2820, L2830, L4002
L1836K0672, L2750, L2780, L2810, L2820, L2830,L4002
L1843K0672, L2275, L2390, L2425,L2430, L2750, L2780, L2810, L2820, L2830, L4002
L1845K0672, L2275, L2390, L2425,L2430, L2750, L2780, L2810, L2820, L2830,L4002
L1847K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830,L4002
L1848K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830,L4002
L1850K0672, L2750, L2780, L2810, L2820, L2830, L4002
L1851K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002
L1852K0672,  L2275, L2390, L2425, L2430​, L2750, L2780, L2810, L2820, L2830, L4002

CUSTOM-FABRICATED KNEE ORTHOSES
The following table lists addition codes that describe components or features that can be and frequently are physically incorporated into the specified custom-fabricated base orthosis. Addition codes may be separately payable when all of the following criteria are met:
  • They are provided with the related base code orthosis.
  • The base orthosis is medically necessary.
  • The addition is medically necessary.
Addition codes are considered not medically necessary and, therefore, not covered if the base orthosis is not medically necessary or the addition is not medically necessary.

Base Code
Addition Codes - Eligible for Separate Payment
L1834L2795
L1840L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2755, L2785, L2795
L1844L2385, L2390, L2395, L2397, L2405, L2492, L2755, L2785
L1846L2385, L2390, L2395, L2397, L2405, L2415, L2492, L2755, L2785, L2795, L2800
L1860There are no addition codes that are eligible for separate payment.

The following table lists addition codes that describe components or features that can be physically incorporated into the specified custom-fabricated base orthosis but are considered not medically necessary and, therefore, not covered. These addition codes, if they are billed with the related base code, will be considered as not medically necessary and, therefore, not covered:

Base Code
Addition Codes - Not medically Necessary
L1834L2397, L2800
L1840L2275, L2800
L1844No additional components/accessories can be billed with L1844.
L1846No additional components/accessories can be billed with L1846.
L1860L2397

The following table lists addition codes that describe components or features that can be physically incorporated into the specified custom-fabricated base orthosis but that are considered to be included in the allowance for the orthosis. The addition codes will be considered as not separately payable if they are billed with the related base code:

Base Code
Addition Codes - Not Separately Payable
L1834K0672, L2820, L2830, L4002
L1840K0672, L2320, L2330, L2750, L2780, L2810, L2820, L2830, L4002
L1844K0672, L2275, L2320, L2330, L2425, L2430, L2750, L2780, L2810, L2820, L2830,L4002
L1846K0672, L2275, L2320, L2330, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002
L1860K0672, L2820, L2830, L4002

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 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 durable medical equipment (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
​​L1832

​Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1843Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
​L1845​


​Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise​
​L1851​
​Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf​
​​L1852
​Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf​

​​
REQUIRED DOCUMENTATION


The need for a custom-fabricated knee orthoses must be supported by documentation specifying the custom fabrication. If the need for the custom-fabricated orthosis is not supported, coverage will be for the medically appropriate alternative, a prefabricated orthosis.

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 durable medical equipment (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 30 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 10 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 computer-aided design/computer-aided manufacturing (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.​​

Guidelines

This policy is consistent with Medicare's coverage criteria. The Company's payment methodology may differ from Medicare.

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable Evidence of Coverage, knee orthoses are covered as durable medical equipment under the medical benefits of the Company’s Medicare Advantage products when the medical necessity criteria listed in this policy are met.

Description

An orthosis, orthotic, or a splint is a rigid or semi-rigid device that is used to support a weak or deformed body part, or to restrict or eliminate motion in a diseased or injured part of the body.

The purpose of an orthosis is to improve physical function, slow disease progression, and diminish pain. A knee orthosis usually consists of a hinge at the knee, a supportive structure such as a rigid shell, and straps to secure the orthosis to the leg. A knee orthosis may contain a locking knee joint, an adjustable knee joint, a rigid knee, or an adjustable flexion and extension joint.

