Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    “Orthotic devices” and “orthotic services” are covered for QualChoice’s fully-insured plans in compliance with Arkansas law (Arkansas Code Annotated § 23-99-403 et seq. Please see Background for details of the Law) and as reflected in your Evidence of Coverage and Benefits Summary. Per Arkansas law “off-the-shelf” products (carried in stock and sold without therapeutic modification) do not meet the criteria for orthotics and are therefore not covered.

2)    All codes listed in the policy are not necessarily covered. Please see Medical Policy Statement for coverage of specific orthotics. Codes for customized orthotics that are NOT listed in any medical policy require prior authorization.

3)    QualChoice does not cover replacement of an orthotic device or associated orthotic services more frequently than one (1) time every three (3) years unless medically necessary or indicated by other coverage criteria under the QualChoice fully-insured plan. However, QualChoice will replace or repair an orthotic device, if necessary, due to anatomical changes or normal use. The replacement or repair will be subject to co-payments, deductibles, and co-insurance, as set out in your Benefits Summary.

4)    Only specific types of knee braces are covered by QualChoice.

5)    Requests for custom fabricated knee orthotics require prior authorization and as outlined below:

a)  Must be submitted by the ordering provider’s office (not by the vendor), along with the member’s medical records, such as clinic progress notes. Information submitted on a vendor request form will not be accepted.

The following knee braces are covered by QualChoice as outlined below:

1)    Knee orthosis with joints (L1810, L1812) or knee orthosis with condylar pads and joints with or without patellar control (L1820) is considered medically necessary for:

-      Members who are ambulatory AND

-      Have weakness or deformity of the knee AND

-      Require stabilization.

2)    Knee orthosis with a locking knee joint (L1831) or a rigid knee orthosis  (L1836) is considered medically necessary for:

-      Flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees (i.e., a non-fixed contracture).

3)    Knee immobilizer without joints (L1830), 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, L1852), is considered medically necessary for:

-      A recent (within 3 weeks) injury OR

-      Post-operative surgical procedure on the knee(s).

4)    (L1850) Knee orthosis, Swedish type, prefabricated is covered for:

-      A member who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee.

5)    The following knee orthoses require documentation of knee instability and joint laxity on physical examination (e.g., varus/valgus instability, anterior/posterior Drawer test):

-      (L-1832) Knee orthosis with adjustable knee joints, positional orthosis, rigid support, prefabricated item that has been customized to fit the patient by an individual with expertise;

-      (L1833) Knee orthosis with adjustable knee joints, positional orthosis, rigid support, prefabricated, off-the-shelf;

-      (L1843) Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with/without varus/valgus adjustment, prefabricated item that has been customized to fit the patient by an individual with expertise;

-      (L 18450)Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with/without varus/valgus adjustment, prefabricated item that has been customized to fit the patient by an individual with expertise;

-      (L1850) Knee orthosis, Swedish type, prefabricated off-the-shelf;

-      Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with/without varus/valgus adjustment, prefabricated, off-the-shelf;

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

6)    Custom–fabricated knee braces (L1834, L1840, L1844, L1846, L1860) require prior authorization and are covered as outlined below:

-      Member is ambulatory AND

-      There is deformity of the leg or knee such that a prefabricated brace cannot be used, AND

-      Member’s exact measurements of thigh and calf are submitted.

7)    Additions to the knee braces–(L2385) straight knee joint, heavy–duty, each joint is considered medically necessary when:

-      The coverage criteria for the base orthosis code is met AND

-      The member weighs more than 300lbs.

Codes Used In This BI:

K0672            Addtn to lower extremity orthotic, removable soft interface, all components, rplcmt only, ea

L1810             Knee orthosis, elastic w/joints, prefabricated item that has been customized to fit a specific patient by an indiv w/expertise

L1812             Knee orthosis, elastic w/joints, prefabricated, off-the-shelf

L1820             Knee orthotic, elastic w/condylar pads & joints, w/or w/out control, prefabricated, incl fitting & adjust

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

L1831             Knee orthotic, locking knee joint(s), positional orthotic, prefabricated, incl fitting & adjust

L1832             Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been customized to fit a specific patient by an indiv w/expertise

