CAM 147

Knee Braces, Orthopaedic Casts, Splints

Category:Durable Medical Equipment   Last Reviewed:January 2021
Department(s):Medical Affairs   Next Review:January 2022
Original Date:November 1997    

Description:
A brace is an orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body and that allows for motion of that part.  It must be a rigid or semi-rigid device, used for the purpose of supporting a weak or deformed part or of restricting or eliminating motion in a diseased or injured part of the body.  It must provide support and counterforce on the limb for which it is being used.

Knee braces typically consist of three components: a superstructure (usually a rigid shell), a hinge and a strap system. The superstructure extends proximally and distally to a hinge centered around the knee axis of motion. The strapping system secures the brace to the limb. Knee braces can be subdivided into 4 categories that are based on their intended use:

  1. Prophylactic braces are those that attempt to prevent or reduce the severity of knee ligament injuries. These braces are primarily designed to prevent injuries to the medial collateral ligament, which is among the most common athletic knee injuries.
  2. Rehabilitation braces are designed to allow protected motion of injured knees that have been treated operatively or non-operatively. These braces allow for controlled joint motion and typically consist of hinges that can be locked into place to limit range of motion. Rehabilitation braces are commonly used for 6 to 12 weeks after injury. Rehabilitation braces are usually purchased off-the-shelf and are not custom-made.
  3. Functional braces are designed to assist or provide stability for unstable knees during activities of daily living or sports and may be either off-the-shelf or custom-made. De-rotation braces are typically used after injuries to ligaments and have medial and lateral bars with varying hinge and strap designs. These de-rotation braces are designed to permit significant motion and speed; in many instances, the braces are worn only during elective activities, such as sports. Braces made of graphite, titanium or other lightweight materials are specifically designed for high-performance sports. Functional knee braces have also been used in patients with osteoarthritis to decrease the weight on painful joints.
  4. Unloader knee braces are specifically designed to reduce the pain and disability associated with osteoarthritis of the medial compartment of the knee by bracing the knee in the valgus position to unload the compressive forces on the medial compartment.

Knee braces may be off-the-shelf (prefabricated) or custom-made. 

Policy:
Knee braces are considered MEDICALLY NECESSARY when the following medical criteria are met:

  • Recent (within 6 weeks prior to brace application) surgical intervention or injury to the ligaments of the knee, requiring range of motion limitations OR
  • Member is ambulatory and has instability due to ligament insufficiency/deficiency or reconstruction.  

Prefabricated rigid knee orthosis without joints and knee orthosis with joints that lock a knee into a particular position are considered MEDICALLY NECESSARY for persons with non-fixed flexion contractures of the knee.

A prefabricated knee orthosis locking joints and inflatable air support chambers is considered NOT MEDICALLY NECESSARY because there is no proven clinical benefit to the inflatable air bladder incorporated into the design of this knee orthosis.

Examples of prefabricated knees braces include: knee immobilizer, knee orthosis with double uprights and adjustable flexion and extension joints, knee orthosis with double uprights, adjustable flexion and extension joint, and medial-lateral and rotational control and knee orthosis with double uprights and thigh and calf pads (Swedish-type knee orthosis).

Custom-made functional braces (also known as "custom-fabricated" or "molded" knee orthosis) are considered MEDICALLY NECESSARY if the member meets the criteria for a knee brace listed above but is unable to be fitted with a prefabricated (off-the-shelf) knee brace.  Examples that may meet criteria for a custom-made knee brace include, but are not limited to:

  • Deformity of the knee or leg that interferes with fitting
  • Disproportionate size of thigh or calf
  • Minimal muscle mass on which to suspend an orthosis.

Custom fabricated orthosis are NOT CONSIDERED MEDICALLY NECESSARY for treatment of knee contractures.

Knee orthoses with varus or valgus adjustment are considered MEDICALLY NECESSARY for ambulatory persons with the following:

  • Moderate to severe unicompartmental osteoarthritis or
  • Meniscal cartilage derangement or
  • Knee ligamentous disruption or
  • Failed total knee arthroplasty or
  • Aseptic necrosis of the tibia/fibula or
  • Tibial plateau fracture.

