LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone Toll-free: 866.814.0192 or 305.436.5030
Fax Toll-free: 866.818.0373 or 305.436.0086
E-mail Address: orders {at] LEEDerGroup [dot] com

2007-07 LCD for Ankle-Foot/Knee-Ankle-Foot Orthosis (L11527)

Ambulation boot Multi Podus with Fleece
  • Click Video Arrow for Measurement, Application and Assembly:

LCD for Ankle-Foot/Knee-Ankle-Foot Orthosis (L11527)

Contractor Information

Contractor Name

TriCenturion

Contractor Number

77011

Contractor Type

DME PSC

DME MAC/DMERC this DME PSC is affiliated with

AdminaStar Federal, Inc (Region B), National Heritage Insurance Company (Region A)

LCD Information

LCD ID Number

L11527

LCD Title

Ankle-Foot/Knee-Ankle-Foot Orthosis

Contractor’s Determination Number

AFO20070701

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ? 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy

None

Primary Geographic Jurisdiction

Connecticut
District of Columbia
Delaware
Illinois
Indiana
Kentucky
Massachusetts
Maryland
Maine
Michigan
Minnesota
New Hampshire
New Jersey
New York – Entire State
Ohio
Pennsylvania
Rhode Island
Virginia
Vermont
Wisconsin
West Virginia

Oversight Region

Region III
Region V

DME Region LCD Covers

Jurisdiction A/B

Original Determination Effective Date

For services performed on or after 10/01/1993

Original Determination Ending Date

Revision Effective Date

For services performed on or after 07/01/2007

Revision Ending Date

Indications and Limitations of Coverage and/or Medical Necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this medical policy, the criteria for “reasonable and necessary” are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

AFOs NOT USED DURING AMBULATION:

A static ankle-foot orthosis (AFO) (L4396) is covered if either all of criteria 1 – 4 or criterion 5 is met:

1) Plantar flexion contracture of the ankle (ICD-9 diagnosis code 718.47) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and,

2) Reasonable expectation of the ability to correct the contracture; and,

3) Contracture is interfering or expected to interfere significantly with the patient’s functional abilities; and,

4) Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.

5) The patient has plantar fasciitis (ICD-9 diagnosis code 728.71)

If a static AFO is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home).

A static AFO and replacement interface will be denied as not medically necessary if the contracture is fixed. A static AFO and replacement interface will be denied as not medically necessary for a patient with a foot drop but without an ankle flexion contracture. A component of a static AFO that is used to address positioning of the knee or hip will be denied as not medically necessary because the effectiveness of this type of component is not established.

If code L4396 is covered, a replacement interface (L4392) is covered as long as the patient continues to meet indications and other coverage rules for the splint. Coverage of a replacement interface is limited to a maximum of one (1) per 6 months. Additional interfaces will be denied as not medically necessary.

Medicare does not reimburse for a foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394). A foot drop splint/recumbent positioning device and replacement interface will be denied as not medically necessary in a patient with foot drop who is nonambulatory because there are other more appropriate treatment modalities.

AFOs AND KAFOs USED DURING AMBULATION:

Ankle-foot orthoses (AFO) described by codes L1900-L1990, L2106-L2116, L4350, L4360, and L4386 are covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.

Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory patients for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not medically necessary.

AFOs and KAFOs that are molded-to-patient-model, or custom-fabricated, are covered for ambulatory patients when the basic coverage criteria listed above and one of the following criteria are met:

1) The patient could not be fit with a prefabricated AFO, or

2) The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months), or

3) There is a need to control the knee, ankle or foot in more than one plane, or

4) The patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury, or

5) The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

If the specific criteria for a molded-to-patient-model or custom-fabricated orthosis are not met, but the criteria for a prefabricated, custom fitted orthosis are met, payment will be based on the allowance for the least costly medically appropriate alternative.

L coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2830) will be denied as not medically necessary if either the base orthosis is not medically necessary or the specific addition is not medically necessary.

Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are an integral part of a brace.

MISCELLANEOUS:

Replacement of a complete orthosis or component of an orthosis due to loss, significant change in the patient’s condition, or irreparable accidental damage is covered if the device is still medically necessary. The reason for the replacement must be documented in the supplier’s record.

Quantities of supplies greater than those described in the policy as the usual maximum amounts, in the absence of documentation clearly explaining the medical necessity of the excess quantities, will be denied as not medically necessary.

Coverage Topic

Braces (arm, leg, back, and neck)

Coding Information

CPT/HCPCS Codes

The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service.
GY – Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
LT – Left Side
RT – Right Side

HCPCS CODES:

L1900

ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND, CUSTOM-FABRICATED

L1901

ANKLE ORTHOSIS, ELASTIC, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (E.G. NEOPRENE, LYCRA)

L1902

ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L1904

ANKLE FOOT ORTHOSIS, MOLDED ANKLE GAUNTLET, CUSTOM-FABRICATED

L1906

ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L1907

AFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICATED

L1910

ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L1920

ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE), CUSTOM-FABRICATED

L1930

ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L1932

AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L1940

ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATED

L1945

ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION), CUSTOM-FABRICATED

L1950

ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOM-FABRICATED

L1951

ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L1960

ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED

L1970

ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED

L1971

ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L1980

ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR ‘BK’ ORTHOSIS), CUSTOM-FABRICATED

L1990

ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (DOUBLE BAR ‘BK’ ORTHOSIS), CUSTOM-FABRICATED

L2000

KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR ‘AK’ ORTHOSIS), CUSTOM-FABRICATED

L2005

KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCE CONTROL, AUTOMATIC LOCK AND SWING PHASE RELEASE, MECHANICAL ACTIVATION, INCLUDES ANKLE JOINT, ANY TYPE, CUSTOM FABRICATED

L2010

KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR ‘AK’ ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM-FABRICATED

L2020

KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (DOUBLE BAR ‘AK’ ORTHOSIS), CUSTOM-FABRICATED

L2030

KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS, (DOUBLE BAR ‘AK’ ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATED

L2034

KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, MEDIAL LATERAL ROTATION CONTROL, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED

L2035

KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, STATIC (PEDIATRIC SIZE), WITHOUT FREE MOTION ANKLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L2036

KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED

L2037

KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED

L2038

KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE, MULTI-AXIS ANKLE, CUSTOM FABRICATED

L2106

ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED

L2108

ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED

L2112

ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L2114

ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L2116

ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L2126

KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED

L2128

KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED

L2132

KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L2134

KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L2136

KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L2180

ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH ANKLE JOINTS

L2182

ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINT

L2184

ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINT

L2186

ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTABLE MOTION KNEE JOINT, LERMAN TYPE

L2188

ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, QUADRILATERAL BRIM

L2190

ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELT

L2192

ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND, THIGH FLANGE, AND PELVIC BELT

L2200

ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT

L2210

ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT

L2220

ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST, EACH JOINT

L2230

ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENT

L2232

ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L2240

ADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE ATTACHMENT

L2250

ADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT MODEL, STIRRUP ATTACHMENT

L2260

ADDITION TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP (SCOTT-CRAIG TYPE)

L2265

ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUP

L2270

ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION (‘T’) STRAP, PADDED/LINED OR MALLEOLUS PAD

L2275

ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION, PADDED/LINED

L2280

ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOT

L2300

ADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP INVOLVEMENT), JOINTED, ADJUSTABLE

L2310

ADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHT

L2320

ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L2330

ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L2335

ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BAND

L2340

ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODEL

L2350

ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENT MODEL, (USED FORPTB’ ‘AFOORTHOSES)

L2360

ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANK

L2370

ADDITION TO LOWER EXTREMITY, PATTEN BOTTOM

L2375

ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID STIRRUP

L2380

ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINT

L2385

ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT

L2387

ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS, EACH JOINT

L2390

ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT

L2395

ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT

L2397

ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE

L2405

ADDITION TO KNEE JOINT, DROP LOCK, EACH

L2415

ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE, OR EQUAL), ANY MATERIAL, EACH JOINT