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

L1834             Knee orthotic (KO), w/out knee joint, rigid, and custom fabricated

L1836             Knee orthosis, rigid, w/out 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, & calf, w/adjust flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, w/ or w/out varus/valgus adjust, prefabricated item that has been customized to fit a specific patient by an indiv w/ expertise

L1844             Knee orthotic (KO), single upright, thigh & calf, w/adjust flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, w/ or w/out varus/valgus adjust, custom fabricated

L1845             Knee orthosis, double upright, thigh & calf, w/adjust flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, w/ or w/out varus/valgus adjust, prefabricated item that has been customized to fit a specific patient by an indiv w/ expertise

L1846             Knee orthotic, double upright, thigh & calf, w/adjust flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, w/ or w/out varus/valgus adjust, custom fabricated

L1847             Knee orthosis, double upright w/adjust joint, w/inflatable air support chamber(s), prefabricated item that has been customized to fit a specific patient by an indiv w/ expertise

L1848             Knee orthosis, double upright w/adjust joint, w/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 & calf, w/adjust flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, w/ or w/out varus/valgus adjust, prefabricated, off-the-shelf

L1852             Knee orthosis (KO), double upright, thigh & calf, w/adjust flexion & extension joint (unicentric or polycentric), medial-lateral & rotation control, w/ or w/out varus/valgus adjust, prefabricated, off-the-shelf

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

L1950             Ankle-foot orthosis (AFO), spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated

L2385             Addtn to lower extremity, straight knee joint, heavy-duty, ea joint

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

L2395             Addtn to lower extremity, offset knee joint, heavy-duty, ea joint

L2397             Addtn to lower extremity orthotic, suspension sleeve

L2405             Addtn to knee joint, drop lock, each

L2415             Addtn to knee lock with integrated release mechanism

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

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

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

L2750             Addtn to lower extremity orthotic, plating chrome or nickel, per bar

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

L2760             Addtn to orthotics extension per bar for Lineal adjustment for growth

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

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

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

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

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

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

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

L2840             Addtn to lower extremity orthotic, tibial length sock, fracture or equal, ea

L2850             Addtn to lower extremity orthotic, femoral length sock, fracture or equal, ea

QualChoice does not cover ANY knee brace not listed above. The following examples of knee braces and associated accessories are considered not medically necessary and are not covered. This list may not be all-inclusive.

1)    Prophylactic knee braces;

2)    Functional knee braces utilized solely for participation in sports or to improve athletic performance;

3)    Patellofemoral knee braces/sleeves for the treatment of postoperative knee effusion or patellofemoral syndrome without subluxation or dislocation;

4)    Functional knee braces after successful reconstructive ligament surgery;

5)    Socks and brace sleeves used in conjunction with the orthotic device;

6)    Additional removable or non-removable interface dispensed with the initial device are not separately reimbursable;

7)    Inflatable air bladder incorporated into the design, as it has no proven clinical benefit.

1)    American Academy of Orthopedic Surgeons (AAOS). The use of knee braces [position statement]. Rosemont, IL: AAOS; 1997 Oct. Revised 2003 Dec. Retired December 2008. Accessed April 9, 2008. Available at URL address: http://www.aaos.org/about/papers/position/1124.asp

2)    American Academy of Orthopedic Surgeons (AAOS). Treatment of Osteoarthritis of the Knee. Evidence-based Guideline 2nd Edition. Adopted May 2013. Accessed April 10, 2014. Available at URL address: http://www.aaos.org

3)    American Academy of Pediatrics Committee on Sports Medicine. Knees brace use in the young athlete. Pediatrics. 2001 Aug; 108(2):503-7.

4)    Beaudreuil J, Bendaya S, Faucher M, Coudeyre E, Ribinik P, Revel M, Rannou F. Clinical practice guidelines for rest orthosis, knee sleeves, and unloading knee braces in knee osteoarthritis. Joint Bone Spine. 2009 Dec; 76(6):629-36.

Addendum:

Effective 02/01/2018: Codes updated. L2390, L2405, L2415, L2425, L2430, L2492, L2750, L2755, L2768, L2780, L2785, L2800 are not covered. L2760 (additions to orthotics for Lineal adjustment for growth) is covered.