Prophylactic braces:  Designed to reduce the likelihood or severity of knee ligament injuries in a relatively stable knee.  These knee braces are generally indicated for the protection of the medial-collateral ligament against valgus knee stresses and ACL protection from rotational stress in similar situations.  Examples of these braces are DonJoy Protective Knee Guard (dj Orthopedics, Inc.) and McDavid Protective Knee Guard (McDavid Sport Medical Products, Woodridge, Il).  Both The American Academy of Orthopedic Surgeons (AAOA) and the American Academy of Pediatrics (AAP) indicate that there is insufficient evidence to provide strong conclusions that the use of prophylactic knee braces significantly decreases/reduces knee injuries.  Prophylactic knee braces are NOT CONSIDERED MEDICALLY NECESSARY for the treatment of disease or injury.

Functional and Rehabilitation Braces:  NOT MEDICALLY NECESSARY EXCEPT for those listed below - custom vs. prefabricated or off-the-shelf:

  • Deformity of the knee or leg that interferes with fitting
  • Disproportionate size of thigh or calf
  • Minimal muscle mass on which to suspend an orthosis.           

Exceptionally tall or short stature or obesity does not, by itself, establish MEDICAL NECESSITY for custom-made functional knee braces.  Tall persons can typically be fitted with a prefabricated brace with extensions, short persons can be typically fitted with a pediatric prefabricated brace and obese persons can be typically fitted with a prefabricated knee brace with extra-large straps.

Unloader Braces (Osteoarthritis braces):  MEDICALLY NECESSARY as an alternative to surgery for those members with severe (Grade 4) symptomatic osteoarthritis of the knee who have pain that has failed to respond to medical therapy and knee bracing with a neoprene sleeve, who have progressive limitations in their ADLs and who do NOT have ANY of the following:

  • Arthritis other than Grade 4 osteoarthritis
  • A recent knee operation (within the previous 6 weeks)
  • Symptomatic disease of the hip, ankle or foot
  • Diseases that would preclude the use of a brace (e.g. skin disease, peripheral vascular disease, varicose veins, etc.)
  • Severe cardiovascular deficit
  • Paresis or other diseases that would preclude ambulation
  • Inability to apply the brace (e.g., physical limitations such as arthritis in the hands or ability or inability to bend)

Cast braces (fracture braces):
Non-therapeutic cast braces are CONSIDERED MEDICALLY NECESSARY after a fracture or surgery. Typically utilized after the patient has been in a walking cast.  Usually removable, allowing patient the ability to bathe the affected extremity. May also be used when a fracture is slow to heal or non-healing. Usage of a removable cast replaces monthly cast changes.


Functional cast braces are CONSIDERED MEDICALLY NECESSARY after a fracture or surgery.  It is typically used following a short period of standard fracture treatment using a non-weight bearing or partial weight-bearing cast or immediately following surgery. These casts have become the standard brace for certain fractures, including tibial-femoral fractures.

Cervical (Neck) Braces:
MEDICALLY NECESSARY for neck injury or other appropriate indications. Cervical foam neck collars are not considered DME as they are not durable and not made to withstand prolonged use.

Childhood Hip Braces:
MEDICALLY NECESSARY
for children with hip disorders to stabilize the hip and/or to correct and maintain hip abduction. Typically, these are specialized and are considered integral to the management of the hip disorder.


Braces for Congenital Defects:
Orthopedic braces are considered MEDICALLY NECESSARY in the treatment of congenital defects. Replacement braces are also considered MEDICALLY NECESSARY when the member has outgrown the previous brace or because his/her condition has changed such that the previous brace is not usable.

Wheaton Brace:
MEDICALLY NECESSARY
to treat metatarsus adductus in infants, replacing the need for serial casting.


Splints and Immobiliziers:
Dynamic Splinting devices

Includes, but not limited to: Dynasplint Systems, LMB Proglide, EMPI Advance, Ultraflex and Advance Bio Mechanics. Dynamic splinting is considered MEDICALLY NECESSARY for the use of the knee, elbow and wrist in ANY of the following clinical settings:

In the sub-acute injury or postoperative period (> 3 weeks but < 4 months after injury or operation) in  patients with signs/symptoms of persistent joint stiffness despite maximum physical therapy efforts.

