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| Section: | Orthotic & Prosthetic Devices |
| Number: | O-8 |
| Topic: | Braces and Supports |
| Effective Date: | October 11, 2010 |
| Issued Date: | January 17, 2011 |
| Date Last Reviewed: |
Indications and Limitations of Coverage
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 considered not 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) 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). 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. |
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| L0160 | L0180 | L0190 | L0200 | L0621 | L0622 |
| L0628 | L0629 | L0630 | L8300 | L8310 | L8320 |
| L8330 | L8499 |
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This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits, or a contract. Benefits are determined by the Federal Employee Program. |
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CMS On-Line Manual Pub. 100-02 Ch. 15 Section 130 CMS On-Line Manual Pub. 100-03 Ch. 1 Section 280.12 |
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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.
Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.
Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Highmark West Virginia plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.
Highmark West Virginia retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of Highmark West Virginia. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.
