Notification

Knee Orthoses


Notification Issue Date: 04/06/2018

This version of the policy will become effective 05/07/2018.

The 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 HCPCS 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



Medical Policy Bulletin


Title:Knee Orthoses

Policy #:05.00.47n



The Company makes decisions on coverage based on Policy Bulletins, benefit plan documents, and the member’s medical history and condition. Benefits may vary based on contract, and individual member benefits must be verified. The Company determines medical necessity only if the benefit exists and no contract exclusions are applicable.

When services can be administered in various settings, the Company reserves the right to reimburse only those services that are furnished in the most appropriate and cost-effective setting that is appropriate to the member’s medical needs and condition. This decision is based on the member’s current medical condition and any required monitoring or additional services that may coincide with the delivery of this service.

This Medical Policy Bulletin document describes the status of medical technology at the time the document was developed. Since that time, new technology may have emerged or new medical literature may have been published. This Medical Policy Bulletin will be reviewed regularly and be updated as scientific and medical literature becomes available. For more information on how Medical Policy Bulletins are developed, go to the About This Site section of this Medical Policy Web site.



Policy

Coverage is subject to the terms, conditions, and limitations of the member's contract. State mandates do not automatically apply to self-funded groups; therefore, individual group benefits must be verified.

MEDICALLY NECESSARY

PREFABRICATED KNEE ORTHOSES (L1810, L1812, L1820, 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), 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. (refer to the Description section for the definition).

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).

A knee immobolizer without joints (L1830) or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851 and L1852) are considered medically necessary and, therefore, covered when all of the following criteria are met:
  • The individual has sustained a recent diagnosed injury to, or a surgical procedure on, the knee.
  • The individual requires an orthoses with range-of-motion limitations.
  • The individual has one of the following diagnoses, such as, but not limited to:
    • Aseptic necrosis of the tibia or fibula
    • Cerebral Palsy
    • Chondromalacia patella
    • Congenital deformity of the knee
    • Cystic meniscus of the knee
    • Dislocation of the knee
    • Failed total knee arthroplasty
    • Felty's syndrome of the knee
    • Fracture of the femur, distal end
    • Fracture of the patella
    • Fracture of the tibia and/or fibula, proximal end
    • Hemiplegia, unspecified; dominant side; nondominant side
    • Knee ligamentous disruption
    • Late effect of fracture of lower extremities (i.e., late effect or residual effect caused directly by an earlier acute phase of a fracture of lower extremities, or caused indirectly by the treatment for an earlier fracture of lower extremities.)
    • Malunion of a fracture
    • Meniscal cartilage derangement
    • Multiple sclerosis
    • Nontraumatic rupture of the quadriceps tendon
    • Nontraumatic rupture of the patellar tendon
    • Nonunion of a fracture
    • Osteoarthritis
    • Osteonecrosis, due to drugs, of tibia/fibia
    • Paraplegia
    • Pathologic fracture of the femur, tibia, or fibula
    • Rheumatoid arthritis
    • Sprains and strains of the knee
    • Spontaneous rupture of extensor tendons, of lower leg
    • Stress fracture of the femur following an orthopedic implant, joint prosthesis, or bone plate of leg
    • Stress fracture of the tibia or fibula

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) and has either of the following indications:
  • Specified acquired deformities of the lower leg
  • Congenital deformity of the knee

For codes L1832, L1833, L1843, L1845, L1850, L1851, and L1852, 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).

CUSTOM-FABRICATED KNEE ORTHOSES (L1834, L1840, L1844, L1846, L1860)
A custom-fabricated knee orthosis (including molded-to-patient-model brace) 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, the size of the thigh and calf, deformity of the leg or knee, and 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 orthotic without joints (L1834) is considered medically necessary and, therefore, covered for an individual when the coverage criteria for a custom-fabricated orthosis is met, and the above-listed coverage criteria for the prefabricated knee brace (L1830) are also met.

A custom-fabricated derotation knee brace (L1840) for instability due to internal ligamentous disruption of the knee is considered medically necessary and, therefore, covered for an individual with one of the following conditions:
  • 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 the above-listed coverage criteria for a custom-fabricated orthosis is met, and the above-listed criteria for the prefabricated knee orthoses codes are 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 is met, and has 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.

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.

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.

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.

A knee orthosis with an inflatable air bladder incorporated into the design (L1847 and 1848) is considered not medically necessary and, therefore, not covered, because the available published peer-reviewed literature does not support its use in the diagnosis or treatment of illness or injury.

NONCOVERED

A garment, belt, sleeve or other covering, elastic or similar stretchable material (e.g., A4467) are not covered by the Company, because they are not rigid or semi-rigid devices. Therefore, they are not eligible for reimbursement consideration.

An under-sleeve used in conjunction with an orthosis (L9900) is 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.