In the acute postoperative period for patient who is undergoing additional surgery to improve the range of motion of a previously affected joint.

For patients who are unable to benefit from standard physical therapy modalities due to an inability to exercise.

**No significant change after 4 months is prophylactic use in contractures and is NOT MEDICALLY NECESSARY**.

Dynamic splinting is considered NOT MEDICALLY NECESSARY/INVESTIGATIONAL, as there is lack of scientific evidence demonstrating effectiveness, for the following:

  • Use in the management of chronic joint stiffness and/or chronic or fixed contractures
  • Use in shoulders, fingers, toes or any other condition not listed above
  • Bi-directional static progressive stretch splinting (including, but not limited to, Joint Active Systems (JAS splints) and Air Cast)

Certain orthopedic problems are routinely treated with splint and splint-like devices. The following are considered to be MEDICALLY NECESSARY:

  • Clavicle splint (figure 8 splint)
  • Acromio-clavicular splint

Unna Boots:
MEDICALLY NECESSARY only for non-fracture care. They can be utilized to treat the following:

  • Treat sprains and torn ligaments
  • Provide protection for other soft tissue injuries
  • May be used after certain surgical procedures as a protective cover to promote healing

Unna boots are NOT CONSIDERED MEDICALLY NECESSARY when used in conjunction with fracture treatment.

Air Casts:
MEDICALLY NECESSARY for treatment of fractures or other injuries (i.e., sprains, torn ligaments). They may be used as an alternative to plaster casts to immobilize an elbow, ankle or knee.

Each benefit plan defines which services are covered or non-covered, which are subject to monetary dollar caps or other limitations.  Please see specific benefit contract guidelines for determination of exclusion, limitations, etc.

References:

  1. van Rhijn LW, Plasmans CM, Veraart BE. Changes in curve pattern after brace treatment for idiopathic scoliosis. Acta Orthop Scand. 2002;73(3):277-281.
  2. Gepstein R, Leitner Y, Zohar E, et al. Effectiveness of the Charleston bending brace in the treatment of single-curve idiopathic scoliosis. J Pediatr Orthop. 2002;22(1):84-87.
  3. South Carolina Medicare; CMS: Centers for Medicare and Medicaid Services. DMERC. Local Coverage Determination. Accessed December 2005.
  4. OrthoRehab. Protonics for patellofemoral pain.  Accessed December 2005.

