Clinical Policy Bulletins
Number: 0009
Subject: Orthopedic Casts, Braces and Splints
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Important Note
This Clinical Policy Bulletin expresses Aetna's determination of
whether certain services or supplies are medically necessary. Aetna has
reached these conclusions based upon a review of currently available
clinical information (including clinical outcome studies in the
peer-reviewed published medical literature, regulatory status of the
technology, evidence-based guidelines of public health and health
research agencies, evidence-based guidelines and positions of leading
national health professional organizations, views of physicians
practicing in relevant clinical areas, and other relevant factors).
Aetna expressly reserves the right to revise these conclusions as
clinical information changes, and welcomes further relevant
information. Each
benefit plan defines which services are covered, which are excluded,
and which are subject to dollar caps or other limits. Members and their
providers will need to consult the member's benefit plan to determine
if there are any exclusions or other benefit limitations applicable to
this service or supply. The conclusion that a particular
service or supply is medically necessary does not constitute a
representation or warranty that this service or supply is covered
(i.e., will be paid for by Aetna) for a particular member. The member's
benefit plan determines coverage. Some plans exclude coverage for
services or supplies that Aetna considers medically necessary. If there
is a discrepancy between this policy and a member's plan of benefits,
the benefits plan will govern. In addition, coverage may be mandated by
applicable legal requirements of a State, the Federal government or CMS
for Medicare and Medicaid members.
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Policy
Note: Most Aetna traditional plans cover durable medical equipment (DME) as a standard benefit. Standard Aetna HMO plans do not
cover DME without a policy rider. Please check benefit plan
descriptions for details. Certain orthopedic casts, braces and splints
are covered under HMO plans without the DME rider because their use is
integral to the treatment of certain orthopedic fractures and recovery
after certain orthopedic procedures.
The following braces may be considered medically necessary for the
listed indications when they are prescribed by a doctor, are made of
durable material (i.e., made to withstand prolonged use), and are used
to treat disease or injury.
- Back Braces
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- Supportive Back Braces
Aetna considers a supportive back brace medically necessary for any of the following indications:
- To reduce pain by restricting mobility of the trunk; or
- 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 otherwise support weak spinal muscles and/or a deformed spine.
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.
Note: Back braces are considered durable medical equipment (DME), except when used as a postoperative brace (see section 1, B).
- Postoperative Back Braces:
Aetna
considers postoperative back braces 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.
Note: Postoperative back braces are considered part of the surgical protocol for certain back operations.
- Elastic Rib Belts and Inflatable Lumbar Supports
Elastic
rib belts and inflatable lumbar supports (Tech Belts, air belts) do not
meet Aetna's 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.* In
addition, elastic rib belts and inflatable lumbar supports have not
been proven to be effective treatments for back injuries.
- Protective Body Socks
Protective
body socks do not meet Aetna's definition of covered durable medical
equipment because they are not made to withstand prolonged use.
- Knee Braces
- Functional Knee Brace
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Functional
(derotational) knee braces are considered medically necessary DME to
improve stability for an unstable or postoperative knee in activities
of daily living. Functional knee braces may be off-the-shelf or custom
made. Custom-made functional braces are considered medically necessary
if the member is unable to be fitted with an off-the-shelf knee brace
because of a deformity of the knee or leg that interferes with fitting.
Exceptionally tall or short stature or obesity does not, by itself,
establish the need for custom-made functional knee braces.
Exceptionally tall persons can usually be fitted with an off-the-shelf
brace with extensions, short persons can usually be fitted with a
pediatric off-the-shelf brace, and obese persons can usually be fitted
with an off-the-shelf knee brace with extra large straps.
Example: Lenox Hill Brace, Boston Knee Brace, DonJoy CI Brace
Note: Custom-made knee braces may be identified by HCPCS codes for "custom-fabricated" and "molded" knee orthoses.
- Prophylactic Knee Braces
Prophylactic
knee braces are designed to reduce the likelihood or severity of knee
ligament injuries in a relatively normal (stable) knee.
Prophylactic
knee braces are not considered medically necessary for treatment of
disease or injury. The American Academy of Orthopedic Surgeons has
concluded that prophylactic bracing has not been proven to be effective
and, in some cases, may actually contribute to knee injury.