ADDITION CODES

PREFABRICATED KNEE ORTHOSES
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 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
L1810 There are no addition codes that are eligible for separate payment
L1812There are no addition codes that are eligible for separate payment
L1820 There are no addition codes that are eligible for separate payment
L1830 There are no addition codes that are eligible for separate payment
L1831 There are no addition codes that are eligible for separate payment
L1832 L2397, L2795, L2810
L1833L2397, L2795, L2810
L1836 There are no addition codes that are eligible for separate payment
L1843 L2385, L2395, L2397
L1845 L2385, L2395, L2397, L2795
L1847 There are no addition codes that are eligible for separate payment
L1848There are no addition codes that are eligible for separate payment
L1850 L2397
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
L1810 L2397
L1812L2397
L1820 L2397
L1830 L2397
L1831 L2397, L2795
L1832 L2405, L2415, L2492, L2785
L1833L2405, L2415, L2492, L2785
L1836 L2397
L1843 L2405, L2492, L2785
L1845 L2405, L2415, L2492, L2785
L1847 L2397, L2795
L1848L2397, L2795
L1850 L2275
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
L1810 L2390, L2750, L2780,L4002
L1812L2390, L2750, L2780, L4002
L1820 L2390, L2750, L2780, L2810, L4002
L1830 K0672, L4002
L1831 K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002
L1832 K0672, L2390, L2425, L2430, L2750, L2780, L2820, L2830, L4002
L1833K0672, L2390, L2425, L2430, L2750, L2780, L2820, L2830, L4002
L1836 K0672, L2750, L2780, L2810, L2820, L2830,L4002
L1843 K0672, L2275, L2390, L2425,L2430, L2750, L2780, L2810, L2820, L2830, L4002
L1845 K0672, L2275, L2390, L2425,L2430, L2750, L2780, L2810, L2820, L2830,L4002
L1847 K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830,L4002
L1848K0672, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830,L4002
L1850 K0672, L2750, L2780, L2810, L2820, L2830, L4002
L1851K0672, L2275, L2390, L2425, L2430, L2750, L2780, L2810, L2820, L2830, L4002
L1852K0672, 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.
Base Code
Addition Codes - Eligible for Separate Payment
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 There 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
L1834 L2397, L2800
L1840 L2275, L2800
L1844 No additional components/accessories can be billed with L1844.
L1846 No additional components/accessories can be billed with L1846.
L1860 L2397

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

REQUIRED DOCUMENTATION

The need for a custom-fabricated knee orthosis 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. This policy is consistent with Medicare's documentation requirements, including the following required documentation:

PRESCRIPTION (ORDER) REQUIREMENTS
Before submitting a claim to the Company, the supplier must have on file a timely, appropriate, and complete 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 order at the time of an audit or after an audit for submission as an original order, reorder, or updated order will not satisfy the requirement to maintain a timely professional provider order on file.

PROOF OF DELIVERY
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
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 seven 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 five days before the individual would exhaust their on-hand supply.

If required documentation is not available on file to support a claim at the time of an audit or record request, the durable medical equipment (DME) supplier may be required to reimburse the Company for overpayments.

MANDATES

In accordance with the State of New Jersey's orthotic and prosthetic appliances mandate, members who are enrolled in New Jersey commercial products may obtain a knee orthotic from any licensed orthotist or prosthetist or certified pedorthotist. The professional provider must determine that the knee orthotic is medically necessary for the individual.
Guidelines

KNEE ORTHOSES/BRACES

Prefabricated functional knee orthoses include, but are not limited to, the following device trade names:
  • Bledsoe Force 1, Force 2, Force 3
  • Bledsoe Pro Shifter ACL, Proshifter Contact
  • Comfy Lite Knee
  • Comfy Spring-loaded Goniometer Knee
  • Comfy Standard Knee
  • Comfy TorqKnee
  • Deroyal Three-D
  • DonJoy Gold Point
  • DonJoy Legend
  • DonJoy Monarch
  • DonJoy 4-Point Supersport
  • Innovation OAsys
  • Medical Designs Lorus
  • Omni Scientific Spectrum, OS-5
  • Orthomedics Ecko II
  • Orthotech Contender, Controller
  • Spademan ACL Sport
  • Townsend Off-shelf
  • Vixie Enterprise MKS2 OTS
  • Zinco Lehrman Multilig, MSO

Custom-fabricated functional knee orthoses include, but are not limited to, the following device trade names:
  • DonJoy CE 2000, Defiance, Monarch
  • Generation II GII Sports Brace
  • Innovation Sports CTi2 OA Custom
  • Innovation Sports CTi Pro Sport
  • Innovation Sports CTi Standard
  • Lennox Hill Regular, Light, Spectralite
  • MedTechna Can Am
  • Omni Scientific Elite, TS-7
  • Orthotech Oti Performer
  • Spademan Custom
  • Sutter Talon
  • Townsend Design Air Custom, Original
  • Vixie Enterprise MKS2 Custom, MKS2 PCL
  • Zimmer Sports Caster I, Sports Caster II

