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Clinical Policy Bulletins
Number: 0009
Subject: Orthopedic Casts, Braces and Splints
Important Note
This Clinical Policy Bulletin expresses Aetna’s determination of whether certain services or supplies are medically necessary. Aetna has reached these conclusions based upon a review of currently available clinical information (including clinical outcome studies in the peer-reviewed published medical literature, regulatory status of the technology, evidence-based guidelines of public health and health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors). Aetna expressly reserves the right to revise these conclusions as clinical information changes, and welcomes further relevant information. Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member’s benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member’s benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy and a member’s plan of benefits, the benefits plan will govern. In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members.
Policy
Note: Most Aetna traditional plans cover durable medical equipment (DME) as a standard benefit. Standard Aetna HMO plans do not cover DME without a policy rider. Please check benefit plan descriptions for details. Certain orthopedic casts, braces and splints are covered under HMO plans without the DME rider because their use is integral to the treatment of certain orthopedic fractures and recovery after certain orthopedic procedures.
The following braces may be considered medically necessary for the listed indications when they are prescribed by a doctor, are made of durable material (i.e., made to withstand prolonged use), and are used to treat disease or injury.
Back Braces
1. Supportive Back Braces
Aetna considers a supportive back brace medically necessary for any of the following indications:
• To reduce pain by restricting mobility of the trunk; or
• To facilitate healing following an injury to the spine or related soft tissues; or
• To facilitate healing following a surgical procedure on the spine or related soft tissue (see section on Postoperative Back Braces below); or
• To otherwise support weak spinal muscles and/or a deformed spine.
Following a strain/sprain, supportive back braces (back supports, lumbosacral supports, support vests) are used to render support to an injured site of the back. The main effect is to support the injured muscle and reduce discomfort.
Note: Back braces are considered durable medical equipment (DME), except when used as a postoperative brace (see section 1, B).
2. Postoperative Back Braces:
Aetna considers postoperative back braces medically necessary to facilitate healing when applied within 6 weeks following a surgical procedure on the spine or related soft tissue.
A postoperative back brace is used to immobilize the spine following laminectomy with or without fusion and metal screw fixation is considered medically necessary. This brace promotes healing of the operative site by maintaining proper alignment and immobilization of the spine.
Note: Postoperative back braces are considered part of the surgical protocol for certain back operations.
3. Elastic Rib Belts and Inflatable Lumbar Supports
Elastic rib belts and inflatable lumbar supports (Tech Belts, air belts) do not meet Aetna’s definition of covered durable medical equipment because they are not durable (not made to withstand prolonged use) and because they are not mainly used in the treatment of disease or injury or to improve body function lost as the result of a disease or injury.* In addition, elastic rib belts and inflatable lumbar supports have not been proven to be effective treatments for back injuries.
4. Protective Body Socks
Protective body socks do not meet Aetna’s definition of covered durable medical equipment because they are not made to withstand prolonged use.
Knee Braces
1. Functional Knee Brace
Functional (derotational) knee braces are considered medically necessary DME to improve stability for an unstable or postoperative knee in activities of daily living. Functional knee braces may be off-the-shelf or custom made. Custom-made functional braces are considered medically necessary if the member is unable to be fitted with an off-the-shelf knee brace because of a deformity of the knee or leg that interferes with fitting. Exceptionally tall or short stature or obesity does not, by itself, establish the need for custom-made functional knee braces. Exceptionally tall persons can usually be fitted with an off-the-shelf brace with extensions, short persons can usually be fitted with a pediatric off-the-shelf brace, and obese persons can usually be fitted with an off-the-shelf knee brace with extra large straps.
Example: Lenox Hill Brace, Boston Knee Brace, DonJoy CI Brace
Note: Custom-made knee braces may be identified by HCPCS codes for “custom-fabricated” and “molded” knee orthoses.
2. Prophylactic Knee Braces
Prophylactic knee braces are designed to reduce the likelihood or severity of knee ligament injuries in a relatively normal (stable) knee.
Prophylactic knee braces are not considered medically necessary for treatment of disease or injury. The American Academy of Orthopedic Surgeons has concluded that prophylactic bracing has not been proven to be effective and, in some cases, may actually contribute to knee injury.
3. Osteoarthritis Braces (Unloader Braces)
Aetna considers custom-made unloader braces medically necessary DME as an alternative to surgery for members with severe 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 limitation in ADLs, and who do not have any of the following:
• Arthritis other than osteoarthritis; or
• A recent knee operation (within the previous 6 months); or
• Symptomatic disease of the hip, ankle or foot; or
• Diseases that would preclude use of a brace (e.g., skin disease, peripheral vascular disease, or varicose veins); or
• Severe cardiovascular deficit; or
• Paresis or other disease that would preclude ambulation; or
• Inability to apply the brace because of physical limitations such as arthritis of the hands or inability to bend over.