L2425

ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION, EACH JOINT

L2430

ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION, EACH JOINT

L2492

ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING

L2500

ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT BEARING, RING

L2510

ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, MOLDED TO PATIENT MODEL

L2520

ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, CUSTOM FITTED

L2525

ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM MOLDED TO PATIENT MODEL

L2526

ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM, CUSTOM FITTED

L2530

ADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LACER, NON-MOLDED

L2540

ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENT MODEL

L2550

ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH ROLL CUFF

L2750

ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BAR

L2755

ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L2760

ADDITION TO LOWER EXTREMITY ORTHOSIS, EXTENSION, PER EXTENSION, PER BAR (FOR LINEAL ADJUSTMENT FOR GROWTH)

L2768

ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BAR

L2770

ADDITION TO LOWER EXTREMITY ORTHOSIS, ANY MATERIALPER BAR OR JOINT

L2780

ADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE 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

ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION

L2830

ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE SECTION

L2840

ADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTH SOCK, FRACTURE OR EQUAL, EACH

L2850

ADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORAL LENGTH SOCK, FRACTURE OR EQUAL, EACH

L2860

ADDITION TO LOWER EXTREMITY JOINT, KNEE OR ANKLE, CONCENTRIC ADJUSTABLE TORSION STYLE MECHANISM, EACH

L2999

LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED

L4002

REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE

L4010

REPLACE TRILATERAL SOCKET BRIM

L4020

REPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MODEL

L4030

REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTED

L4040

REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L4045

REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L4050

REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L4055

REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY

L4060

REPLACE HIGH ROLL CUFF

L4070

REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO

L4080

REPLACE METAL BANDS KAFO, PROXIMAL THIGH

L4090

REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH

L4100

REPLACE LEATHER CUFF KAFO, PROXIMAL THIGH

L4110

REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH

L4130

REPLACE PRETIBIAL SHELL

L4205

REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES

L4210

REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS

L4350

ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L4360

WALKING BOOT, PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L4370

PNEUMATIC FULL LEG SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L4386

WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L4392

REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO

L4394

REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT

L4396

STATIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, PRESSURE REDUCTION, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

L4398

FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

ICD-9 Codes that Support Medical Necessity

The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on “Indications and Limitations of Coverage and/or Medical Necessity” for other coverage criteria and payment information.

For HCPCS codes L4392 and L4396:

718.47

CONTRACTURE OF ANKLE AND FOOT JOINT

728.71

PLANTAR FASCIAL FIBROMATOSIS

Diagnoses that Support Medical Necessity

For the specific HCPCS codes indicated above, refer to previous section. For all other HCPCS codes, diagnoses are not specified.

ICD-9 Codes that DO NOT Support Medical Necessity

For the specific HCPCS code indicated above, all ICD-9 codes that are not specified in the preceding section. For all other HCPCS codes, diagnoses are not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity

For the specific HCPCS code indicated above, all diagnoses that are not specified in the preceding section. For all other HCPCS codes, diagnoses are not specified.

General Information

Documentation Requirements

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider.” It is expected that the patient’s medical records will reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each new or full replacement item must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

The order must list the unique features of the base code that is billed plus every addition that will be billed on a separate claim line. The medical record must contain information which supports the medical necessity of the item and all additions that are ordered. An order is not necessary for the repair of an orthosis.

The supplier must include on the claim for a static AFO (L4396) or replacement interface material (L4392) the ICD-9 diagnosis code for the underlying condition.

For custom-fabricated orthoses, there must be documentation in the supplier’s records to support the medical necessity of that type device rather than a prefabricated orthosis. This information does not have to be routinely sent in with the claim, but must be available upon request.

