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.

Guidelines for specific braces and supports are provided below.

Elastic Support
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.

Hernia Support
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.

Sykes Hernia Control
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 following braces may be considered medically necessary for the listed indications.

Back Braces

Supportive Back Braces

A supportive back brace is medically necessary for any of the following indications:

• To facilitate healing following an injury to the spine or related soft tissues; or
• To facilitate healing following a surgical procedure on the spine or related soft tissue (see section on Postoperative Back Braces below); or
• To reduce pain by restricting mobility of the trunk; or
• To support weak spinal muscles and/or a deformed spine.

Supportive back braces are considered not medically necessary for other indications. 

Following a strain/sprain, supportive back braces (back supports, lumbosacral supports, support vests) are used to render support to an injured site of the back. The main effect is to support the injured muscle and reduce discomfort. The following additional criteria apply to custom-fitted and custom-fabricated back braces.

•  A custom-fitted back brace (a prefabricated back brace modified to fit a specific member) is considered medically necessary where there is a failure, contraindication or intolerance to an unmodified, prefabricated (off-the-shelf) back brace.
• A custom-fitted back brace is considered medically necessary as the initial brace after surgical stabilization of the spine following traumatic injury.
• A custom-fabricated back brace (individually constructed to fit a specific member from component materials) is considered medically necessary if there is a failure, contraindication, or intolerance to a custom-fitted back brace.
• Custom-fitted and custom-fabricated back braces are considered not medically necessary when these criteria are not met.  

Postoperative Back Braces

Postoperative back braces are considered part of the surgical protocol for certain back operations.

Postoperative back braces are medically necessary to facilitate healing when applied within 6 weeks following a surgical procedure on the spine or related soft tissue.

A postoperative back brace is used to immobilize the spine following laminectomy with or without fusion and metal screw fixation is considered medically necessary. This brace promotes healing of the operative site by maintaining proper alignment and immobilization of the spine. Postoperative back braces are considered not medically necessary for other indications. 

Inflatable Lumbar Supports

Inflatable lumbar supports do not meet the definition of covered durable medical equipment because they are not durable (not made to withstand prolonged use) and because they are not mainly used in the treatment of disease or injury or to improve body function lost as the result of a disease or injury. A participating, preferred or network provider can bill the member for the non-covered device.

Protective Body Socks

Protective body socks do not meet the definition of covered durable medical equipment because they are not made to withstand prolonged use.  A participating, preferred, or network provider can bill the member for the non-covered service.

Cast-Braces (also called Fracture Braces)

1. Comfort, Non-Therapeutic
   
   Comfort, non-therapeutic cast-braces are considered medically necessary after a fracture or surgery. Comfort, non-therapeutic cast-braces are considered not medically necessary for other indications. 
   
   These braces are often used after the patient has been in a walking cast. They are usually removable. Molded casts, which allow the user to remove the cast to bathe the affected extremity, can also be used when a fracture is slow to heal or non-healing. The use of these removable casts replaces monthly cast changes. A removable cast of this type offers no therapeutic advantages over a non-removable cast.
   
   Example: Cam Walker
   
   
2. Functional Cast-Brace
   
   Functional cast-braces are considered medically necessary after a fracture or surgery. These have become the standard brace for certain fractures, including tibial-femoral fractures. The functional cast-brace is used following a short period of standard fracture treatment using a non-weight bearing or partial weight-bearing cast, or immediately following surgery. It allows protected weight bearing, and motion of the joints above and below the fracture. The joints are moved earlier, contractures are prevented, and early healing is affected due to the weight bearing. Functional cast-braces are considered not medically necessary for other indications.  
   
   Examples: PTB cast brace, PTB fracture brace, MAFO (molded ankle-foot orthosis) fracture brace with pelvic band, Achilles tendon hinged brace
   

Rehabilitation Braces 

Rehabilitation braces are often part of the surgical or fracture care protocol.

Other post-operative and post-injury braces are medically necessary when applied within six weeks of surgery or injury. These braces are considered not medically necessary for other indications.

Cervical (Neck) Braces

Cervical (neck) braces are considered medically necessary for members with neck injury and other appropriate indications.