- Osteoarthritis Braces (Unloader Braces)
Aetna
considers custom-made unloader braces medically necessary DME as an
alternative to surgery for members with severe symptomatic
osteoarthritis of the knee who have pain that has failed to respond to
medical therapy and knee bracing with a neoprene sleeve, who have
progressive limitation in ADLs, and who do not have any of the following:
- Arthritis other than osteoarthritis; or
- A recent knee operation (within the previous 6 months); or
- Symptomatic disease of the hip, ankle or foot; or
- Diseases that would preclude use of a brace (e.g., skin disease, peripheral vascular disease, or varicose veins); or
- Severe cardiovascular deficit; or
- Paresis or other disease that would preclude ambulation; or
- Inability to apply the brace because of physical limitations such as arthritis of the hands or inability to bend over.
Examples: Generation II Unloader, Orthotech Performer, Vixie Enterprise MKSIII
- Rehabilitation Knee Braces
Aetna
considers post-operative and post-injury knee braces (also known as
rehabilitation braces) medically necessary to allow protected motion of
an injured knee treated operatively or non-operatively when applied
within 6 weeks after injury or surgery. Post-operative and post-injury
knee braces (also known as rehabilitation braces) are also considered
medically necessary to allow protected motion of an injured knee
treated operatively or non-operatively early after injury.
Examples: Bledsoe Postop Brace, DonJoy IROM Brace
Note:
Rehabilitation knee braces are considered standard orthopedic protocol
following certain types of knee surgery and tibial plateau fractures.
- Cast-Braces (also called fracture braces)
- Comfort, Non-Therapeutic
Comfort,
non-therapeutic cast-braces are considered medically necessary DME
after a fracture or surgery. They are often used after the patient has
been in a walking cast. They are usually removable. Molded casts, which
allow the patient 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
- 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 effected due to the
weight bearing.
Examples: PTB cast
brace, PTB fracture brace, MAFO (molded ankle-foot orthosis) fracture
brace with pelvic band, Achilles tendon hinged brace.
Note: Functional cast-braces are considered integral to the treatment of the fracture.
- Rehabilitation Braces
Aetna
considers other post-operative and post-injury braces medically
necessary when applied within six weeks of surgery or injury.
Note: Rehabilitation braces are considered an integral part of the surgical or fracture care protocol.
- Cervical (Neck) Braces
Cervical (neck) braces are considered medically necessary DME for members with neck injury and other appropriate indications.
Example: Philadelphia Cervical Collar
Note:
Cervical foam neck collars do not meet Aetna's 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.
Example: Pavlik Harness, Frejka Pillow Splint, Friedman Strap.
Note: Childhood hip braces are considered integral to the management of hip disorders in children.
Braces for Congenital Defects
Aetna
considers orthopedic braces medically necessary in the treatment of
congenital defects. Aetna also considers replacement braces 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.
- Plastic Braces (MAFOs)
Increasing
use is made of plastic braces. These devices have various names and are
often called molded ankle-foot orthoses (AFO's) or molded ankle-foot
orthoses (MAFO's). They may also be called orthotics. For information
on ankle-foot orthotics, see CPB 565 - Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs).
Orthotics of this type should not be confused with simple, removable
orthotic arch supports or shoe inserts. For information on foot
orthotics, see CPB 451 - Foot Orthotics.
- Wheaton Brace
A
Wheaton Brace considered medically necessary DME to treat metatarsus
adductus in infants replacing the need for serial casting.
- Scoliosis Braces
For Aetna's policy on scoliosis braces, see CPB 398 - Idiopathic Scoliosis Treatment.
Splints and Immobilizers
Certain
orthopedic problems are routinely treated with splints or splint-like
devices. The following are considered medically necessary:
- Shoulder immobilizer.
- Clavicle splint (also called a figure-8 splint).
- Acromio-clavicular splint (also called a Zimmer splint).
- Finger splints.
- Carpal tunnel splints.
- Dynasplints when applied within 6 weeks of a surgical procedure. (See CPB 405 - Dynamic Splinting for Contracture and Joint Stiffness.)
- Denis Browne Splint for children with clubfoot or metatarsus valgus to maintain and correct abduction.
Unna Boots
Unna boots are considered medically necessary only for non-fracture care. Unna boots are not
considered medically necessary 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 controversial.
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.
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.
*Note: Certain non-durable items (e.g., arm slings, Ace
bandages, splints, foam cervical collars, etc.) may be eligible for
payment in some circumstances even though they are not durable and do
not fit within the definition of durable medical equipment. These
non-durable items may be covered when charges are made by a hospital,
surgical center, home health care agency, or doctor for necessary
medical and surgical supplies used in connection with treatment
rendered at the time the supply is used. However, charges for take home
supplies (i.e., extra bandages, cervical pillows, etc.) are not covered. Please check benefit plan descriptions for details.
