LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone Toll-free: 866.814.0192 or 305.436.5030
Fax Toll-free: 866.818.0373 or 305.436.0086
E-mail Address: orders {at] LEEDerGroup [dot] com

2011-02 (LCD) for Ankle-Foot/Knee-Ankle-Foot Orthosis (L11517)

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Local Coverage Determination (LCD) for Ankle-Foot/Knee-Ankle-Foot Orthosis (L11517) Contractor Number 18003 Contractor Type DME MAC LCD ID Number L11517

LCD Title
Ankle-Foot/Knee-Ankle-Foot Orthosis

Contractor’s Determination Number
AFO

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

L11517

LCD Title
Ankle-Foot/Knee-Ankle-Foot Orthosis

Contractor’s Determination Number
AFO

AMA CPT/ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2010 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

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Alabama
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Florida
Georgia
Louisiana
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North Carolina
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Oklahoma
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South Carolina
Tennessee
Texas
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West Virginia

Oversight Region
Region IV

DME Region LCD Covers
Jurisdiction C

Original Determination Effective Date
For services performed on or after 10/01/1993

Original Determination Ending Date

Revision Effective Date
For services performed on or after 02/04/2011
CMS National Coverage Policy
None
Indications and Limitations of Coverage and/or Medical Necessity
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for “reasonable and necessary”, based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not reasonable and necessary.

AFOs NOT USED DURING AMBULATION:

An L4396 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria 1 – 4 or criterion 5 is met:
Plantar flexion contracture of the ankle (ICD-9 diagnosis code 718.47) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and
Reasonable expectation of the ability to correct the contracture; and
Contracture is interfering or expected to interfere significantly with the patient’s functional abilities; and
Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.

The patient has plantar fasciitis (ICD-9 diagnosis code 728.71)

If an L4396 is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home).

An L4396 and replacement interface (L4392) will be denied as not reasonable and necessary if the contracture is fixed. Codes L4396 and L4392 will be denied as not reasonable and necessary for a patient with a foot drop but without an ankle flexion contracture. A component of a static/dynamic AFO that is used to address positioning of the knee or hip will be denied as not reasonable and necessary because the effectiveness of this type of component is not established.

If code L4396 is covered, a replacement interface (L4392) is covered as long as the patient continues to meet indications and other coverage rules for the splint. Coverage of a replacement interface is limited to a maximum of one (1) per 6 months. Additional interfaces will be denied as not reasonable and necessary.

Medicare does not reimburse for a foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394). A foot drop splint/recumbent positioning device and replacement interface will be denied as not reasonable and necessary in a patient with foot drop who is nonambulatory because there are other more appropriate treatment modalities.

AFOs AND KAFOs USED DURING AMBULATION:

Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386 and L4631 are covered for ambulatory patients with weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.

Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory patients for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable and necessary.

AFOs and KAFOs that are custom-fabricated are covered for ambulatory patients when the basic coverage criteria listed above and one of the following criteria are met:
The patient could not be fit with a prefabricated AFO, or
The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months), or
here is a need to control the knee, ankle or foot in more than one plane, or
The patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury, or
The patient has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria 1-5 for a custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not reasonable and necessary.

L coded additions to AFOs and KAFOs (L2180-L2550, L2750-L2768, L2780-L2830) will be denied as not reasonable and necessary if either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary.

Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are an integral part of a brace.

MISCELLANEOUS:

Replacement of a complete orthosis or component of an orthosis due to loss, significant change in the patient’s condition, or irreparable accidental damage is covered if the device is still reasonable and necessary. The reason for the replacement must be documented in the supplier’s record.

Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are denied as not reasonable and necessary.

Quantities of supplies greater than those described in the policy as the usual maximum amounts, in the absence of documentation clearly explaining the medical necessity of the excess quantities, will be denied as not reasonable and necessary.

Coding Information
Bill Type Codes:

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Revenue Codes:

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes
The appearance of a code in this section does not necessarily indicate coverage.

HCPCS MODIFIERS:

EY – No physician or other licensed health care provider order for this item or service.

GA – Waiver of liability statement issued as required by payer policy, individual case