If an AFO or KAFO is used solely for the treatment of edema and/or for the prevention or treatment of a pressure ulcer, the GY modifier must be added to the base code and any related addition code. If a walking boot (L4360, L4386), static AFO (L4396) or foot drop splint/recumbent positioning device (L4398) is used solely for the prevention or treatment of a pressure ulcer, the GY modifier must be added to the base code and to the code for the replacement liner (L4392, L4394). When the GY modifier is added to a code there must be a short narrative statement indicating why the GY modifier was used – e.g., “used to prevent pressure ulcer” or “used to treat pressure ulcer” or “used to treat edema”. This statement should be entered in the narrative field of an electronic claim or attached to a hard copy claim.

A claim for code L2999 must include either a narrative description of the item (for custom fabricated items) or the manufacturer name and model name/number (for pre-fabricated items). For replacement components billed with code L2999, there must also be a HCPCS code or the manufacturer name and model name/number of the base orthosis. This information should be entered in the narrative field of an electronic claim.

A claim for code L4205 must include an explanation of what is being repaired. A claim for code L4210 must include a description of each item that is billed. This information should be entered in the narrative field of an electronic claim.

All codes for orthoses or repairs of orthoses billed with the same date of service must be submitted on the same claim.

When billing for quantities of supplies greater than those described in the policy as the usual maximum amounts, there must be documentation in the patient’s medical record supporting the medical necessity for the higher utilization. This information must be available upon request.

Refer to the Orthopedic Footwear policy for information on documentation requirements for shoes and related items which are an integral part of a brace.

Refer to the Supplier Manual for more information on documentation requirements.

Appendices

Utilization Guidelines

Refer to Indications and Limitations of Coverage and/or Medical Necessity.

Sources of Information and Basis for Decision

Advisory Committee Meeting Notes

Start Date of Comment Period

04/16/1993

End Date of Comment Period

05/31/1993

Start Date of Notice Period

08/01/1993

Revision History Number

AFO013

Revision History Explanation

Revision Effective Date: 07/01/2007
INDICATIONS AND LIMITATIONS OF COVERAGE:
Removed: References to DMERC.
DOCUMENTATION REQUIREMENTS:
Removed: References to DMERC.

06/01/2007 – In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

03/01/2006 – In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TriCenturion (77011) from DMERC Tricenturion (77011).

Revision Effective Date: 01/01/2006
HCPCS CODES AND MODIFIERS:
Added: L2034 and L2387
Deleted: L2039
DOCUMENTATION REQUIREMENTS:
Removed requirement for documentation to be attached to the claim.

Revision Effective Date: 04/01/2005
HCPCS CODES AND MODIFIERS:
Added: L1932, L2005, L2232, L4002
Revised: L2035, L2036, L2037, L2038, L2039, L2320, L2330, L2755, L2800, L4040, L4045, L4050, L4055
Deleted: L2435

Revision Effective Date: 07/01/2004
LMRP converted to LCD and Policy Article
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added coverage of codes L4392 and L4396 for the treatment of plantar fasciitis (ICD-9 diagnosis code 728.71).

Revision Effective Date: 04/01/2004
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added codes L4360 and L4386 to paragraph describing coverage of braces used for edema and pressure ulcers.
HCPCS CODES AND MODIFIERS:
Added: L1907, L1951 and L1971
Revised: L1950, L4350, L4360, L4386
DOCUMENTATION REQUIREMENTS:
Added L4360 and L4386 to list of codes requiring the use of modifier GY when used to treat pressure ulcers

Revision Effective Date: 07/01/2003
HCPCS CODES AND MODIFIERS:Corrected HCPCS array to add L4350 – L4370 which were inadvertently omitted from 04/01/2003 revision.

