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

2014-01 LDC L11527 Ankle-Foot/Knee-Ankle-Foot Orthosis

KYDEX-PRO

STRONGER

SAFER

LEEDerGroup.com

Local Coverage Determination (LCD) for Ankle-Foot/Knee-
Ankle-Foot Orthosis (L11527)
Contractor Information
Contractor Name
NHIC, Corp.
Contract Number
16003
Contract Type
DME MAC
LCD Information
Document Information
LCD Database ID Number
L11527
LCD Title
Ankle-Foot/Knee-Ankle-Foot Orthosis
AMA CPT/ADA CDT Copyright StatementCMS National Coverage Policy
None
Coverage Guidance
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 coverage indications, limitations 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.
For AFO and KAFO orthoses definitions of off-the-shelf and custom fitted, see the related Policy
Article Coding Guidelines section.
AFOs NOT USED DURING AMBULATION:
An L4396 or L4397 (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 (see ICD-9 Diagnosis Codes That Support Medical
Necessity Group 1 Codes section) 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 (see ICD-9 Diagnosis Codes That Support Medical
Necessity Group 1 Codes section)
If an L4396 or L4397 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 or L4397 and replacement interface (L4392) will be denied as not reasonable and
necessary if the contracture is fixed. Codes L4396, L4397 and L4392 will be denied as not
reasonable and necessary for a beneficiary 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 or L4397 is covered, a replacement interface (L4392) is covered as long as the
beneficiary 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 beneficiary 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, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or
deformity of the foot and ankle, who:
1. Require stabilization for medical reasons, and,CMS National Coverage Policy
None
Coverage Guidance
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 coverage indications, limitations 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.
For AFO and KAFO orthoses definitions of off-the-shelf and custom fitted, see the related Policy
Article Coding Guidelines section.
AFOs NOT USED DURING AMBULATION:
An L4396 or L4397 (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 (see ICD-9 Diagnosis Codes That Support Medical
Necessity Group 1 Codes section) 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 (see ICD-9 Diagnosis Codes That Support Medical
Necessity Group 1 Codes section)
If an L4396 or L4397 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 or L4397 and replacement interface (L4392) will be denied as not reasonable and
necessary if the contracture is fixed. Codes L4396, L4397 and L4392 will be denied as not
reasonable and necessary for a beneficiary 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 or L4397 is covered, a replacement interface (L4392) is covered as long as the
beneficiary 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 beneficiary 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, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or
deformity of the foot and ankle, who:
1. Require stabilization for medical reasons, and,
2. Have the potential to benefit functionally.
Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are
covered for ambulatory beneficiaries 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 beneficiaries 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 co-existing 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).
Concentric adjustable torsion style mechanisms used for the treatment of contractures,
regardless of any co-existing 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 beneficiary’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.