Example: Philadelphia Cervical Collar

NOTE:

Cervical foam neck collars do not meet the definition of covered durable medical equipment because they are not durable, and not made to withstand prolonged use.

Childhood Hip Braces

Specialized hip braces are considered medically necessary for children with hip disorders to stabilize the hip and/or to correct and maintain hip abduction. These hip braces are considered not medically necessary for other indications. 

Example: Pavlik Harness, Frejka Pillow Splint, Friedman Strap

Braces for Congenital Defects

Orthopedic braces are medically necessary in the treatment of congenital defects. Replacement braces are also medically necessary when the member has outgrown the previous brace or because his/her condition has changed such as to make the previous brace unusable. This includes scoliosis braces.

A cervical-thoracic-lumbar-sacral or thoracic-lumbar-sacral orthosis may be considered medically necessary for the treatment of scoliosis in juvenile and adolescent patients at high-risk of progression which meets the following criteria:

• Idopathic spinal curve angle between 25 and 40 degrees; AND
• Spinal growth has not been completed (Risser grade 0-3; no more than 1 year post-menarche in females) OR
• Idiopathic spinal curve angle greater than 20 degrees; AND
• There is documented increase in the curve angle; AND
• At least 2 years growth remain (Risser grade 0 or 1; pre-menarche in females)

Use of an orthosis for the treatment of scoliosis that does not meet the criteria above is considered not medically necessary.

Wheaton Brace

A Wheaton Brace is considered medically necessary DME to treat metatarsus adductus in infants replacing the need for serial casting. A Wheaton Brace is considered not medically necessary for other indications. 

Splints and Immobilizers

Certain orthopedic problems are routinely treated with splints or splint-like devices. The following are considered medically necessary:

• Acromio-clavicular splint (also called a Zimmer splint)
• Carpal tunnel splints
• Clavicle splint (also called a figure-8 splint)
• Denis Browne Splint for children with clubfoot or metatarsus valgus to maintain and correct abduction
• Dynasplints under circumstances specified in Medical Policy Bulletin O-10 (See Medical Policy Bulletin O-10, Dynamic Splinting Devices).
• Finger splints
• Shoulder immobilizer.

Unna Boots

Unna boots are considered medically necessary only for non-fracture care. Unna boots have no proven value when used in conjunction with fracture treatment. They can be used to treat sprains and torn ligaments, provide protection for other soft tissue injuries and may be used after certain surgical procedures as a protective cover to promote healing. Occasionally they are used in the first days after a fracture before a cast is put on. Their use in this regard is considered not medically necessary.

Air Casts

Air Casts are considered medically necessary for treatment of fractures or other injuries (i.e., sprains, torn ligaments). Air Casts (air splints) are used as an alternative to plaster casts to immobilize an elbow, ankle, or knee. Air Casts are considered not medically necessary for other indications.

Miscellaneous Covered Services

• Casting of a sprain is considered medically necessary.
• Casting following surgical procedures is considered medically necessary.

Fiberglass vs. Plaster Casts

The casting material used in fracture care can be either fiberglass or plaster. The choice of material is dictated by the individual situation and is left to the discretion of the treating doctor.

For provider overhead expenses, see Medical Policy Bulletin Z-39.

For foot orthotics for conditions other than diabetes, see Medical Policy Bulletin O-12.

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

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

Dispensing of Prosthetic Devices

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.

Orthotics that do not meet the medical necessity criteria outlined in this policy will be denied 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.

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.

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.

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

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

Dixit S, DiFiori JP, Burton M, Mines B.  Management of patellofemoral pain syndrome.  AM Fam Physician.  2007;75(2):194-202.

Chew KT, Lew HL, Date E, Fredericson M.  Current evidence and clinical applications of therapeutic knee braces.  AM J Phys Med Rehabil. 2007;86(8):678-686.

Pollo FE, Jackson RW.  Knee bracing for unicompartmental osteoarthritis.  J AM Acad Orthop Surg.  2006;14(1):5-11.

BCBSA National Policy Reference Manual 2.01.83. 2010.