GZ – Item or service expected to be denied as not reasonable and necessary

KX – Requirements specified in the medical policy have been met

LT – Left Side

RT – Right Side

HCPCS CODES:
A4466 GARMENT, BELT, SLEEVE OR OTHER COVERING, ELASTIC OR SIMILAR STRETCHABLE MATERIAL, ANY TYPE, EACH
A9283 FOOT PRESSURE OFF LOADING/SUPPORTIVE DEVICE, ANY TYPE, EACH
L1900 ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND, CUSTOM-FABRICATED
L1902 ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L1904 ANKLE FOOT ORTHOSIS, MOLDED ANKLE GAUNTLET, CUSTOM-FABRICATED
L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L1907 AFO, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICATED
L1910 ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L1920 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE), CUSTOM-FABRICATED
L1930 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L1932 AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L1940 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATED
L1945 ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION), CUSTOM-FABRICATED
L1950 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOM-FABRICATED
L1951 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L1960 ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED
L1970 ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED
L1971 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L1980 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR ‘BK’ ORTHOSIS), CUSTOM-FABRICATED
L1990 ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (DOUBLE BAR ‘BK’ ORTHOSIS), CUSTOM-FABRICATED
L2000 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR ‘AK’ ORTHOSIS), CUSTOM-FABRICATED
L2005 KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCE CONTROL, AUTOMATIC LOCK AND SWING PHASE RELEASE, MECHANICAL ACTIVATION, INCLUDES ANKLE JOINT, ANY TYPE, CUSTOM FABRICATED
L2010 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE BAR ‘AK’ ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM-FABRICATED
L2020 KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (DOUBLE BAR ‘AK’ ORTHOSIS), CUSTOM-FABRICATED
L2030 KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS, (DOUBLE BAR ‘AK’ ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATED
L2034 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, MEDIAL LATERAL ROTATION CONTROL, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED
L2035 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, STATIC (PEDIATRIC SIZE), WITHOUT FREE MOTION ANKLE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L2036 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED
L2037 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED
L2038 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE, MULTI-AXIS ANKLE, CUSTOM FABRICATED
L2106 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED
L2108 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED
L2112 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L2114 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L2116 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L2126 KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED
L2128 KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED
L2132 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L2134 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L2136 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L2180 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH ANKLE JOINTS
L2182 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINT
L2184 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINT
L2186 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTABLE MOTION KNEE JOINT, LERMAN TYPE
L2188 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, QUADRILATERAL BRIM
L2190 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELT
L2192 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND, THIGH FLANGE, AND PELVIC BELT
L2200 ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT
L2210 ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT
L2220 ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST, EACH JOINT
L2230 ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENT
L2232 ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L2240 ADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE ATTACHMENT
L2250 ADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT MODEL, STIRRUP ATTACHMENT
L2260 ADDITION TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP (SCOTT-CRAIG TYPE)
L2265 ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUP
L2270 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION (‘T’) STRAP, PADDED/LINED OR MALLEOLUS PAD
L2275 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION, PADDED/LINED
L2280 ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOT
L2300 ADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP INVOLVEMENT), JOINTED, ADJUSTABLE
L2310 ADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHT
L2320 ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L2330 ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L2335 ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BAND
L2340 ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODEL
L2350 ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENT MODEL, (USED FORPTB’ ‘AFOORTHOSES)
L2360 ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANK
L2370 ADDITION TO LOWER EXTREMITY, PATTEN BOTTOM
L2375 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID STIRRUP
L2380 ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINT
L2385 ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT
L2387 ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS, EACH JOINT
L2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT
L2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT
L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE
L2405 ADDITION TO KNEE JOINT, DROP LOCK, EACH
L2415 ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE, OR EQUAL), ANY MATERIAL, EACH JOINT
L2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION, EACH JOINT
L2430 ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION, EACH JOINT
L2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING
L2500 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT BEARING, RING
L2510 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, MOLDED TO PATIENT MODEL
L2520 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, CUSTOM FITTED
L2525 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM MOLDED TO PATIENT MODEL
L2526 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM, CUSTOM FITTED
L2530 ADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LACER, NON-MOLDED
L2540 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENT MODEL
L2550 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH ROLL CUFF
L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BAR
L2755 ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L2760 ADDITION TO LOWER EXTREMITY ORTHOSIS, EXTENSION, PER EXTENSION, PER BAR (FOR LINEAL ADJUSTMENT FOR GROWTH)
L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BAR
L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PER BAR
L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACH
L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAP
L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL, FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY
L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD
L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION
L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE SECTION
L2840 ADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTH SOCK, FRACTURE OR EQUAL, EACH
L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORAL LENGTH SOCK, FRACTURE OR EQUAL, EACH
L2999 LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED
L4002 REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE
L4010 REPLACE TRILATERAL SOCKET BRIM
L4020 REPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MODEL
L4030 REPLACE QUADRILATERAL SOCKET BRIM, CUSTOM FITTED
L4040 REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L4045 REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L4050 REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L4055 REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY
L4060 REPLACE HIGH ROLL CUFF
L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO
L4080 REPLACE METAL BANDS KAFO, PROXIMAL THIGH
L4090 REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH
L4100 REPLACE LEATHER CUFF KAFO, PROXIMAL THIGH
L4110 REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH
L4130 REPLACE PRETIBIAL SHELL
L4205 REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES
L4210 REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS
L4350 ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4360 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4370 PNEUMATIC FULL LEG SPLINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4386 WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4392 REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO
L4394 REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT
L4396 STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4398 FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L4631 ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM, ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHER MATERIAL, INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATED

ICD-9 Codes that Support Medical Necessity
The presence of an ICD-9 code listed in this section is not sufficient by itself to assure coverage. Refer to the section on “Indications and Limitations of Coverage and/or Medical Necessity” for other coverage criteria and payment information.