Examples: Generation II Unloader, Orthotech Performer, Vixie Enterprise MKSIII
4. Rehabilitation Knee Braces
Aetna considers post-operative and post-injury knee braces (also known as rehabilitation braces) medically necessary to allow protected motion of an injured knee treated operatively or non-operatively when applied within 6 weeks after injury or surgery. Post-operative and post-injury knee braces (also known as rehabilitation braces) are also considered medically necessary to allow protected motion of an injured knee treated operatively or non-operatively early after injury.
Examples: Bledsoe Postop Brace, DonJoy IROM Brace
Note: Rehabilitation knee braces are considered standard orthopedic protocol following certain types of knee surgery and tibial plateau fractures.
Cast-Braces (also called fracture braces)
1. Comfort, Non-Therapeutic
Comfort, non-therapeutic cast-braces are considered medically necessary DME after a fracture or surgery. They are often used after the patient has been in a walking cast. They are usually removable. Molded casts, which allow the patient to remove the cast to bathe the affected extremity, can also be used when a fracture is slow to heal or non-healing. The use of these removable casts replaces monthly cast changes. A removable cast of this type offers no therapeutic advantages over a non-removable cast.
Example: Cam Walker
2. Functional Cast-Brace
Functional cast-braces are considered medically necessary after a fracture or surgery. These have become the standard brace for certain fractures, including tibial-femoral fractures. The functional cast-brace is used following a short period of standard fracture treatment using a non-weight bearing or partial weight-bearing cast, or immediately following surgery. It allows protected weight bearing, and motion of the joints above and below the fracture. The joints are moved earlier, contractures are prevented, and early healing is effected due to the weight bearing.
Examples: PTB cast brace, PTB fracture brace, MAFO (molded ankle-foot orthosis) fracture brace with pelvic band, Achilles tendon hinged brace.
Note: Functional cast-braces are considered integral to the treatment of the fracture.
Rehabilitation Braces
Aetna considers other post-operative and post-injury braces medically necessary when applied within six weeks of surgery or injury.
Note: Rehabilitation braces are considered an integral part of the surgical or fracture care protocol.
Cervical (Neck) Braces
Cervical (neck) braces are considered medically necessary DME for members with neck injury and other appropriate indications.
Example: Philadelphia Cervical Collar
Note: Cervical foam neck collars do not meet Aetna’s definition of covered durable medical equipment because they are not durable, and not made to withstand prolonged use.
Childhood Hip Braces
Specialized hip braces are considered medically necessary for children with hip disorders to stabilize the hip and/or to correct and maintain hip abduction.
Example: Pavlik Harness, Frejka Pillow Splint, Friedman Strap.
Note: Childhood hip braces are considered integral to the management of hip disorders in children.
Braces for Congenital Defects
Aetna considers orthopedic braces medically necessary in the treatment of congenital defects. Aetna also considers replacement braces medically necessary when the member has outgrown the previous brace or because his/her condition has changed such as to make the previous brace unusable. This includes scoliosis braces.
Plastic Braces (MAFOs)
Increasing use is made of plastic braces. These devices have various names and are often called molded ankle-foot orthoses (AFO’s) or molded ankle-foot orthoses (MAFO’s). They may also be called orthotics. For information on ankle-foot orthotics, see CPB 565 – Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs). Orthotics of this type should not be confused with simple, removable orthotic arch supports or shoe inserts. For information on foot orthotics, see CPB 451 – Foot Orthotics.
Wheaton Brace
A Wheaton Brace considered medically necessary DME to treat metatarsus adductus in infants replacing the need for serial casting.
Scoliosis Braces
For Aetna’s policy on scoliosis braces, see CPB 398 – Idiopathic Scoliosis Treatment.
Splints and Immobilizers
Certain orthopedic problems are routinely treated with splints or splint-like devices. The following are considered medically necessary:
1. Shoulder immobilizer.
2. Clavicle splint (also called a figure-8 splint).
3. Acromio-clavicular splint (also called a Zimmer splint).
4. Finger splints.
5. Carpal tunnel splints.
6. Dynasplints when applied within 6 weeks of a surgical procedure. (See CPB 405 – Dynamic Splinting for Contracture and Joint Stiffness.)