Knee orthoses are classified by the type of manufacturing process:
  • A prefabricated orthosis is manufactured in quantity without a specific individual in mind. A prefabricated orthosis may be trimmed, bent, molded (with or without heat), or otherwise modified (e.g., custom-fitted) for use by a specific individual. An orthosis that is assembled from prefabricated components is considered prefabricated. Any orthosis that does not meet the definition of a custom-fabricated orthosis is considered prefabricated.
  • A custom-fabricated orthosis is made for a specific individual. The process of making a custom-fabricated orthosis starts with basic materials, including, but not limited to: plastic, metal, leather, or cloth in the form of sheets, bars, etc. It entails substantial work, including cutting, bending, molding, and sewing, and it may also incorporate some prefabricated components. This process involves more effort than merely trimming, bending, or making other modifications to a substantially prefabricated item.
  • A molded-to-patient model orthosis is a custom-fabricated orthosis in which an impression of the specific body part is made (by means of a plaster cast, computer-aided design/computer-aided manufacturing [CAD-CAM] technology, or other technique). The impression is used to make a positive model of the body part, and then the orthosis is molded onto the model.
Knee orthoses are also categorized according to their intended use:
  • Functional knee orthoses stabilize the knee for activities of daily living or for participation in sports. A functional orthosis may be used to support an unstable knee and decrease the stress on an osteoarthritic joint. Knee instability, which is the partial or total disengagement of the articular surfaces, causes loss of single-leg stance. It may present as anterior knee pain, patellofemoral subluxation, or patellofemoral dislocation. Individuals may have repetitive episodes of the knee "giving way," locking, interfering with activities of daily living, or causing falls. Functional knee orthoses may also be used for knee contractures, a condition in which there is a shortening of the muscles or tendons, with a resultant decrease in the ability to either extend or flex the joint by passive range of motion. Functional orthoses may be prefabricated or custom-fabricated. The available peer-reviewed literature does not show any advantage of a custom-fabricated functional orthosis over a prefabricated orthosis for activities of daily living.
  • A derotational orthosis is a type of functional orthosis that supports damaged ligaments and is frequently used by individuals participating in sports after an injury.
  • Unloader knee orthoses "unload" some of the weight from the medial compartment of a painful osteoarthritic knee to reduce pain and help increase mobility by bracing the knee in the valgus position. An unloader orthosis is typically custom-fabricated.
  • Rehabilitation knee orthoses moderate joint motion in an injured knee and are typically used within 12 weeks post-injury or post-surgery. They employ locking knee hinges and are usually prefabricated.
  • Prophylactic knee orthoses are used on knees to prevent injuries such as medial collateral ligament tears. They can be either prefabricated or custom-fabricated.

References

Centers for Medicare & Medicaid Services (CMS). Department of Health and Human Services. Final Rule: Prosthetics, Orthotics and Supplies (DMEPOS) Fee Schedule Amounts, DMEPOS Competitive Bidding Program (CBP) Amendments, Standard Elements for a DMEPOS Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Order Prior to Delivery and/or Prior Authorization Requirements. Rules and Regulations. 11/08/2019. Available at: https://www.cms.gov/files/document/esrd-qip-final-rule-2019-24063.pdf-0. Accessed December 18, 2025.


Centers for Medicare & Medicaid Services (CMS). Federal Register. Medicare Program; Updates to Face-to-Face Encounter and Written Order Prior to Delivery List. Final Rule. [Federal Register Web site]. 08/12/2024. Available at: https://www.cms.gov/files/document/required-face-face-encounter-and-written-order-prior-delivery-list.pdf. Accessed December 18, 2025.


Centers for Medicare & Medicaid Services (CMS). Federal Register Vol. 89, No. 93. Medicare Program; Updates to the Master List of Items Potentially Subject to Face-to-Face Encounter and Written Order Prior To Delivery and/or Prior Authorization Requirements; Updates to the Required Face-to-Face and Written Order Prior To Delivery List; and Updates to the Required Prior Authorization List. [Federal Register Web site]. 05/13/2024. Available at: https://www.govinfo.gov/content/pkg/FR-2024-05-13/pdf/2024-10356.pdf. Accessed December 18, 2025.


Centers for Medicare & Medicaid Services (CMS). Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Order Requirements. 05/13/2024. Available at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment. Accessed December 18, 2025.

Noridian Healthcare Solutions. Local Coverage Determination (L33318). Knee Orthosis. [Noridian Healthcare Solutions Web site]. Original: 10/01/2015. (Revised: 01/01/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?LCDId=33318. Accessed December 18, 2025.


