Clinical UM Guideline

 

Subject: Ankle-Foot & Knee-Ankle-Foot Orthoses
Guideline #:  CG-DME-22 Publish Date:    12/27/2017
Status: Revised Last Review Date:    11/02/2017

Description

This document addresses orthoses for the ankle-foot or the knee-ankle-foot. The purpose of an orthosis (rigid or semi-rigid brace) is to support a weak or deformed body part or to restrict or eliminate motion in a diseased or injured part of the body.

Note: Please see the following related documents for additional information:

Clinical Indications

Ankle-foot orthoses (AFOs) used in non-ambulatory individuals

Medically Necessary:

A static AFO is considered medically necessary if all of the following criteria are met:

  1. Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing of at least 10 degrees (that is, a non-fixed contracture); and
  2. Reasonable expectation of the ability to correct or prevent a fixed contracture in those who may become ambulatory; and
  3. Contracture is interfering or expected to interfere significantly with the individual’s functional abilities; and
  4. Used as a component of a therapy program that includes passive stretching of the involved muscles or tendons.

If a static AFO is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home).

Not Medically Necessary:

A static AFO, including replacement interface is considered not medically necessary when used solely for the prevention or treatment of a heel pressure ulcer. For these indications, it does not meet the definition of a brace (that is, 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).

A static AFO and replacement interface is considered not medically necessary if the contracture is fixed.

A static AFO and replacement interface is considered not medically necessary for a non-ambulatory individual with a foot drop but without an ankle flexion contracture.

A component of a static AFO that is used to address positioning of the knee or hip in a non-ambulatory individual is considered not medically necessary.

A foot drop splint/recumbent positioning device and replacement interface is considered not medically necessary when it is used solely for the prevention or treatment of a heel pressure ulcer because this does not meet the definition of a brace.

A foot drop splint/recumbent positioning device and replacement interface is considered not medically necessary in an individual with foot drop who is non-ambulatory.

Ankle-Foot Orthoses (AFOs) and Knee-Ankle-Foot Orthoses (KAFOs) used in ambulatory individuals

Medically Necessary:

Ankle-foot orthosis (AFOs) is considered medically necessary for ambulatory individuals with weakness or deformity of the foot and ankle who require stabilization for medical reasons and have the potential to benefit functionally.

Knee-ankle-foot orthosis (KAFOs) are considered medically necessary for ambulatory individuals for whom an ankle-foot orthosis is appropriate and additional knee stability is required.

AFOs and KAFOs that are custom-fabricated are considered medically necessary for ambulatory individuals when the basic medically necessary criteria listed above are met and one or more of the following criteria are met:

  1. The individual could not be fit with a prefabricated AFO; or
  2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or
  3. There is a need to control the knee, ankle, or foot in more than one plane; or
  4. The individual has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or
  5. The individual has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

Walking boots used to provide immobilization as treatment for an orthopedic condition or after orthopedic surgery are considered medically necessary.

Not Medically Necessary:

AFOs and KAFOs that do not meet the criteria above are considered not medically necessary.

An AFO or KAFO and any related addition, for an ambulatory individual, used solely for the treatment of edema or for the prevention or treatment of a heel pressure ulcer, is considered not medically necessary.

Walking boots used primarily to relieve pressure, especially on the sole of the foot, or used for individuals with foot ulcers, are considered not medically necessary.

Socks used in conjunction with AFOs and KAFOs are considered not medically necessary and do not meet the definition of durable medical equipment.

Repairs and/or Replacement

Medically Necessary:

Repairs to medically necessary AFOs and KAFOs, due to wear or to accidental damage, are considered medically necessary when they are necessary to make the AFO or KAFO functional.

Replacement of an AFO or KAFO or component of an AFO or KAFO due to loss, significant change in the individual’s condition, or irreparable accidental damage is considered medically necessary if the device is still medically necessary.

Not Medically Necessary:

Replacement components (for example, soft interfaces) that are provided on a routine basis without regard to whether the original item is worn out are considered not medically necessary.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

 

L1900-L1990

Ankle-foot orthoses (AFO) [includes codes L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990]

L2000-L2038

Knee-ankle-foot orthoses (KAFO) [includes codes L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038]

L2106-L2116

AFO, fracture orthoses [includes codes L2106, L2108, L2112, L2114, L2116]

L2126-L2136

KAFO, fracture orthoses [includes codes L2126, L2128, L2132, L2134, L2136]

L2180-L2192

Additions to lower extremity fracture orthoses [includes codes L2180, L2182, L2184, L2186, L2188, L2190, L2192]

L2200-L2397

Additions to lower extremity orthoses (shoe-ankle-shin-knee) [includes codes L2200, L2210, L2220, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2385, L2387, L2390, L2395, L2397]

L2405-L2492

Additions to knee joint [includes codes L2405, L2415, L2425, L2430, L2492]

L2500-L2550

Additions to lower extremity, thigh/weight bearing [includes codes L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550]

L2570-L2861

Addition to lower extremity orthoses (general) [includes codes L2570, L2580, L2600, L2610, L2620, L2622, L2624, L2627, L2628, L2630, L2640, L2650, L2660, L2670, L2680, L2750, L2755, L2760, L2768, L2780, L2785, L2795, L2800, L2810, L2820, L2830, L2840, L2850, L2861]

L2999

Lower extremity orthosis, not otherwise specified

L4002-L4130

Replacements (specific repairs) [includes codes L4002, L4010, L4020, L4030, L4040, L4045, L4050, L4055, L4060, L4070, L4080, L4090, L4100, L4110, L4130]

L4350

Ankle control orthosis, stirrup style, rigid, includes any type interface (eg, pneumatic gel), prefabricated, includes fitting and adjustment

L4360

Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

L4386

Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

L4392-L4394

Replacement, soft interface material [includes codes L4392, L4394]

L4396

Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, includes fitting and adjustment

L4398

Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment

L4631

Ankle foot orthosis, 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

 

 

ICD-10 Diagnosis

 

 

All diagnoses

Discussion/General Information

A non-ambulatory ankle-foot orthosis may be either an ankle contracture splint or a foot drop splint.

