Coverage Policies

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 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, subject to co-payments, deductibles, and co-insurance as set out in your Benefits Summary.

4)    Shoe inserts and orthopedic shoes are generally not covered.  For diabetic shoes and inserts, see BI198: Diabetic Shoes and Shoe Inserts and BI039: Foot Care.

5)    Back braces are generally not covered unless there is documentation of spinal stenosis, scoliosis, and fracture of the spine or recovery following spinal surgery. In these situations, only certain specific types of back braces are covered. Evidence does not support the use of back braces for chronic back pain. Please refer to BI534: Back Braces.

6)    The Pre-authorization requests for orthotics require:

a)  Submission by the ordering provider office and not by the vendors AND

b)  Accompanying patient medical records such as provider clinic progress notes. c)  Information submitted on vendor request forms is not acceptable.

1)    The following “orthotics devices” and “orthotic services,” including their fitting and repair, do not require pre-authorization:

a)    L1902, L1906 – Ankle orthotic

b)    L3260 – Surgical shoe

c)    L3650 – L3670 – Shoulder orthotic

d)    L3702, L3710, L3762 – Elbow orthotic

e)    L3806 – L3808 – Wrist-hand-finger orthotic

f)     L3908, L3912 – Wrist-hand orthotic

g)    L3917 – L3935 – Finger orthotic

h)    L3980 – L3984, L3995 – Upper extremity fracture orthotic

i)     L4000 – L4210 – Repair/replacement items

j)     L4350 – L4398– Other lower extremity supports

k)    97760, 97763 – Orthotic Management/training and check-out

2)    For diabetic shoes and inserts, fitting, and modification, please see the following BI’s: BI198: Diabetic Shoes and Shoe Inserts, and BI039: Foot Care.

3)    For knee orthotics and their additions, please see BI553: Knee Braces.

4)    Please see BI534: Back races for back braces and rib belts. In accordance with the definition of an ”orthotic device” under Arkansas law, QualChoice does not  cover the following orthotic devices:

a)    Back braces intended to prevent injury or to permit especially heavy lifting.

b)    Any brace or support intended to enhance function past normal, such as to enable running a marathon or operating a jack-hammer.

c)    Any device that is not prescribed by one of:

(1)  A licensed doctor of medicine,

(2)  A licensed doctor of osteopathy,

(3)  A licensed doctor of podiatric medicine.

d)    Any device that is not provided by one of the above practitioners or by :

(1)  A licensed orthotist

(2)  A licensed prosthetist.

(3)  A licensed Occupational Therapist.

5)    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, for example, in the case of rapid growth of a child means that an orthotic device of a different size is appropriate.

6)      Shoe inserts and orthopedic shoes are generally not covered.

7)      Except as noted above, “off-the-shelf” products (carried in stock and sold without therapeutic modification) do not meet the Arkansas law criteria for orthotics and are therefore not covered.  All other codes (for customized orthotics) require pre-authorization.  

Codes Used In This BI:

1)    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 Back Ground statement of this policy.

2)    Examples of devices that would not be covered for this reason (unless specified in member coverage document),  includes but is not limited to the following examples:

a)    Prophylactic knee braces have not been shown to be effective and are not recommended for use. Functional knee braces do offer a useful adjunct to the rehabilitation of knee ligament injuries.

b)    Services or equipment that are more costly when QualChoice determines that less costly, equally effective services or equipment are available.

c)    Materials or services covered under a manufacturer’s warranty.

d)    Procedures, services or supplies rendered in the course of providing a non-covered service, such as gender-change surgery.

e)    Non-covered items would also include:

i)     Any of the following items that are specifically excluded under Arkansas law as being required to be covered:

(1)  Arch supports,

(2)  Jobst stockings,

(3)  hearing aids (refer to BI049 or BI264),

(4)  Ace bandages,

(5)  Urethane calcaneal brace,

(6)  Cast shoes (refer to BI 198 for foot orthotics coverage).

ii)    Repairs required due to abuse or neglect of the device.

iii)   Dentures are not covered.

In order for a device to be an “orthotic device” as defined by Arkansas law and covered under QualChoice’s fully-insured plans, the device must meet all of the following three (3) requirements:

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:

                                                    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:

                                                    i.     A licensed doctor of medicine,

                                                   ii.     A licensed doctor of osteopathy,

                                                 iii.     A licensed doctor of podiatric medicine

                                                 iv.     A licensed orthodontist

                                                  v.     A licensed prosthetist.

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

·       Any similar device meeting both of these requirements:

                                                    i.          It is carried in stock and sold without therapeutic modification by:

a.     A corset shop

b.     A department store

c.     A drug store

d.     A surgical supply facility

e.     A similar retail entity; and

                                                   ii.          It has no significant impact on the neuromuscular, musculoskeletal or neuromusculoskeletal functions of the body.

1)    In accordance with the above definition, the following are examples of devices not considered to be orthotic devices:

a)    Fixation devices for fractures, sprains or other acute injuries.

                                          i.     Such devices may be covered under other provisions of your coverage document.

                                         ii.     The intent is to prevent injury rather than to restore physiologic function.

b)    Any brace or support intended to enhance function past normal, such as to enable running a marathon or operating a jack-hammer.

                                          i.     The intent is to enhance function above normal, rather than to restore physiologic function.

                                         ii.     For such purposes, braces and supports are not covered under this plan.

c)     Molded shoes, shoe inserts and “foot orthotics” is more frequently for comfort than for restoration of physiologic function.

                                          i.     Used for comfort, not for restoration of physiologic function, they are not covered.

                                         ii.     When used for patients with diabetes to prevent or ameliorate foot damage, they may be covered (see policy BI 198).

                                       iii.     If prescribed and dispensed to restore physiologic function, that purpose must be clearly delineated in a preauthorization request for consideration by QualChoice.

d)    Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

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

Addendum: 

1.     Effective 01/01/2017: Clarifying language was added that, according to AR state law, off-the-shelf products do not meet the definition of orthotic devices. Clarification was also added for when back braces are and are not covered.

2.     Effective 06/01/2017: Added L3995 to upper extremity fracture orthotic code to be covered without prior authorization. For back braces added reference to the new policy BI534 on Back Braces.  Added clarifying verbiage that requests for orthotics will need to be submitted by ordering provider office along with provider’s clinic progress notes. Requests from vendors or on vendor request forms will not be accepted.

3.     Effective 07/01/2017; Made reference to BI198 Diabetic Shoes and Shoe inserts and BI039 Foot Care

4.     Effective 11/01/2017:  Made reference to BI534 on back braces for rib belts.  Made reference to BI553 on Knee braces.

5.     Effective 02/01/2018: Deleted outdated or non-pertinent codes.

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.

The Federal Employees Health Benefit Program (FEHBP) has different coverage. Please see refer to your policy brochure.