Revision Effective Date: 04/01/2003
HCPCS CODES AND MODIFIERS:
Added: L1901, L4386, EY
INDICATIONS ANDLIMITATIONS OF COVERAGE:
Adds standard language concerning coverage of items without an order.
Adds code L4350, L4360, L4370 and L4386 to range of codes used with ambulatory patients only.
DOCUMENTATION REQUIREMENTS:
Adds standard language concerning use of EY modifier for items without an order.
Revised to allow either ICD-9 diagnosis code or narrative description on order for codes L4392 and L4396.

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

04/01/2002 – Added new HCPCS codes descriptors adding “prefabricated.” Added new descriptor for code L4396. Deleted splint codes now under local carrier jurisdiction-L2102, L2104, L2122, L2124. Added definition of custom-fabricated. Added RT and LT modifiers. Added new GY modifier.

06/01/1999 – Added HCPCS codes. Revised text for entire policy.

07/01/1996 – Corrected description for L1980.

04/01/1996 – Corrected description for L1990.

10/01/1995 – Revised Documentation section, removing Certificate of Medical Necessity requirement.

06/01/1994 – Corrected typo in Coverage and Payment Rules section from 1920 to L1920.

Reason for Change

Last Reviewed On Date

Related Documents

Article(s)
A19806 – Ankle-Foot/Knee-Ankle-Foot Orthosis – Policy Article – Effective July 2007

LCD Attachments

There are no attachments for this LCD

Article for Ankle-Foot/Knee-Ankle-Foot Orthosis – Policy Article – Effective July 2007 (A19806)

Contractor Information

Contractor Name, Number, and Type

DME PSC: TriCenturion (77011)
DME MAC: National Government Services (17003) , NHIC (16003)

Article Information

Article ID Number

A19806

Article Type

Article

Key Article

Yes

Article Title

Ankle-Foot/Knee-Ankle-Foot Orthosis – Policy Article – Effective July 2007

AMA CPT / ADA CDT Copyright Statement

CPT codes, descriptions and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. ? 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Primary Geographic Jurisdiction

Connecticut
District of Columbia
Delaware
Illinois
Indiana
Kentucky
Massachusetts
Maryland
Maine
Michigan
Minnesota
New Hampshire
New Jersey
New York – Entire State
Ohio
Pennsylvania
Rhode Island
Virginia
Vermont
Wisconsin
West Virginia

DME Region Article Covers

Jurisdiction A/B

Original Article Effective Date

06/01/2004

Article Revision Effective Date

07/01/2007

Article Text

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES

For an item to be considered for coverage under the Brace benefit category, it must be a rigid or semi-rigid device which is used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. It must provide support and counterforce (i.e., a force in a defined direction of a magnitude at least as great as a rigid or semi-rigid support) on the limb or body part that it is being used to brace. Items that do not meet the definition of a brace are noncovered.

A static Ankle-Foot Orthosis (AFO) and replacement interface (L4392) is noncovered when it is used solely for the prevention or treatment of a heel pressure ulcer because for these indications it is not used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace).

Medicare does not reimburse for a foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394). A foot drop splint/recumbent positioning device and replacement interface is noncovered when it is used solely for the prevention or treatment of a pressure ulcer because for these indications it is not used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace).

The purpose of a brace is to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body. When an AFO or KAFO for an ambulatory patient and any related addition is used solely for the treatment of edema and/or for the prevention or treatment of a pressure ulcer, it will be denied as noncovered. For example, codes L4360 and L4386 are ankle-foot orthoses that are referred to as walking boots. Walking boots used to provide immobilization as treatment for an orthopedic condition or after orthopedic surgery are eligible for coverage under the Brace benefit. When walking boots are used primarily to relieve pressure, especially on the sole of the foot, or are used for patients with foot ulcers, they are noncovered – no Medicare benefit. Medicare covers therapeutic shoes, as described in the Therapeutic Shoes for Persons with Diabetes policy, for the prevention and treatment of diabetic foot ulcers.

Socks (L2840, L2850) used in conjunction with orthoses are noncovered – no Medicare benefit.

Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are not covered.

Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are an integral part of a brace.

