Commercial
Advanced Search

Policy Attachment

05.00.39v
A
05.00.39v
HCPCS Codes
Ankle-Foot/Knee-Ankle-Foot Orthoses

MEDICALLY NECESSARY

THE FOLLOWING CODES ARE USED TO REPRESENT AFOs AND KAFOs FOR AMBULATORY INDIVIDUALS:

L1900Ankle-foot  orthosis (AFO), spring wire, dorsiflexion assist calf band, custom fabricated
L1902Ankle orthosis (AO), ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf
L1904Ankle orthosis (AO) , ankle gauntlet or similar, with or without joints, custom fabricated
L1906Ankle foot orthosis (AO) , multiligamentus ankle support, prefabricated, off-the-shelf
L1907Ankle orthosis (AFO) , supramalleolar with straps, with or without interface/pads, custom fabricated
L1910Ankle-foot orthosis(AFO), posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment
L1920Ankle-foot orthosis (AFO), single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated
L1930Ankle-foot orthosis (AFO), plastic or other material, prefabricated, includes fitting and adjustment
L1932

L1933​		Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
Ankle foot orthosis, rigic anterior tibial section, total carbon fiber or equal material, prefabricated, off-the-shelf
L1940Ankle-foot orthosis (AFO), plastic or other material, custom fabricated
L1945Ankle-foot orthosis (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated
L1950Ankle-foot orthosis (AFO), spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated
L1951

L1952		Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
Ankle foot orthosis, spiral (institute or rehabilitative medicine type), plastic or other material, prefabricated, off-the-shelf
L1960Ankle-foot orthosis (AFO), posterior solid ankle, plastic, custom fabricated
L1970Ankle-foot orthosis (AFO), plastic with ankle joint, custom fabricated
L1971Ankle foot orthosis, plastic or other material with ankle joint, with or without dorsiflexion assist, prefabricated, includes fitting and adjustment
L1980Ankle-foot orthosis (AFO), single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'BK' orthosis), custom fabricated
L1990Ankle-foot orthosis (AFO), double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'BK' orthosis), custom fabricated
L2000Knee-ankle-foot orthosis (KAFO), single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'AK' orthosis), custom fabricated
L2005Knee-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
L2010Knee-ankle-foot orthosis (KAFO), single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'AK' orthosis), without knee joint, custom fabricated
L2020Knee-ankle-foot orthosis (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'AK' orthosis), custom fabricated
L2030Knee-ankle-foot orthosis (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'AK' orthosis), without knee joint, custom fabricated
L2034Knee-ankle-foot orthosis (KAFO), full plastic, single upright, with or without free motion knee, medial-lateral rotation control, with or without free motion ankle, custom fabricated
L2035Knee-ankle-foot orthosis (KAFO), full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment
L2036Knee-ankle-foot orthosis (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated
L2037Knee-ankle-foot orthosis (KAFO), full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated
L2038Knee-ankle-foot orthosis (KAFO), full plastic, with or without free motion knee, multi-axis ankle, custom fabricated
L2106Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated
L2108Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture cast orthosis, custom fabricated
L2112Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment
L2114Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment
L2116Ankle-foot orthosis (AFO), fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment
L2126Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated
L2128Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, custom fabricated
L2132Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment
L2134Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment
L2136Knee-ankle-foot orthosis (KAFO), fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment
L3161Foot, adductus positioning device, adjustable
L4350Ankle control orthosis (AFO) , stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf
L4360Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L4361Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf
L4370Pneumatic full leg splint, prefabricated, off-the-shelf
L4386Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L4387Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf
L4631Ankle-foot orthosis (AFO) , walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated

THE FOLLOWING CODES ARE USED TO REPRESENT ADDITIONS TO AFOs OR KAFOs:

L2180Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints
L2182Addition to lower extremity fracture orthosis, drop lock knee joint
L2184Addition to lower extremity fracture orthosis, limited motion knee joint
L2186Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type
L2188Addition to lower extremity fracture orthosis, quadrilateral brim
L2190Addition to lower extremity fracture orthosis, waist belt
L2192Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt
L2200Addition to lower extremity, limited ankle motion, each joint
L2210Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
L2220Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
L2230Addition to lower extremity, split flat caliper stirrups and plate attachment
L2232Addition to lower extremity orthosis, rocker bottom for total contact ankle-foot orthosis (AFO), for custom fabricated orthosis only
L2240Addition to lower extremity, round caliper and plate attachment
L2250Addition to lower extremity, foot plate, molded to patient model, stirrup attachment
L2260Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)
L2265Addition to lower extremity, long tongue stirrup
L2270Addition to lower extremity, varus/valgus correction ('T') strap, padded/lined or malleolus pad
L2275Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
L2280Addition to lower extremity, molded inner boot
L2300Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
L2310Addition to lower extremity, abduction bar, straight
L2320Addition to lower extremity, nonmolded lacer, for custom fabricated orthosis only
L2330Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
L2335Addition to lower extremity, anterior swing band
L2340Addition to lower extremity, pretibial shell, molded to patient model
L2350Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses)
L2360Addition to lower extremity, extended steel shank
L2370Addition to lower extremity, Patten bottom
L2375Addition to lower extremity, torsion control, ankle joint and half solid stirrup
L2380Addition to lower extremity, torsion control, straight knee joint, each joint
L2385Addition to lower extremity, straight knee joint, heavy-duty, each joint
L2387Addition to lower extremity, polycentric knee joint, for custom fabricated knee-ankle-foot orthosis (KAFO), each joint
L2390Addition to lower extremity, offset knee joint, each joint
L2395Addition to lower extremity, offset knee joint, heavy-duty, each joint
L2397Addition to lower extremity orthosis, suspension sleeve
L2405Addition to knee joint, drop lock, each
L2415Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each joint
L2425Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint
L2430Addition to knee joint, ratchet lock for active and progressive knee extension, each joint
L2492Addition to knee joint, lift loop for drop lock ring
L2500Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring
L2510Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model
L2520Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted
L2525Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model
L2526Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted
L2530Addition to lower extremity, thigh/weight bearing, lacer, nonmolded
L2540Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model
L2550Addition to lower extremity, thigh/weight bearing, high roll cuff
L2750Addition to lower extremity orthosis, plating chrome or nickel, per bar
L2755Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis  only
L2760Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth)
L2768Orthotic side bar disconnect device, per bar
L2780Addition to lower extremity orthosis, noncorrosive finish, per bar
L2785Addition to lower extremity orthosis, drop lock retainer, each
L2795Addition to lower extremity orthosis, knee control, full kneecap
L2800Addition to lower extremity orthosis , knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only
L2810Addition to lower extremity orthosis, knee control, condylar pad
L2820Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
L2830Addition to lower extremity orthosis, soft interface for molded plastic, above knee section
L2861Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each

THE FOLLOWING CODES ARE USED TO REPRESENT REPAIRS OR REPLACEMENTS OF SHOES OR SHOES THAT ARE AN INTEGRAL PART OF AN EXISTING AFO OR KAFO:

L3224 Orthopedic footwear, woman's shoe, Oxford, used as an integral part of a brace (orthosis)
L3225 Orthopedic footwear, man's shoe, Oxford, used as an integral part of a brace (orthosis)

THE FOLLOWING CODE IS USED TO REPRESENT SHOES THAT ARE AN INTEGRAL PART OF A COVERED BRACE:

L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified

THE FOLLOWING CODES ARE USED TO REPRESENT STATIC AFO FOR NONAMBULATORY (OR MINIMALLY AMBULATORY) INDIVIDUALS:

L4396 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
L4397 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf

THE FOLLOWING CODES ARE USED TO REPRESENT AFOs/ KAFOs USED FOR NIGHT SPLINTING IN CHILDREN WITH NEUROMUSCULAR DISORDERS/ ORTHOTIC MANAGEMENT AT REST SPLINTING:

L1960Ankle-foot orthosis (AFO), posterior solid ankle, plastic, custom fabricated
L1970Ankle-foot orthosis  (AFO), plastic with ankle joint, custom fabricated
L2035Knee-ankle-foot orthosis (KAFO), full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment

THE FOLLOWING CODE IS USED TO REPRESENT CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISMS TO ASSIST KNEE JOINT EXTENSION AND/OR ANKLE JOINT PLANTARFLEXION OR DORSIFLEXION:

L2999 Lower extremity orthosis, not otherwise specified​

THE FOLLOWING CODES ARE USED TO REPRESENT ALL OTHER REPAIRS OR REPLACEMENTS:

L4002Replacement strap, any orthosis, includes all components, any length, any type
L4010Replace trilateral socket brim
L4020Replace quadrilateral socket brim, molded to patient model
L4030Replace quadrilateral socket brim, custom fitted
L4040Replace molded thigh lacer, for custom fabricated orthosis only
L4045Replace nonmolded thigh lacer, for custom fabricated orthosis only
L4050Replace molded calf lacer, for custom fabricated orthosis only
L4055Replace nonmolded calf lacer, for custom fabricated orthosis only
L4060Replace high roll cuff
L4070Replace proximal and distal upright for KAFO
L4080Replace metal bands KAFO, proximal thigh
L4090Replace metal bands KAFO-AFO, calf or distal thigh
L4100Replace leather cuff KAFO, proximal thigh
L4110Replace leather cuff KAFO-AFO, calf or distal thigh
L4130Replace pretibial shell
L4205Repair of orthotic device, labor component, per 15 minutes
L4210Repair of orthotic device, repair or replace minor parts
L4392Replacement, soft interface material, static AFO

NOT MEDICALLY NECESSARY

L4394Replace soft interface material, foot drop splint
L4398Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf

NOT COVERED

A4467Belt, strap, sleeve, garment, or covering, any type
A9285Inversion/eversion correction device
L2840Addition to lower extremity orthosis, tibial length sock, fracture or equal, each
L2850Addition to lower extremity orthosis, femoral length sock, fracture or equal, each ​

4/8/2024
4/8/2024
10/1/2025
Medical Policy Bulletin
Commercial
966bd452-6338-41a9-92af-732491b02dc4
Yes