Coding Section

Codes Number Description
HCPCS  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 orthosis, 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 orthosis, 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 orthosis, without knee joint, rigid, custom fabricated 
  L1836  Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf 
  L1840  Knee orthosis, 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 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, 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 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, custom fabricated 
  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 
  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 orthosis, modification of supracondylar prosthetic socket, custom fabricated (sk) 
  L1900  Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom-fabricated
  L1902 Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf
  L1904 Ankle orthosis, ankle gauntlet or similiar, with or without joints, custom fabricated
  L1906 Ankle foot orthosis, multiligamentus ankle support, prefabricated, off-the-shelf 
  L1907 Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated 
  L1910 Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment 
  L1920 Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated 
  L1930 Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment 
  L1932 Afo, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment 
  L1940 Ankle foot orthosis, plastic or other material, custom fabricated 
  L1945 Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated 
  L1950 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated 
  L1951 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment 
  L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated 
  L1970 Ankle foot orthosis, plastic with ankle joint, custom fabricated 
  L1971 Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment 
  L1980 Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'bk' orthosis), custom fabricated 
  L1990 Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'bk' orthosis), custom fabricated 
  L2106  Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated 
  L2108 Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, custom fabricated 
  L2112 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment 
  L2114  Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment 
  L2116  Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment 
  L4350  Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf 
  L4360  Walking 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 
  L4370 Pneumatic full leg splint, prefabricated, off-the-shelf
  L4386  Walking 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 
  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 
  L4398  Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf 
  L2000  Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), custom fabricated 
  L2005  Knee ankle foot orthosis, any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated 
  L2010  Knee ankle foot orthosis, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), without knee joint, custom fabricated 
  L2020  Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'ak' orthosis), custom fabricated 
  L2030  Knee ankle foot orthosis, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'ak' orthosis), without knee joint, custom fabricated 
  L2034  Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free motion ankle, custom fabricated 
  L2035  Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment 
  L2036  Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated 
  L2037  Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated 
  L2126  Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated 
  L2128  Knee ankle foot orthosis, fracture orthosis, femoral fracture cast orthosis, custom fabricated 
  L2132  Knee ankle foot orthosis (Kafo), fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment 
  L2134  Knee ankle foot orthosis (Kafo), fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment 
  L2136  Knee ankle foot orthosis (Kafo), fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment 
  L2180  Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints 
  L2182  Addition to lower extremity fracture orthosis, drop lock knee joint 
  L2184  Addition to lower extremity fracture orthosis, limited motion knee joint 
  L2186  Addition to lower extremity fracture orthosis, adjustable motion knee joint, lerman type 
  L2188  Addition to lower extremity fracture orthosis, quadrilateral brim 
  L2190  Addition to lower extremity fracture orthosis, waist belt 
  L2192  Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt 
  L2200  Addition to lower extremity, limited ankle motion, each joint 
  L2210 Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint 
  L2220  Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint 
  L2230  Addition to lower extremity, split flat caliper stirrups and plate attachment
  L2232  Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only
  L2240  Addition to lower extremity, round caliper and plate attachment 
  L2250  Addition to lower extremity, foot plate, molded to patient model, stirrup attachment 
  L2260  Addition to lower extremity, reinforced solid stirrup (scott-craig type) 
  L2265  Addition to lower extremity, long tongue stirrup 
  L2270  Addition to lower extremity, varus/valgus correction ('t') strap, padded/lined or malleolus pad 
  L2275  Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined 
  L2280  Addition to lower extremity, molded inner boot 
  L2300  Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable 
  L2310  Addition to lower extremity, abduction bar-straight 
  L2320  Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only 
  L2330  Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only 
  L2335  Addition to lower extremity, anterior swing band 
  L2340  Addition to lower extremity, pre-tibial shell, molded to patient model 
  L2350  Addition to lower extremity, prosthetic type, (bk) socket, molded to patient model, (used for 'ptb' 'afo' orthoses) 
  L2360  Addition to lower extremity, extended steel shank 
  L2370  Addition to lower extremity, patten bottom 
  L2375  Addition to lower extremity, torsion control, ankle joint and half solid stirrup 
  L2380  Addition to lower extremity, torsion control, straight knee joint, each joint 
  L2385  Addition to lower extremity, straight knee joint, heavy duty, each joint 
  L2387  Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, 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 
  L2500  Addition to lower extremity, thigh/weight bearing, gluteal/ ischial weight bearing, ring 
  L2510  Addition to lower extremity, thigh/weight bearing, quadri- lateral brim, molded to patient model 
  L2520  Addition to lower extremity, thigh/weight bearing, quadri- lateral brim, custom fitted 
  L2525  Addition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim molded to patient model 
  L2526  Addition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim, custom fitted 
  L2530  Addition to lower extremity, thigh-weight bearing, lacer, non-molded 
  L2540  Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model 
  L2550  Addition to lower extremity, thigh/weight bearing, high roll cuff 
  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 
  L2760  Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth) 
  L2768  Orthotic side bar disconnect device, per bar
  L2780  Addition to lower extremity orthosis, non-corrosive 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 
  L4360  Walking 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 
  L4361  Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf 
  L4370  Pneumatic full leg splint, prefabricated, off-the-shelf 
  L4386  Walking 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 

Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive. 

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross and Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology© American Medical Association.  All Rights Reserved" 

 History From 2014 Forward     

01/08/2021 

Annual review, no change to policy intent. 

08/18/2020 

Updated Coding Section. No other changes made. 

01/02/2020 

Annual review, no change to policy intent. 

06/21/2019 

Interim review to add "or" between criteria for knee braces. No other changes made.. 

01/02/2019 

Annual review, no change to policy intent. 

01/03/2018 

Annual review, no change to policy intent. 

01/18/2017 

Annual review, no change to policy intent.

01/11/2016 

Annual review, no change to policy intent. Added HCPCS coding. 

01/22/2015 

No change to policy. Formatted policy.

06/11/2014

Annual review, no changes made.

 


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