Mountain State Medical Policy Bulletin
Section: Orthotic & Prosthetic Devices
Number: O-8
Topic: Braces and Supports
Effective Date: January 1, 2006
Issued Date: January 2, 2006
Date Last Reviewed: 01/2006

General Policy Guidelines

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 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 (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.
In addition, the following criteria should be met:
  • 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.
However, when this device is used as a supportive foot device, as a training device for ambulation, or as a measure to prevent decubitus ulcers, the device is not covered and should be denied as such. Some contraindications for use of this device would be fixed contractures, arthritic conditions (other than rheumatoid arthritis), severe degenerative joint disease and sensory deficit in the lower extremity.

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.

Procedure Codes

L0160L0180L0190L0200L0621L0622
L0628L0629L0630L0960L1901L3651
L3652L3701L3909L3911L4392L4394
L4396L4398L8300L8310L8320L8330
L8499     

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

Refer to General Policy Guidelines

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

MCM 2133

MCIM 70-1, 70-2

View Previous Versions

[Version 001 of O-8]

Table Attachment

Text Attachment

Procedure Code Attachment


Glossary




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 Mountain State Blue Cross Blue Shield 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.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.