7. Denis Browne Splint for children with clubfoot or metatarsus valgus to maintain and correct abduction.
Unna Boots
Unna boots are considered medically necessary only for non-fracture care. Unna boots are not considered medically necessary when used in conjunction with fracture treatment. They can be used to treat sprains and torn ligaments, provide protection for other soft tissue injuries and may be used after certain surgical procedures as a protective cover to promote healing. Occasionally they are used in the first days after a fracture before a cast is put on. Their use in this regard is controversial.
Air Casts
Air Casts are considered medically necessary for treatment of fractures or other injuries (i.e., sprains, torn ligaments). Air Casts (air splints) are used as an alternative to plaster casts to immobilize an elbow, ankle, or knee.
Miscellaneous Covered Services
1. Casting of a sprain is considered medically necessary.
2. Casting following surgical procedures is considered medically necessary.
Fiberglass vs. Plaster Casts
The casting material used in fracture care can be either fiberglass or plaster. The choice of material is dictated by the individual situation and is left to the discretion of the treating doctor.
Note: Certain non-durable items (e.g., arm slings, Ace bandages, splints, foam cervical collars, etc.) may be eligible for payment in some circumstances even though they are not durable and do not fit within the definition of durable medical equipment. These non-durable items may be covered when charges are made by a hospital, surgical center, home health care agency, or doctor for necessary medical and surgical supplies used in connection with treatment rendered at the time the supply is used. However, charges for take home supplies (i.e., extra bandages, cervical pillows, etc.) are not covered. Please check benefit plan descriptions for details.
Background
This policy is based primarily on Medicare DMERC criteria for spinal orthoses.
The above policy is based on the following references:
1. Littenberg B, Weinstein LP, McCarren M, et al. Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment. J Bone Joint Surg Am. 1998;80(2):174-183.
2. Alexy C, De Carlo M. Rehabilitation and use of protective devices in hand and wrist injuries. Clin Sports Med. 1998;17(3):635-655.
3. Buckley SL. Current trends in the treatment of femoral shaft fractures in children and adolescents. Clin Orthop. 1997;338:60-73.
4. McFarland EG, Curl LA, Urquhart MW, Kellam K. Shoulder immobilization devices. Orthop Nurs. 1997;16(6):47-54.
5. Kramer JF, Dubowitz T, Fowler P, et al. Functional knee braces and dynamic performance: A review. Clin J Sport Med. 1997;7(1):32-39.
6. Jerosch J, Thorwesten L, Bork H, Bischof M. Is prophylactic bracing of the ankle cost effective? Orthopedics. 1996;19(5):405-414.
7. Liu SH, Mirzayan R. Current review. Functional knee bracing. Clin Orthop. 1995;317:273-281.
8. Fernandez-Feliberti R, Flynn J, Ramirez N, et al. Effectiveness of TLSO bracing in the conservative treatment of idiopathic scoliosis. J Pediatr Orthop. 1995;15(2):176-181.
9. Albright JP, Saterbak A, Stokes J. Use of knee braces in sport. Current recommendations. Sports Med. 1995;20(5):281-301.
10. Chess DG, Hyndman JC, Leahey JL, et al. Short arm plaster cast for distal pediatric forearm fractures. J Pediatr Orthop. 1994;14(2):211-213.
11. McIvor JB, Ross P, Landry G, Davis LA. Treatment of femoral fractures with the cast brace. Can J Surg. 1984;27(6):592-594.
12. Dieppe P, Chard J, Faulkner A, et al. Osteoarthritis. In: Clinical Evidence. 2000;4:649-663.
13. Zuelzer WA. Knee bracing. In: Physical Rehabilitation of the Injured Athlete. Ch.14. JR Andrews, GL Harrelson, eds. Philadelphia, PA: W.B. Saunders Co.; 1991:211-220.
14. No authors listed. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee. 2000 update. Arthritis Rheum. 2000;43(9):1905-1915.
15. Hewett TE, Noyes RF, Barber-Westin SD, et al. Decrease in knee joint pain and increase in function in patients with medial compartment arthrosis: A prospective analysis of valgus bracing. Orthopedics. 1998;21(2):131-138.
16. Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am. 1999;81(4):539-548.
17. Lindenfeld TN, Hewett TE, Andriacchi TP. Joint loading with valgus bracing in patients with varus gonarthrosis. Clin Orthop. 1997;344:290-297.
18. 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.
19. 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.
20. TriCenturion, LLC. Spinal orthoses: TLSO and LSO. Local Medical Review Policy. Medicare DMERC Region A. Policy No. TLSO20030701. Columbia, SC: TriCenturion; July 1, 2003. Available at: http://www.tricenturion.com/content/lmrp_current_dyn.cfm. Accessed February 5, 2004.
Property of Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
February 17, 2004 // end hiding —->Copyright 2001-2004 Aetna Inc.