For HCPCS codes L4392 and L4396:
718.47 CONTRACTURE OF ANKLE AND FOOT JOINT
728.71 PLANTAR FASCIAL FIBROMATOSIS

For HCPCS code L4631:
713.5 ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS

Diagnoses that Support Medical Necessity
For the specific HCPCS codes indicated above, refer to previous section. For all other HCPCS codes, diagnoses are not specified.

ICD-9 Codes that DO NOT Support Medical Necessity
For the specific HCPCS code indicated above, all ICD-9 codes that are not specified in the preceding section. For all other HCPCS codes, diagnoses are not specified.

ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation

Diagnoses that DO NOT Support Medical Necessity
For the specific HCPCS code indicated above, all diagnoses that are not specified in the preceding section. For all other HCPCS codes, diagnoses are not specified.

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General Information
Documentations Requirements
Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider”. It is expected that the patient’s medical records will reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

An order for each new or full replacement item must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

The order must list the unique features of the base code that is billed plus every addition that will be billed on a separate claim line. The medical record must contain information which supports the medical necessity of the item and all additions that are ordered. An order is not necessary for the repair of an orthosis.

The supplier must include on the claim the ICD-9 diagnosis code for the underlying condition for a static or dynamic positioning AFO (L4396) or replacement interface material (L4392).

For custom-fabricated orthoses, there must be documentation in the supplier’s records to support the medical necessity of that type device rather than a prefabricated orthosis. This information must be available upon request.

KX, GA, and GZ MODIFIERS:

Suppliers must add a KX modifier to the AFO/KAFO base and addition codes only if all of the coverage criteria in the “Indications and Limitations of Coverage and or Medical Necessity” section of this policy have been met and evidence of such is retained in the supplier’s files and available to the DME MAC upon request.

If all of the criteria in the Indications and Limitations of Coverage and/or Medical Necessity section have not been met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter the GA modifier on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or the GZ modifier if they have not obtained a valid ABN.

Claims lines billed with codes without a KX, GA or GZ modifier will be rejected as missing information.

MISCELLANEOUS

A claim for code L2999 must include either a narrative description of the item (for custom fabricated items) or the manufacturer name and model name/number (for pre-fabricated items). For replacement components billed with code L2999, there must also be a HCPCS code or the manufacturer name and model name/number of the base orthosis. This information should be entered in the narrative field of an electronic claim.

A claim for code L4205 must include an explanation of what is being repaired. A claim for code L4210 must include a description of each item that is billed. This information should be entered in the narrative field of an electronic claim.

All codes for orthoses or repairs of orthoses billed with the same date of service must be submitted on the same claim.

When billing for quantities of supplies greater than those described in the policy as the usual maximum amounts, there must be documentation in the patient’s medical record supporting the medical necessity for the higher utilization. This information must be available upon request.

Refer to the Orthopedic Footwear policy for information on documentation requirements for shoes and related items which are an integral part of a brace.

Refer to the Supplier Manual for more information on documentation requirements.
Appendices
Utilization Guidelines
Refer to Indications and Limitations of Coverage and/or Medical Necessity.
Sources of Information and Basis for Decision
Advisory Committee Meeting Notes
Start Date of Comment Period
04/16/1993
End Date of Comment Period
05/31/1993
Start Date of Notice Period
08/01/1993
Revision History Number
016
Revision History Explanation
Revision Effective Date: 02/04/2011
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added: Statement from policy article regarding routine replacement of components
Deleted: Least costly alternative for custom fabricated orthoses
HCPCS CODES AND MODIFIERS (Effective 1/1/2011):
Added: Code L4631
Revised: GA modifier
ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: Code L4631 and ICD-9 code 713.5

Revision Effective Date: 01/01/2010
HCPCS CODES AND MODIFIERS:
Added: A4466
Deleted: L1901
Revised: L4396 Description
Revision Effective Date: 12/01/2009
HCPCS CODES AND MODIFIERS:
Added: GA and GZ modifiers
Deleted: GY modifier
DOCUMENTATION REQUIREMENTS:
Added: Instructions for the use of GA and GZ modifiers

11/15/2009 – The description for CPT/HCPCS code L4396 was changed in group 1
11/15/2009 – CPT/HCPCS code L1901 was deleted from group 1