A static AFO is a prefabricated ankle-foot orthosis that has all of the following characteristics:

  1. Designed to accommodate an ankle with a plantar flexion contracture up to 45; and
  2. Applies a dorsiflexion force to the ankle; and
  3. Allows pressure reduction; and
  4. Has a soft interface.

A foot drop splint/recumbent positioning device is a prefabricated ankle-foot orthosis that has all of the following characteristics:

  1. Designed to maintain the foot at a fixed position of zero degrees (that is, perpendicular to the lower leg); and
  2. Not designed to accommodate an ankle with a plantar flexion contracture; and
  3. Used by an individual who is non-ambulatory; and
  4. Has a soft interface.

The Centers for Medicare and Medicaid (CMS) criteria were utilized in the development of this document.

Definitions

Ankle flexion contracture: A condition in which there is shortening of the muscles or tendons that plantar-flex the ankle with the resulting inability to bring the ankle to zero degrees by passive range of motion (zero degrees ankle position is when the foot is perpendicular to the lower leg).

Ankle-foot orthoses (AFOs): These extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. These features distinguish them from foot orthoses which are shoe inserts that do not extend above the ankle.

Custom-fabricated orthosis: An orthosis that is individually made for a specific individual starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. The process involves substantial work such as cutting, bending, molding, sewing, etc. It may involve the incorporation of some prefabricated components and it involves more than trimming, bending, or making other modifications to a substantially prefabricated item.

Foot drop: A condition in which there is weakness or lack of use of the muscles that dorsiflex the ankle, but there is the ability to bring the ankle to zero degrees by passive range of motion.

Knee-ankle-foot-orthoses (KAFOs): An orthosis designed to control knee and ankle motion that extends from the upper portion of the thigh, crossing the knee and ankle and ending at the toes.

Orthosis (brace): A rigid or semi-rigid device that is used for the purpose of supporting a weak or deformed body part, or for restricting or eliminating motion in a diseased or injured part of the body. An orthosis can be either prefabricated or custom-fabricated.

Prefabricated orthosis: An orthosis that 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 for use by a specific individual (that is, custom fitted). 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.

References

Government Agency, Medical Society, and Other Authoritative Publications:

  1. CGS Administrators, LLC. Local Coverage Determination for Ankle-Foot/Knee-Ankle-Foot Orthosis (L33686). Revised 01/01/2017. Available at: http://www.cms.gov/mcd/index_local_alpha.asp?from=alphalmrp&letter=A. Accessed on October 4, 2017.
  2. Noridian Healthcare Solutions, LLC. Local Coverage Determination for Ankle-Foot/Knee-Ankle-Foot Orthosis (L33686). Revised 01/01/2017. Available at: http://www.cms.gov/mcd/index_local_alpha.asp?from=alphalmrp&letter=A. Accessed on October 4, 2017.
Index

Ankle-Foot Orthosis
Knee-Ankle-Foot Orthosis

History

Status

Date

Action

Revised

11/02/2017

Medical Policy & Technology Assessment Committee (MPTAC) review. Updated References section. Title change. The document header wording updated from “Current Effective Date” to “Publish Date.”

Reviewed

11/03/2016

MPTAC review. Updated Reference section.

Revised

11/05/2015

MPTAC review. Clarifications to Clinical Indications. Updated References. Removed ICD-9 codes from Coding section.

Reviewed

11/13/2014

MPTAC review. Updated References.

Reviewed

11/14/2013

MPTAC review. No change to Clinical Indications.

Reviewed

11/08/2012

MPTAC review. Updated References.

Reviewed

11/17/2011

MPTAC review. Updated References.

Reviewed

11/18/2010

MPTAC review. Updated References. Updated Coding section with 01/01/2011 HCPCS changes.

Reviewed

11/19/2009

MPTAC review. Removed Place of Service section. Updated References. Updated Coding section with 01/01/2010 HCPCS changes; removed L1901, L2770 deleted 12/31/2009.

Reviewed

11/20/2008

MPTAC review. Updated references, Discussion/General Information section and Definitions. Coding section updated with 01/01/2009 HCPCS changes; removed L2860 deleted 12/31/2008.

Reviewed

11/29/2007

MPTAC review. References and coding updated. Clarification of wording.

Reviewed

12/07/2006

MPTAC review. References and coding updated; removed HCPCS L2039 deleted 12/31/2005.

New

12/01/2005

MPTAC initial document development.

Pre-Merger Organizations

Last Review Date

Document Number

Title

Anthem, Inc.

 

 

No Document

Anthem CO/NV

10/29/2004

DME.708

Ankle-Foot/Knee-Ankle-Foot Orthotics

WellPoint Health Networks, Inc.

 

 

No Document