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, trusses, etc.] are not eligible for payment. Supports (L0160, L0180-L0200, L0621, L0622, L0628, L0629, L0630, L0960) and trusses with pads (L8300-L8330) are considered semi-rigid, however, and are covered items.

For compression stockings, see Medical Policy Bulletin E-1.

A hernia support which meets the definition of a covered brace, whether in the form of a corset (L0628, L0629) 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 L0628 or L0629.

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.

Ankle-foot orthosis and knee-ankle-foot orthoses 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 ankle-foot orthosis, or
2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than six 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 all the criteria on the medical policy are not met, the claim will deny as not medically necessary.  A participating, preferred, or network provider cannot bill the member for the denied service unless the provider has given advance written notice, informing the member that the service may be deemed not medically necessary and providing an estimate of the cost. The member must agree in writing to assume financial responsibility, in advance of receiving the service. The signed agreement should be maintained in the provider's records.

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.

CMS On-Line Manual Pub. 100-02 Ch. 15 Section 130

CMS On-Line Manual Pub. 100-03 Ch. 1 Section 280.12