CIGNA HEALTHCARE COVERAGE POSITION
Subject Knee Braces
Effective Date……………………….5/15/2005
Coverage Position Number………….0362
Table of Contents
Related Coverage Positions
Foot Orthosis, Ankle Orthosis, Ankle-Foot Orthosis (AFO), Knee-Ankle-Foot Orthosis (KAFO)
Joint Stretch Devices
Coverage Position………………………………………..1
General Background…………………………………….2
Coding/Billing Information……………………………..6
References………………………………………………….8
INSTRUCTIONS FOR USE
Coverage Positions are intended to supplement certain standard CIGNA HealthCare benefit plans. Please note, the terms of a participant’s particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Positions are based. For example, a participant’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Position. In the event of a conflict, a participant’s benefit plan document always supercedes the information in the Coverage Positions. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of 1) the terms of the applicable group benefit plan document in effect on the date of service; 2) any applicable laws/regulations; 3) any relevant collateral source materials including Coverage Positions and; 4) the specific facts of the particular situation. ©2005 CIGNA Health Corporation
Coverage Position
Under most CIGNA HealthCare benefit plans, coverage for medically necessary knee orthoses is subject to the terms, conditions and limitations of the External Prosthetic Appliances (EPA) benefit. Some CIGNA HealthCare benefit plans may exclude or limit coverage for orthotic devices. Please refer to the applicable CIGNA HealthCare plan document to determine benefit availability and terms and conditions of coverage.
In addition, unmodified, prefabricated orthoses are generally used in treating conditions prior to the use of a custom-fitted orthosis (prefabricated orthoses that are modified by bending or molding for a specific patient). Custom-fitted orthoses are generally attempted prior to the use of custom-fabricated orthoses (individually constructed from materials).
If coverage for orthotic devices (prefabricated, custom-fitted, or custom-fabricated) is available, then the following conditions apply.
CIGNA HealthCare covers a fracture knee brace or a rehabilitative knee brace as medically necessary when applied immediately after initial stabilization (e.g., post-surgery, post-injury, post- fracture).
CIGNA HealthCare covers a patellofemoral knee brace as medically necessary for the treatment of patellofemoral dislocations or chronic patellar symptomatic subluxation when EITHER of the following criteria has been met:
- following reduction for an acute (initial) patellar dislocation
- There is written documentation of failure of a three-month exercise and strengthening rehabilitative program for a diagnosis of dislocation/subluxation of the patella confirmed by ANY ONE of the following:
Page 1 of 10
Coverage Position Number: 0362 - plain radiography
- computerized tomography (CT) scan
- history and physical findings consistent with diagnosis
CIGNA HealthCare covers functional knee braces as medically necessary when there is documented knee instability, and the patient is not considered a surgical candidate for ligament reconstruction.
CIGNA HealthCare covers unloading/offloading knee braces as medically necessary for the treatment of moderate to severe osteoarthritis of the knee when ALL of the following criteria are met: - unicompartmental disease that requires load reduction to an affected compartment
- documented failure of prior medical treatment modalities (e.g., nonsteroidal antiinflammatory medications, steroid injections, viscoelastic supplementation)
- radiographic documentation of single-compartment osteoarthritis with or without varus/valgus deformity
- persistent knee pain limiting activities of daily living
CIGNA HealthCare does not cover ANY of the following knee braces as they are considered not medically necessary (this list may not be all inclusive): - prophylactic knee braces
- functional knee braces utilized solely for participation in sports
- patellofemoral knee braces/sleeves for the treatment of postoperative knee effusion or patellofemoral syndrome
- functional knee braces after successful reconstructive ligament surgery
Note: The proposed application of the requested knee brace (rather than the name of the brace) needs to be determined in order to apply the above coverage criteria.
General Background
The knee is the body’s primary weight-bearing joint and is one of the most frequently injured joints. The medial-collateral and anterior-cruciate ligaments are the major stabilizers of the knee and can be injured when forces (direct or indirect) are applied to the knee. Several types of knee braces are available that may be utilized in treating patients with injuries or disorders of the knee. In some cases, they are used primarily for prevention of injuries while participating in sports. They can be constructed from a variety of materials, such as foam, metal, plastic, elastic material or straps and include three basic components: a superstructure (rigid shell), a hinge, and a strap system.
A brace is defined as an orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body and that allows for motion of that part. It must be a rigid or semi-rigid device, used for the purpose of supporting a weak or deformed body member or of restricting or eliminating motion in a diseased or injured part of the body. It must provide support and counterforce on the limb on which it is being used.
The major functions of current knee brace designs are to resist abnormal joint motions, to augment the inherent mechanical stability of a normal knee, and to assist in restoration of normal mechanical stability in an injured or rehabilitating knee (France and Paulos, 1994). Tibiofemoral knee braces are recommended for treatment of knee instability due to injury (e.g., fracture) or surgery, for treatment of painful osteoarthritis of the knee, or when required to perform activities of daily living. Knee braces may also be indicated for prevention of further injury due to previous knee instability; however, knee braces are not considered medically necessary when used for participation in sports or recreational activities or in the absence of disease. Participation in sports and recreational activities are considered elective activities.