Noridian Healthcare Solutions. Local Coverage Article (A52465). Knee Orthosis. [Noridian Healthcare Solutions Web site]. Original: 10/01/2015. (Revised: 07/20/2025). Available at: https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleId=52465. Accessed December 18, 2025.​

Coding

CPT Procedure Code Number(s)
N/A
ICD - 10 Procedure Code Number(s)
N/A
ICD - 10 Diagnosis Code Number(s)
Report the most appropriate diagnosis code in support of medical necessity as listed in the policy.
HCPCS Level II Code Number(s)

MEDICALLY NECESSARY

K0672 Addition to lower extremity orthotic, removable soft interface, all components, replacement only, each

L1810 Knee orthosis (KO), elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1812 Knee orthosis (KO), elastic with joints, prefabricated, off-the-shelf

L1820 Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1821 Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, off the shelf

L1830 Knee orthosis (KO), immobilizer, canvas longitudinal, prefabricated, off-the-shelf

L1831 Knee orthosis (KO), locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment

L1832 Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1833 Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf

L1834 Knee orthosis (KO), without knee joint, rigid, custom fabricated

L1836 Knee orthosis (KO), rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf

L1840 Knee orthosis (KO), derotation, medial-lateral, anterior cruciate ligament, custom fabricated

L1843 Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1844 Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated

L1845 Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1846 Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated

L1850 Knee orthosis (KO), swedish type, prefabricated, off-the-shelf

L1851 Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

L1852 Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

L1860 Knee orthosis (KO), modification of supracondylar prosthetic socket, custom fabricated (SK)

L2275 Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

L2320 Addition to lower extremity, nonmolded lacer, for custom fabricated orthosis  only

L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis  only

L2385 Addition to lower extremity, straight knee joint, heavy-duty, each joint

L2390 Addition to lower extremity, offset knee joint, each joint

L2395 Addition to lower extremity, offset knee joint, heavy-duty, each joint

L2397 Addition to lower extremity orthosis , suspension sleeve

L2405 Addition to knee joint, drop lock, each

L2415 Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each joint

L2425 Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint

L2430 Addition to knee joint, ratchet lock for active and progressive knee extension, each joint

L2492 Addition to knee joint, lift loop for drop lock ring

L2750 Addition to lower extremity orthosis , plating chrome or nickel, per bar

L2755 Addition to lower extremity orthosis , high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only

L2780 Addition to lower extremity orthosis , noncorrosive finish, per bar

L2785 Addition to lower extremity orthosis , drop lock retainer, each

L2795 Addition to lower extremity orthosis , knee control, full kneecap

L2800 Addition to lower extremity orthosis , knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only

L2810 Addition to lower extremity orthosis , knee control, condylar pad

L2820 Addition to lower extremity orthosis , soft interface for molded plastic, below knee section

L2830 Addition to lower extremity orthosis , soft interface for molded plastic, above knee section

L4002 Replacement strap, any orthosis, includes all components, any length, any type

L4205 Repair of orthotic device, labor component, per 15 minutes

L4210 Repair of orthotic device, repair or replace minor parts

 

THE FOLLOWING CODE IS USED TO REPRESENT CONCENTRIC ADJUSTABLE TORSION-STYLE ORTHOTIC KNEE EXTENSION DEVICE

L2999 Lower extremity orthoses, not otherwise specified

 

NOT MEDICALLY NECESSARY

L1847 Knee orthosis (KO), double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1848 Knee orthosis (KO), double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf

 

NOT COVERED

A4467 Belt strap, sleeve, garment or covering, any type

 

THE FOLLOWING CODE IS USED TO REPRESENT AN UNDER-SLEEVE USED IN CONJUNCTION WITH ORTHOSES

L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code

Revenue Code Number(s)
N/A


​



Coding and Billing Requirements

Policy History

Revisions From MA05.013k:
​01/25/202​​6
​This version of the policy will be issued on  04/06/2026 with a retroactively effective date of 01/25/2026.

Criteria for the following Prefabricated Knee Orthoses have been revised to reflect revisions made by the Centers for Medicare and Medicaid Services.:
  •  immobilizer knee orthosis without joints 
  • ​knee orthosis with adjustable knee joints 
  • ​a knee orthosis with adjustable knee joints or a prefabricated Swedish type knee orthosis
  • a knee orthosis with single or double upright, adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment

Revisions From MA05.013j:

07/01/2025

This version of the policy will become effective on 07​/01/2025.

 

The following criterion has been added to this policy:

  • Knee orthosis for an individual that has knee instability.


Revisions From MA05.013i:

10/01/2024

​​This policy has been identified for the ICD CM code update, effective 10/01/2024.