Background
This policy is based primarily on Medicare DMERC criteria for spinal orthoses.
The above policy is based on the following references:
- Littenberg B, Weinstein LP, McCarren M, et al.
Closed fractures of the tibial shaft. A meta-analysis of three methods
of treatment. J Bone Joint Surg Am. 1998;80(2):174-183.
-
Alexy C, De Carlo M. Rehabilitation and use of protective devices in
hand and wrist injuries. Clin Sports Med. 1998;17(3):635-655.
-
Buckley SL. Current trends in the treatment of femoral shaft fractures
in children and adolescents. Clin Orthop. 1997;338:60-73.
- McFarland EG, Curl LA, Urquhart MW, Kellam K. Shoulder immobilization devices. Orthop Nurs. 1997;16(6):47-54.
-
Kramer JF, Dubowitz T, Fowler P, et al. Functional knee braces and
dynamic performance: A review. Clin J Sport Med. 1997;7(1):32-39.
-
Jerosch J, Thorwesten L, Bork H, Bischof M. Is prophylactic bracing of
the ankle cost effective? Orthopedics. 1996;19(5):405-414.
- Liu SH, Mirzayan R. Current review. Functional knee bracing. Clin Orthop. 1995;317:273-281.
-
Fernandez-Feliberti R, Flynn J, Ramirez N, et al. Effectiveness of TLSO
bracing in the conservative treatment of idiopathic scoliosis. J
Pediatr Orthop. 1995;15(2):176-181.
- Albright JP, Saterbak A, Stokes J. Use of knee braces in sport. Current recommendations. Sports Med. 1995;20(5):281-301.
-
Chess DG, Hyndman JC, Leahey JL, et al. Short arm plaster cast for
distal pediatric forearm fractures. J Pediatr Orthop.
1994;14(2):211-213.
- McIvor JB, Ross P, Landry G, Davis LA. Treatment of femoral fractures with the cast brace. Can J Surg. 1984;27(6):592-594.
- Dieppe P, Chard J, Faulkner A, et al. Osteoarthritis. In: Clinical Evidence. 2000;4:649-663.
-
Zuelzer WA. Knee bracing. In: Physical Rehabilitation of the Injured
Athlete. Ch.14. JR Andrews, GL Harrelson, eds. Philadelphia, PA: W.B.
Saunders Co.; 1991:211-220.
- No authors listed.
American College of Rheumatology Subcommittee on Osteoarthritis
Guidelines. Recommendations for the medical management of
osteoarthritis of the hip and knee. 2000 update. Arthritis Rheum.
2000;43(9):1905-1915.
- Hewett TE, Noyes RF,
Barber-Westin SD, et al. Decrease in knee joint pain and increase in
function in patients with medial compartment arthrosis: A prospective
analysis of valgus bracing. Orthopedics. 1998;21(2):131-138.
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Kirkley A, Webster-Bogaert S, Litchfield R, et al. The effect of
bracing on varus gonarthrosis. J Bone Joint Surg Am.
1999;81(4):539-548.
- Lindenfeld TN, Hewett TE,
Andriacchi TP. Joint loading with valgus bracing in patients with varus
gonarthrosis. Clin Orthop. 1997;344:290-297.
- van Rhijn
LW, Plasmans CM, Veraart BE. Changes in curve pattern after brace
treatment for idiopathic scoliosis. Acta Orthop Scand.
2002;73(3):277-281.
- Gepstein R, Leitner Y, Zohar E, et
al. Effectiveness of the Charleston bending brace in the treatment of
single-curve idiopathic scoliosis. J Pediatr Orthop. 2002;22(1):84-87.
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TriCenturion, LLC. Spinal orthoses: TLSO and LSO. Local Medical Review
Policy. Medicare DMERC Region A. Policy No. TLSO20030701. Columbia, SC:
TriCenturion; July 1, 2003. Available at: http://www.tricenturion.com/content/lmrp_current_dyn.cfm. Accessed February 5, 2004.
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Property of Aetna Inc. All rights reserved.
Clinical Policy Bulletins are developed by Aetna to assist in
administering plan benefits and constitute neither offers of coverage
nor medical advice. This Clinical Policy Bulletin contains only a
partial, general description of plan or program benefits and does not
constitute a contract. Aetna does not provide health care services and,
therefore, cannot guarantee any results or outcomes. Participating
providers are independent contractors in private practice and are
neither employees nor agents of Aetna or its affiliates. Treating
providers are solely responsible for medical advice and treatment of
members. This Clinical Policy Bulletin may be updated and therefore is
subject to change. February 17, 2004
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