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

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2013-08 Updated LCD L11527 Ankle-Foot/Knee-Foot Orthosis, Part 1

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Local Coverage Determination (LCD):
Ankle-Foot/Knee-Ankle-Foot Orthosis (L11527)
Contractor Information
Contractor Name
NHIC, Corp.
Contractor Number
16003
Contractor Type
DME MAC
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LCD Information
Document Information
LCD ID Number
L11527
LCD Title
Ankle-Foot/Knee-Ankle-Foot Orthosis
Contractor’s Determination Number
AFO
AMA CPT/ADA CDT Copyright Statement
CPT only copyright 2002-2012 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.
Applicable FARS/DFARS Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. The Code on Dental Procedures and Nomenclature (Code) is published in Current Dental Terminology (CDT). Copyright © American Dental Association. All rights reserved. CDT and CDT-2010 are trademarks of the American Dental Association.
Primary Geographic Jurisdiction
Connecticut
District of Columbia
Delaware
Massachusetts
Maryland
Maine
New Hampshire
New Jersey
New York – Entire State
Pennsylvania
Rhode Island
Vermont
Oversight Region
Region I
DME Region LCD Covers
Jurisdiction A
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 07/01/2012
Revision Ending Date
CMS National Coverage Policy
None

  • Coverage Indications Limitations 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 detailed written order (DWO) 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 DWO, 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:
    1. 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,
    2. Reasonable expectation of the ability to correct the contracture; and,
    3. Contracture is interfering or expected to interfere significantly with the beneficiary’s functional abilities; and,
    4. Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.
    5. The beneficiary 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 molded-to-patient-model, or custom-fabricated, are covered for ambulatory patients when the basic coverage criteria listed above and one of the following criteria are met:
    1. The beneficiary could not be fit with a prefabricated AFO, or
    2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months), or
    3. There is a need to control the knee, ankle or foot in more than one plane, or
    4. The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury, or
    5. The beneficiary 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.
    Concentric adjustable torsion style mechanisms used to assist knee joint extension are coded as L2999 and are covered for beneficiaries who require knee extension assist in the absence of any co-existing joint contracture. Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion are coded as L2999 and are covered for beneficiaries who require ankle plantar or dorsiflexion assist in the absence of any co-existing joint contracture. Concentric adjustable torsion style mechanisms used for the treatment of contractures, regardless of any coexisting condition(s), are coded as E1810 and/or E1815 and are covered under the Durable Medical Equipment benefit (see related Policy Article Coding Guidelines for additional information). Claims for devices incorporating concentric adjustable torsion style mechanisms used for the treatment of any joint contracture and coded as L2999 will be denied as incorrect coding.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.
  • 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.
    N/A
    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), CUSTOMFABRICATED
    L1950
    ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOMFABRICATED
    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, ANY TYPE 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

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