The following ICD CM code narratives have been revised in this policy:
FROM: L1820 Knee orthosis (KO), elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment
TO:  L1820 Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise​

The following ICD CM code has been added to this policy:
  • L1821 Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, off the shelf​​​

Revisions From MA05.013h:

09/13/2024

​This version of the policy will become effective 09/13/2024.

 

In accordance with Medicare, Face-to-Face requirements have been removed per CMS Final Rule for the following HCPCS code:


  • L1833 Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf

In accordance with Medicare, Face-to-Face requirements have been added per CMS Final Rule for the following HCPCS code:


  • L1845 Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1852 Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

Revisions From MA05.013g:

04/08/2024

This version of the policy will become effective 04/08/2024.


In accordance with Medicare,  face-to-face requirement language has been added per CMS Final Rule for the following HCPCS codes:


  • L1832 Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise​
  • L1833 Knee orthosis (KO), adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf
  • ​L1851 Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf​
​
Revisions From MA05.013f:​
​01/01/2024
​Effective 01/01/2024 this policy applies to New Jersey Medicare Advantage (MA) lines of business.​
09/25/2023

The version of the policy will become effective on 09/25/2023.


Face-to-face requirement language and documentation requirements have been removed for HCPCS codes L1832, L1833, L1834, L1840, L1844, L1845, L1846, L1851, L1852 and L1860 in accordance with the 2023 CMS New Final Rule on Face-to-Face Encounters.​

​

Revisions From MA05.013e:
​04/06/2022

​This policy has been reissued in accordance with the Company's annual review process.​
08/02/2021

This version of the policy will become effective 08/02/2021​

The policy has been updated to communicate the Company's continuing position on Knee Orthoses.​​

"Not eligible for separate reimbursement" statement added. 

The following procedure codes have been added to the policy: base code L1830, addition code: L2397​​


Revisions From MA05.013d:

03/15/2021​​​

This version of the policy will become effective 03/15/2021. The intent of this policy remains unchanged; however, billing requirements have been incorporated to clarify reimbursement for repair and/or replacement of knee orthoses.

The following criteria have been added to this policy:

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 co-existing joint contracture.

REPAIR AND REPLACEMENT
Repair and replacement for knee orthoses are considered medically necessary and, therefore, covered when the criteria listed in this policy are met for the specific orthosis.

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/repair for an orthotic component that is coded with a specific Healthcare Common Procedure Coding System (HCPCS) code is included in the reimbursement for that component. The allowance for the labor (L4205) involved in the replacement/repair of 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.

In accordance with Medicare, Face-to-Face Requirement language has been added for HCPCS codes L1832, L1833, L1834, L1840, L1843, L1844, L1845, L1846, L1851, L1852, L1860 and documentation requirements per CMS New Final Rule.

The following HCPCS codes have been added to this policy:

L2999 Lower extremity orthoses, not otherwise specified

L4002 Replacement strap, any orthosis, includes all components, any length, any type

L4205 Repair of orthotic device, labor component, per 15 minutes

L4210 Repair of orthotic device, repair or replace minor parts ​

Revisions From MA05.013c:
05/07/2018The following policy changes are included in this policy update:
  • The title of the policy was revised from Knee Braces to Knee Orthoses.
  • Throughout the policy the term "brace(s)" was replaced with the term "orthosis" or "orthoses".
The Company’s coverage position has changed from Medically Necessary to Not Medically Necessary on the following codes:
  • L1847 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1848 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf

Revisions From MA05.013b:
01/01/2017This policy has been identified for the annual HCPCS code update effective 01/01/2017.

The following codes were added:
A4467 Belt, strap, sleeve, garment, or covering, any type

L1851 Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

L1852 Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

The following codes were termed and removed from the policy: A4466, K0901 & K0902

Revisions From MA05.013a:
07/31/2015This version of the policy will become effective 07/31/2015.

This policy has been reviewed and reissued to communicate the Company's continuing coverage of knee braces.

Various base and addition codes were added to the tables in the policy section that address prefabricated knee braces.

New language added for noncovered items. Code A9270 was replaced with L9900.

Revisions From MA05.013:
01/01/2015This is a new policy.

1/25/2026
4/6/2026
MA05.013
Medical Policy Bulletin
Medicare Advantage
No
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Independence Blue Cross is a subsidiary of Independence Health Group, Inc. — independent licensees of the Blue Cross and Blue Shield Association, serving the health insurance needs of Philadelphia and southeastern Pennsylvania.