Braces and supports are used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body. Payment may be made for rigid and semi-rigid braces and supports when prescribed by a physician. Purchase of more than two of the same type of brace or support on the same day is not considered medically necessary.

Completely elastic supports [e.g., athletic supporter, joint supports (L1901, L3651, L3652, L3701, L3909, L3911), trusses, etc.] are not eligible for payment. Supports (K0630, K0631, K0637, K0638, K0639, L0160, L0180-L0200, L0960) and trusses with pads (L8300-L8330) are considered semi-rigid, however, and are covered items. In addition to the previously listed semi-rigid braces, elastic stockings (L8100-L8239) are covered if prescribed by a physician and medically necessary for treatment of illness or injury, e.g., ambulatory patients. Coverage for elastic stockings (L8100-L8239) is limited to three pairs or six single stockings in a six-month period.

A hernia support which meets the definition of a covered brace, whether in the form of a corset (K0637, K0638) or a truss (L8300-L8330), is eligible for payment when the patient's hernia is reducible. When a corset is prescribed for use as a hernia support, the claim should be processed under procedure code K0637 or K0638.

The Sykes Hernia Control (a spring-type, U-shaped, strapless truss)(L8499) is not more beneficial than a conventional truss. Reimbursement for this device should be based on the allowance for a conventional truss (codes L8300-L8310).

The lower leg/foot orthotic device (e.g. Multi-Podus splint, E-Z boot) is eligible for reimbursement and should be reported under procedure code L4396. This device is useful in treating the following correctable conditions:

1. Foot drop
   
   1. 40 percent or less (as measured in degrees) and
   2. has existed for less than six months
2. Hip rotation
3. Lower leg contractures that are not permanent and have existed for less than two years.

• The joint is not fixed (i.e., it is mobile).
• The patient must be in an active rehabilitation/physical medicine program, and must have received treatment for their condition within the preceding 30 days.

If a separate charge is received for fleece-like lining in addition to the lower leg/foot device, the separate charge should be combined with the lower leg/foot device and payment should be made only for the device. Make payment for the fleece-like lining (L4392) only if it is billed independently as a replacement for the original lining. Payment for the replacement lining should be made only once every six months.

Prosthetic devices which are dispensed to a patient prior to performance of the procedure that will necessitate use of the device are not covered. Dispensing a prosthetic device in this manner would not be considered reasonable and necessary for the treatment of the patient's condition.

Coverage for Prosthetics and Orthotics is determined according to individual or group customer benefits.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Elastic stockings (L8100-L8220) are eligible for payment.

PRN References

02/2004, Blue Shield revises coverage guidelines for antiembolism stockings and elastic stockings

MCM 2133

MCIM 70-1, 70-2