CODING GUIDELINES

Ankle flexion contracture is a condition in which there is shortening of the muscles and/or tendons that plantarflex the ankle with the resulting inability to bring the ankle to 0 degrees by passive range of motion. (0 degrees ankle position is when the foot is perpendicular to the lower leg.)

Foot drop is a condition in which there is weakness and/or lack of use of the muscles that dorsiflex the ankle but there is the ability to bring the ankle to 0 degrees by passive range of motion.

Plantar fasciitis is an inflammation of the heel of the foot typically resulting from trauma to the deep tissue of the foot (i.e., plantar fascia).

A prefabricated orthosis is one which is manufactured in quantity without a specific patient in mind. A prefabricated orthosis may be trimmed, bent, molded (with or without heat), or otherwise modified for use by a specific patient (i.e., custom fitted). An orthosis that is assembled from prefabricated components is considered prefabricated. Any orthosis that does not meet the definition of a custom-fabricated orthosis is considered prefabricated.

A custom-fabricated orthosis is one which is individually made for a specific patient starting with basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of sheets, bars, etc. It involves substantial work such as cutting, bending, molding, sewing, etc. It may involve the incorporation of some prefabricated components. It involves more than trimming, bending, or making other modifications to a substantially prefabricated item.

A molded-to-patient-model orthosis is a particular type of custom-fabricated orthosis in which an impression of the specific body part is made (by means of a plaster cast, CAD-CAM technology, etc.) and this impression is then used to make a positive model (of plaster or other material) of the body part. The orthosis is then molded on this positive model.

Ankle-foot orthoses extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. These features distinguish them from foot orthotics which are shoe inserts that do not extend above the ankle.

A nonambulatory ankle-foot orthosis may be either an ankle contracture splint, night splint or a foot drop splint.

A static AFO (L4396) is a prefabricated ankle-foot orthosis which has all of the following characteristics:

1) Designed to accommodate either plantar fasciitis or an ankle with a plantar flexion contracture up to 45°; and,

2) Applies a dorsiflexion force to the ankle; and,

3) Used by a patient who is minimally ambulatory, or nonambulatory; and,

4) Has a soft interface.

A foot drop splint/recumbent positioning device (L4398) is a prefabricated ankle-foot orthosis which has all of the following characteristics:

1) Designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg); and,

2) Not designed to accommodate an ankle with a plantar flexion contracture; and,

3) Used by a patient who is nonambulatory; and,

4) Has a soft interface.

Codes L1900, L1904, L1907, L1920, L1940-L1950, L1960-L1970, L1980-L2030, L2034-L2108, and L2126-L2128 describe custom-fabricated orthoses. These codes must not be used for prefabricated (i.e., non-custom-fabricated) orthoses.

Codes L1901, L1902, L1906, L1910, L1930, L1951, L1971, L2035, L2112-L2116,and L2132-L2136 describe prefabricated orthoses. These codes must not be used for custom-fabricated orthoses.

Codes L1900-L1990, L2106-L2116, L4350, L4360, and L4386 are used for an ankle-foot orthosis which is worn when a patient is ambulatory. Code L4396 is used for an ankle-foot orthosis which is worn when a patient is nonambulatory, or minimally ambulatory. Code L4398 is used for an ankle-foot orthosis which is worn when a patient is nonambulatory.

Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. For example, replacement soft interfaces used with ankle contracture orthoses or foot drop splints are billed with codes L4392 and L4394, respectively. Replacement components that do not have a unique HCPCS code must be billed with a “not otherwise specified” code – L2999. HCPCS codes L4050-L4055 do not describe replacement soft interfaces used with contracture orthoses.

Code L4205 is used for the labor component of repair of a previously provided orthosis except for any labor involved in the replacement of an orthotic component that has a specific L code. It may only be billed for the actual time involved in the repair of an orthosis. It must not be used for any labor involved in the evaluation, fabrication, or fitting of a new or full replacement orthosis. Labor involved in the replacement of an orthotic component that has a specific L code is not separately billable.

