An orthotic is a rigid or semi-rigid device used to support, restore, or protect body function. Orthotics may also redirect or restrict motion of an impaired body part.

Orthotic devices are considered medically necessary when prescribed by a qualified provider to be used for the therapeutic support, protection, restoration, or function for an impaired body part. Orthotic devices used for other diagnoses or conditions are considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Orthotic devices include:

• braces for leg, arm, neck, back, and shoulder;
• corsets for back or for use after special surgical procedures;
• splints for extremities;
• trusses

See Medical Policy Bulletin O-12 for additional information on Foot orthotics for conditions other than diabetes.

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. The following codes are not covered for FEP: L3040, L3050, L3060, L3215, L3216, L3217, L3219, L3221, L2120, L3222, L3332, L3480 and L3485.

Blue Cross Blue Shield Association Medical Policy 1.03.01; Issue 1:2003