Coverage Policies

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. See Background for details of the Law) and as reflected in your Certificate of Coverage or Evidence of Coverage and Benefits Summary. Per Arkansas law, “off-the-shelf” products (carried in stock and sold without therapeutic modification) do not meet criteria for orthotics and are therefore not covered.

2)    All codes listed in this medical policy are not necessarily covered services. Please see details under the “Medical Policy Statement” section for coverage of specific services. HCPC codes for back braces that are not specified under the medical policy statement are not considered medically necessary and are therefore not covered.

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 the orthotic if necessary due to anatomical changes or normal use.  Replacement will be made based on necessity due to normal use if: (a) the orthotic has been rendered unusable, (b) the damage was not caused by neglect or misuse, (c) the cost of repair exceeds the replacement cost, and (d) the orthotic is not currently covered by warranty. The replacement of an orthotic device is subject to co-payments, deductibles, and co-insurance, as set out in your Benefits Summary.

4)    Back braces are generally not covered unless there is documentation of spinal stenosis, certain types of scoliosis, acute fracture of the spine or recovery following spinal surgery. In these situations, only specific types of back braces (as outlined in the medical policy statement) are covered. Evidence does not support the use of back braces for chronic back pain.

As defined by Arkansas law (Arkansas Code Annotated § 23-99-403 et seq. see Background for details of the Law) and covered under QualChoice’s fully-insured plans, the brace must meet all of the following three (3) requirements for an orthotic device:

1)    The external device is:

a)    Intended to restore physiological function or cosmesis to a patient; AND

b)    Custom-designed, fabricated, assembled, fitted, or adjusted for the patient using the device prior to or concurrent with the delivery of the device to the patient.

2)    The device must be prescribed by one of the following:

                                          i.    A licensed doctor of medicine,

                                        ii.    A licensed doctor of osteopathy,

                                       iii.    A licensed doctor of podiatric medicine.

3)    The device must be provided by one of the following:

                                          i.    A licensed doctor of medicine,

                                        ii.    A licensed doctor of osteopathy,

                                       iii.    A licensed doctor of podiatric medicine,

                                       iv.    A licensed orthotist,

                                        v.     A licensed prosthetist.

In accordance with the above definition, any brace or support intended to enhance function past normal, such as back braces intended to prevent injury or to permit especially heavy lifting, are not considered an orthotic device, and are not covered. QualChoice only covers selected back braces based on medical necessity and cost effectiveness.

I. The following back braces are covered without preauthorization as outlined below:

A) Rib belt (L0220) with diagnosis of rib fracture(s) (S22.000A – S22.9XXS)

B) Sacral and Thoracic/Lumbar/Sacral Orthotics (L0450, L0454, L0626, L0627 &  

     L0630) with a diagnosis of:

·         Spinal stenosis (M48.04, M48.05, M48.06, M48.061, M48.062, M48.07, M48.08);

·         Thoracic vertebral fractures (S22.000A – S22.089S);

·         Lumbar vertebral fractures  (S32.000A – S32.059S);

·         Sacral fractures (S32.10XA – S32.19XS);

·         Lumbar spondylolisthesis (M43.16);  

·         Osteomyelitis of lumbar vertebra (M46.26);

·         Lumbar discitis (M46.46);

·         Lumbar spine instability (M53.2X6); 

·         Subluxation lumbar spine (M99.13);

·         Lumbar surgeries: fusion of spine thoracolumbar region (M43.25), lumbar spinal fusion (M43.26), post laminectomy syndrome (M96.3), post-laminectomy lordosis (M96.4) with any diagnosis, and other post-procedural state, lumbar discectomy, lumbar laminectomy (Z98.89);

·         Any diagnosis code if requested within 10 days post-op for a thoracic and/or lumbar spinal surgery:

    63003 – 63012, 63016 – 63017, 63030 – 63035, 63042, 63044,

63046 – 63048, 63085 – 63091, 63101 – 63103, 63170 – 63173,

63185 – 63191, 63195, 63197, 63199 – 63200, 63251 – 63252,

63266 – 63268, 63271 – 63273, 63276 – 63278, 63281 – 63283,

63286 – 63295, 63301 – 63303, 63305 – 63308.

C)  Scoliosis Orthotics (L1000 – L1290) with a diagnosis of:

·         Infantile idiopathic scoliosis, cervicothoracic-lumbosacral (M41.03 – M41.07);

·         Juvenile scoliosis, cervicothoracic-lumbosacral (M41.113 – M41.117);

·         Adolescent scoliosis, cervicothoracic-lumbosacral (M41.123 – M41.127);

·         Idiopathic scoliosis, cervicothoracic-lumbosacral (M41.23 – M41.27);

·         Thoracogenic scoliosis (M41.34 – M41.35);

·         Neuromuscular cervicothoracic-lumbosacral (M41.43 – M41.47);

·         Other secondary scoliosis, cervicothoracic-lumbosacral (M41.53 – M41.57);

·         Other forms of scoliosis, cervicothoracic-lumbosacral (M41.83 – M41.87);

·         Orthotic management/training (97760, 97763)

Codes Used In This BI:

1)    Back Braces codes that are not specified in the medical policy statement are not covered.

2)    No appliance or device will be covered as an orthotic device and no service will be covered as an orthotic service if it does not meet the definitions of orthotic device and orthotic service under Arkansas law and as set forth in the Background statement of this policy.

3)    Services or equipment that is more costly are not covered when QualChoice determines that less costly, equally effective services or equipment is available.

4)    Materials or services covered under a manufacturer’s warranty are not covered.

5)    Procedures, services, or supplies rendered in the course of providing a non-covered service are not covered.

An “orthotic device” means an external device that is:

(i)  Intended to restore physiological function or cosmesis to a patient; and

(ii)  Custom-designed, fabricated, assembled, fitted, or adjusted for the patient using the device prior to or concurrent with the delivery of the device to the patient.

An “orthotic device” does not include a cane, a crutch, a corset, a dental appliance, an elastic hose, an elastic support, a fabric support, a generic arch support, a low-temperature plastic splint, a soft cervical collar, a truss, or other similar device that:

(i)  Is carried in stock and sold without therapeutic modification by a corset shop, department store, drug store, surgical supply facility, or similar retail entity; and

(ii)  Has no significant impact on the neuromuscular, musculoskeletal, or neuromusculoskeletal functions of the body.

1)    Arkansas Code Annotated § 23-99-403 et seq.

2)    Williams KD. Fractures, dislocations, and fracture-dislocations of the spine. In: Canale ST, Beaty JH, editors. Campbell`s Operative Orthopedics. 12th ed. Philadelphia, PA: Elsevier Mosby; 2013:1559-628.

3)    Chang V, Holly LT. Bracing for thoracolumbar fractures. Neurosurgical Focus 2014; 37(1):E3. DOI: 10.3171/2014.4.FOCUS1477.

4)    Bakhsheshian J, Dahdaleh NS, Fakurnejad S, Scheer JK, Smith ZA. Evidence-based management of traumatic thoracolumbar burst fractures: a systematic review of non-operative management. Neurosurgical Focus 2014; 37(1):E1. DOI: 10.3171/2014.4.FOCUS14159

5)    Hresko MT. Clinical practice. Idiopathic scoliosis in adolescents. New England Journal of Medicine 2013; 368(9):834-41. DOI: 10.1056/NEJMcp1209063.

6)    Altaf F, Gibson A, Dannawi Z, Noordeen H. Adolescent idiopathic scoliosis. British Medical Journal 2013; 346:f2508.