Ankle-foot orthoses extend well above the ankle (usually to near the top of the calf) and are fastened around the lower leg above the ankle. Foot orthotics are shoe inserts that do not extend above the ankle. The correct codes for foot orthotics provided for patients without diabetes are L3000-L3090 (Refer to the Orthopedic Footwear policy for more information). Multiple density foot orthotics used in the management of diabetic foot problems are coded K0628 and K0629 (Refer to the Therapeutic Shoes for Persons with Diabetes policy for more information).

Code L2860 is invalid for claim submission. Claims for prefabricated or custom-fabricated devices that contain a concentric adjustable torsion style mechanism in the knee or ankle joint and that are being used to treat a joint contracture should be coded as E1810 (dynamic adjustable knee extension/flexion device) or E1815 (dynamic adjustable ankle extension/flexion device), respectively. If a concentric adjustable torsion style mechanism in the knee or ankle joint is used in a custom-fabricated orthosis to provide an assist function to joint motion during ambulation, it should be coded as L2999.

The right (RT) and left (LT) modifiers must be used with orthosis base codes, additions, and replacement parts. When the same code for bilateral items (left and right) is billed on the same date of service, bill both items on the same claim line using the LTRT modifiers and 2 units of service.

Evaluation of the patient, measurement and/or casting, and fitting of the orthosis are included in the allowance for the orthosis. There is no separate payment for these services.

Repairs to a covered orthosis due to wear or to accidental damage are covered when they are necessary to make the orthosis functional. The reason for the repair must be documented in the supplier’s record. If the expense for repairs exceeds the estimated expense of providing another entire orthosis, no payment will be made for the amount in excess.

The allowance for the labor involved in replacing an orthotic component that is coded with a specific L code is included in the allowance for that component. The allowance for the labor involved in replacing an orthotic component that is coded with the miscellaneous code L4210 is separately payable in addition to the allowance for that component.

Suppliers should contact the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) for guidance on the correct coding of these items.

A column II code must not be billed in addition to the corresponding column I code when provided at the same time for the same limb.

Column I (Column II)
L1900, L1910, L1920, L1980, L1990 (L4002, L4090, L4110)
L2000-L2030 (L4002, L4070, L4080, L4090, L4100, L4110)
L2034, L2036, L2037 (L4002, L4070)
L2188 (L4002, L4020, L4030)
L2320 (L4045, L4055)
L2330 (L4040, L4050)
L2335 (L4090)
L2340 (L4130)
L2510 (L4020)
L2520 (L4030)
L2530 (L4045)
L2540 (L4040)
L2550 (L4060)

Coverage Topic

Braces (arm, leg, back, and neck)

Other Information

Revision History Explanation

Revision Effective Date: 07/01/2007
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Changed title of previous Therapeutic Shoes for Diabetics LMRP, to the new LCD title – Therapeutic Shoes for Persons with Diabetes.
CODING GUIDELINES:
Changed title of previous Therapeutic Shoes for Diabetics LMRP, to the new LCD title – Therapeutic Shoes for Persons with Diabetes.
Removed: Reference to DMERC.

06/01/2007 – In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

03/01/2006 – In accordance with Section 911 of the Medicare Modernization Act of 2003, this article was transitioned to DME PSC TriCenturion (77011) from DMERC Tricenturion (77011).

Revision Effective Date: 01/01/2006
CODING GUIDELINES:
Added: L2034
Deleted: L2039

Revision Effective Date: 04/01/2005
CODING GUIDELINES:
Add L4002 to correct coding table

Revision Effective Date: 07/01/2004
LMRP Converted to LCD and Policy Article
CODING GUIDELINES:
Revised definition of L4396 to include use in the treatment of plantar fasciitis

Related Documents

LCD
L11527 – Ankle-Foot/Knee-Ankle-Foot Orthosis