Revision Effective Date: 06/01/2009
HCPCS CODES AND MODIFIERS:
Added: KX modifier
Deleted: L2770
DOCUMENTATION:
Added: Instructions for use of KX modifier with both the base and addition code(s)

Revision Effective Date: 04/01/2009
INDICATIONS AND LIMITATIONS OF COVERAGE:
Deleted: L1901 and L2770 from code range of AFO-KAFO used with ambulation (Note: Code L2770 invalid for claims with DOS on or after 07/01/2008
HCPCS CODES AND MODIFIERS:
Revised: Code L4360 descriptor
Deleted: Code L2860

11/09/2008 – The description for CPT/HCPCS code L4360 was changed in group 1

03/01/2008 – In accordance with Section 911 of the Medicare Modernization Act, this policy was transitioned to DME MAC CIGNA Government Services (18003) LCD L11517 from DME PSC TrustSolutions (77012) LCD L11517.

Revision Effective Date: 01/01/2008
HCPCS CODES AND MODIFIERS:
Added: A9283

Revision Effective Date: 07/01/2007
INDICATIONS AND LIMITATIONS OF COVERAGE:
Removed: References to DMERC.
DOCUMENTATION REQUIREMENTS:
Removed: References to DMERC.

06/01/2007 – In accordance with Section 911 of the Medicare Modernization Act of 2003, Virginia and West Virginia were transitioned from DME PSC TriCenturion (77011) to DME PSC TrustSolutions (77012).

03/01/2006 – In accordance with Section 911 of the Medicare Modernization Act of 2003, this policy was transitioned to DME PSC TrustSolutions (77012) from DMERC Palmetto GBA (00885).

Revision Effective Date: 01/01/2006
HCPCS CODES AND MODIFIERS:
Added: L2034 and L2387
Deleted L2039
DOCUMENTATION REQUIREMENTS:
Removed requirement for documentation to be attached to the claim.
Revision Effective Date: 04/01/2005
HCPCS CODES AND MODIFIERS:
Added: L1932, L2005, L2232, L4002
Revised: L2035, L2036, L2037, L2038, L2039, L2320, L2330, L2755, L2800, L4040, L4045, L4050, L4055
Deleted: L2435

07/01/2004 – Indications and Limitations of Coverage: Added coverage of codes L4392 and L4396 for the treatment of plantar fasiitis (ICD-9 diagnosis code 728.71. LMRP converted to LCD and Policy Article.

Revision Effective Date: 04/01/2004
INDICATIONS AND LIMITATIONS OF COVERAGE:
Added codes L4360 and L4386 to paragraph describing coverage of braces used for edema and pressure ulcers.
HCPCS CODES AND MODIFIERS:
Added: L1907, L1951 and L1971
Revised: L1950, L4350, L4360, L4386
DOCUMENTATION REQUIREMENTS:
Added: L4360 and L4386 to list of codes requiring the use of modifier GY when used to treat pressure ulcers

Revision Effective Date: 07/01/2003
HCPCS CODES AND MODIFIERS:
Corrected HCPCS array to add L4350-L4370 which were inadvertently omitted from 04/01/2003 revision.

Revision Effective Date: 07/01/2003
HCPCS CODES AND MODIFIERS:
Corrected HCPCS array to add L4350 – L4370 which were inadvertently omitted from 04/01/2003 revision.

Revision Effective Date: 04/01/2003
HCPCS CODES AND MODIFIERS:
Added: L1901, L4386, EY
INDICATIONS AND LIMITATIONS OF COVERAGE:
Adds standard language concerning coverage of items without an order.
Adds code L4350, L4360, L4370 and L4386 to range of codes used with ambulatory patients only.
DOCUMENTATION REQUIREMENTS:
Adds standard language concerning use of EY modifier for items without an order.
Revised to allow either ICD-9 diagnosis code or narrative description on order for codes L4392 and L4396.

The revision dates listed below are the dates the revisions were published and not necessarily the effective dates for the revisions.

04/01/2002 – Added new HCPCS codes descriptors adding “prefabricated.” Added new descriptor for code L4396. Deleted splint codes now under local carrier jurisdiction-L2102, L2104, L2122, L2124. Added definition of custom-fabricated. Added RT and LT modifiers. Added new GY modifier.

06/01/1999 – Added HCPCS codes. Revised text for entire policy.

07/01/1996 – Corrected description for L1980.

04/01/1996 – Corrected description for L1990.

10/01/1995 – Revised Documentation section, removing Certificate of Medical Necessity requirement.

06/01/1994 – Corrected typo in Coverage and Payment Rules section from 1920 to L1920.
Reason for Change
CMS Requirement
Last Reviewed On Date
Related Documents
Article(s)
A19885 – Ankle-Foot/Knee-Ankle-Foot Orthosis – Policy Article – Effective January 2011 opens in new window

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