Unloader knee orthoses include, but are not limited to, the following device trade names:
  • DonJoy Monarch
  • Generation II FX™
  • Generation II Unloader XT
  • Orthotech Montana

Rehabilitation knee orthoses include, but are not limited to, the following device trade names:
  • Bledsoe Extender
  • Breg Post-Op Lite Knee Brace
  • Breg Post-Op Rehab Knee Brace
  • Breg Quick Fit
  • Core International 3-Panel Knee Immobilizer
  • DonJoy Telescoping Cool TROM
  • DonJoy Telescoping IROM
  • DonJoy Telescoping TROM
  • Generation II E Splint
  • Generation II Rehab Contour Air Light
  • Generation II Rehab Short
  • Generation II Universal Air Light
  • Mueller Pro-Level
  • Orthomerica Polaris™
  • Orthomerica Universal Laser-Lock™
  • Royce Medical Universal 3-Panel Knee Immobilizer

BENEFIT APPLICATION

Subject to the terms and conditions of the applicable benefit contract, knee orthoses are covered as durable medical equipment under the medical benefits of most of the Company’s products when the medical necessity criteria in this medical policy are met.

Coverage and reimbursement for the repair and/or replacement of orthotic devices vary by product and/or group contract. Therefore, individual member benefits must be verified.

MANDATES

This policy is consistent with applicable state mandates. The laws of the state where the benefit contract is issued determine the mandated coverage.
  • The State of New Jersey mandates coverage of orthotics for individuals enrolled in New Jersey commercial products when such items are determined to be medically necessary by the individual's professional healthcare provider. This mandate is effective for all newly issued contracts and contracts renewed on or after April 11, 2008.

US FOOD AND DRUG ADMINISTRATION (FDA) STATUS

The FDA has approved several types of knee orthoses.

Description

An orthosis, an 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 brace to the leg. Knee orthoses 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 brace 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 custom-fabricated functional orthoses over prefabricated orthoses for activities of daily living. A derotational brace is a type of functional brace that supports damaged ligaments and is frequently used by individuals participating in sports after an injury.
  • Unloader knee orthosis "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


Brouwer RW, Jakma TS, et al. Braces and orthosis for treating osteoarthritis of the knee. Cochrane Database Syst Rev.2005;(1):CD004020.

Brouwer RW, van Raaij TM, Verhaar JA, et al. Brace treatment for osteoarthritis of the knee: a prospective randomized multi-centre trial. Osteoarthritis Cartilage.2006;14(8):777-83.

Martin TJ, Committee on Sports Medicine and Fitness. American Academy of Pediatrics: Technical report: Knee brace use in the young athlete. Pediatrics. 2001;108(2):503-7. Reaffirmed April 2010. Available at: http://pediatrics.aappublications.org/content/108/2/503.full.pdf+html?sid=0e9bc025-fd59-4347-87e4-008750c12838. Accessed January 10, 2018.

Noridian Healthcare Solutions, LLC. Local Coverage Determination (LCD). L33318: Knee Orthoses. [Noridan website]. 01/01/2017. Available at:
https://med.noridianmedicare.com/documents/2230703/7218263/Knee+Orthoses/fd6a6496-2857-4b1b-b6d3-4d6830105a10. Accessed January 10, 2018.

Noridian. Noncovered items. [Noridian Web site]. Revised: April 26, 2017. Available at: https://med.noridianmedicare.com/web/jadme/topics/noncovered-items. Accessed January 10, 2018.

New Jersey Mandate, P.L. 2007, c. 345 - Health Benefits Coverage for Orthotic and Prosthetic Appliances. Available at: http://www.state.nj.us/dobi/bulletins/blt08_10.pdf. Accessed January 10, 2018.




Coding

Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.

The Coding Table lists any CPT, ICD-9, ICD-10, and HCPCS billing codes related only to the specific policy in which they appear.

CPT Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


ICD - 10 Procedure Code Number(s)

N/A


Professional and outpatient claims with a date of service on or before September 30, 2015, must be billed using ICD-9 codes. Professional and outpatient claims with a date of service on or after October 1, 2015, must be billed using ICD-10 codes.

Facility/Institutional inpatient claims with a date of discharge on or before September 30, 2015, must be billed with ICD-9 codes. Facility/Institutional inpatient claims with a date of discharge on or after October 1, 2015, must be billed with ICD-10 codes.


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

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

L1820 Knee orthotic (KO), elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment

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

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

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

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

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

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

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

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

L1844 Knee orthotic (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, 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 orthotic, 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, 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 orthotic (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 orthotic only

L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthotic 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 orthotic, 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 orthotic, plating chrome or nickel, per bar

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

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

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

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

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

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

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

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


NOT MEDICALLY NECESSARY

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


NONCOVERED

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


Cross References


Policy History

Revisions from 05.00.47n
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 HCPCS 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


Effective 10/05/2017 this policy has been updated to the new policy template format.

Version Effective Date: 05/07/2018
Version Issued Date: 05/07/2018
Version Reissued Date: N/A



2017 AmeriHealth.