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

CIGNA AFO-KAFO COVERAGE POSITION FOR PROVIDERS

KYDEX-PRO

STRONGER

SAFER

LEEDerGroup.com

  • LEEDer Group comment: acupuncture, custom-molded foot orthoses, electron-generating devices, extracorporeal shock wave therapy, laser therapy, microwave diathermy, orthoses with magnetic foil, radiotherapy, stereotactic radiofrequency thermal lesioning are considered not medically necessary or considered of unproven benefit (this list may not be all-inclusive).
  • Whereas, Night Splints are recommended. Soft Ankle Support
LEEDerGroup.com: KYDEX Pro Multi Podus boot with ambulation pad Prevent Mitigate Heel UlcersKYDEX-PRO Ambulation OrthosisKYDEX PRO Multi PodusFlex-E-Core Techology
  • The Night Splint that Works! by LEEDer Group. It’s Guaranteed and Doctor Approved. L-4396 ICD-10 M24.576
  • KYDEX-PRO Multi Podus boots, PRO-RESTing Hand Splints, GRIP, DORSAL WHFO’S all with FLEX-E-CORE frames which allow near unlimited molding to the patient’s condition PLUS now with EASY 1 2 3 strap application numbering for Better Outcomes
CIGNA AFO-KAFO COVERAGE POSITION FOR PROVIDERS
  • CIGNA HEALTHCARE COVERAGE POSITION Subject: Foot Orthosis, Ankle Orthosis, Ankle-Foot Orthosis (AFO), Knee-Ankle-Foot Orthosis (KAFO) Coverage Position Number: 0150 Effective Date: 8/15/2004

Table of Contents: Related Coverage Positions: Plantar Fasciitis

  • Coverage Position………………………………………..1
  • General Background…………………………………….2
  • Coding/Billing Information……………………………..6
  • References………………………………………………..12
  • INSTRUCTIONS FOR USE
    Coverage Positions are intended to supplement certain standard CIGNA HealthCare benefit plans. Please note, the terms of a participant’s particular benefit plan document [Group Service Agreement (GSA), Evidence of Coverage, Certificate of Coverage, Summary Plan Description (SPD) or similar plan document] may differ significantly from the standard benefit plans upon which these Coverage Positions are based. For example, a participant’s benefit plan document may contain a specific exclusion related to a topic addressed in a Coverage Position. In the event of a conflict, a participant’s benefit plan document always supercedes the information in the Coverage Positions. In the absence of a controlling federal or state coverage mandate, benefits are ultimately determined by the terms of the applicable benefit plan document. Coverage determinations in each specific instance require consideration of
  • 1) the terms of the applicable group benefit plan document in effect on the date of service;
  • 2) any applicable laws/regulations;
  • 3) any relevant collateral source materials including Coverage Positions and;
  • 4) the specific facts of the particular situation.

©2004 CIGNA Health Corporation Coverage Position

Some CIGNA HealthCare benefit plans may exclude coverage for orthotic devices. Please refer to specific plan language to determine benefit coverage. Coverage may be provided for custom foot orthoses and the following non-foot orthoses under the External Prosthetic Appliance benefit: .. rigid and semi-rigid custom fabricated orthoses .. semi-rigid pre-fabricated and flexible orthoses .. rigid pre-fabricated orthoses, including preparation, fitting and basic additions such as bars and joints.

CIGNA HealthCare covers custom foot orthotics when ANY ONE of the following medical necessity criteria is met:

  • for patients with conditions of impaired peripheral sensation and/or altered peripheral circulation (e.g., diabetic neuropathy and peripheral vascular disease)
  • when the foot orthosis is an integral part of a leg brace and is necessary for the proper functioning of the brace
  • when the foot orthosis is used for a replacement or substitute for missing parts of the foot (for example, amputation) and is necessary for the alleviation or correction of illness, injury or congenital defect
  • for patients with neurologic or neuromuscular conditions (e.g., cerebral palsy, hemiplegia, spina bifida) producing spasticity, malalignment or pathological positioning of the foot, and there is reasonable expectation of improvement

CIGNA HealthCare covers ankle orthotics when any of the following medical necessity criteria are met:

  • ankle fractures
  • ankle sprains Page 1 of 14 Coverage Position Number: 0150
  • ankle injuries requiring immobilization and/or stabilization

CIGNA HealthCare covers ankle-foot orthotics (AFO) and knee-ankle-foot orthotics (KAFO) (ankle contracture splint or foot drop splint) in NON-AMBULATORY patients who have ALL of the following medical necessity criteria:

  • The patient has a plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a non-fixed contracture).
  • There is reasonable expectation of the ability to correct the contracture.
  • The contracture is interfering or expected to interfere significantly with the patient’s functional abilities.
  • The ankle contracture splint is used as a component of a therapy program that includes active stretching of the involved muscles and/or tendons.

CIGNA HealthCare covers ankle-foot orthotics (AFO) in AMBULATORY patients when the patient has weakness or deformity of the foot and ankle, which requires stabilization for medical reasons, and when the patient has the potential to benefit functionally from the device.
CIGNA HealthCare covers knee-ankle-foot orthoses (KAFO) in AMBULATORY patients who meet criteria for ankle-foot orthoses and who require additional knee stability.
CIGNA HealthCare covers molded-to-patient model AFOs and KAFOs in AMBULATORY patients when the BASIC coverage criteria and ANY ONE of the following additional criteria are met:

  1. The patient could not be fitted with a prefabricated (off-the-shelf) AFO.
  2. The condition necessitating the orthosis is expected to be permanent or of long-standing duration (>6 months).
  3. There is a need to control the knee, ankle or foot in more than one plane.
  4. The patient has a documented neurological, circulatory or orthopedic status that necessitates custom fabricating to prevent tissue injury.
  5. The patient has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.

Most CIGNA HealthCare benefit plans do not cover the following orthoses and orthotic devices in most benefit plans:

  1. pre-fabricated foot orthoses
  2. orthotic shoes, shoe additions, procedures for foot orthopedic shoes, shoe modifications and transfers
  3. orthoses primarily used for cosmetic reasons
  4. orthoses primarily for improved athletic performance or sports participation

Note: Unmodified, pre-fabricated orthoses are generally used in treating conditions prior to a custom-fitted orthosis (pre-fabricated orthoses that are modified by bending or molding for a specific patient). Custom-fitted orthoses are generally attempted prior to the use of custom-fabricated orthoses (individually constructed from materials).

General Background
Orthoses are devices added to the body to stabilize or immobilize a body part, prevent deformity, protect against injury or to assist with function. They can be divided into different types based on their intended function: protective, accommodative and functional. Protective devices do not typically provide structural or functional support. Accommodative devices of the foot are designed to protect fixed or long-term malalignment, to cushion bones exposed by tissue atrophy or to protect skin at risk from neuropathic anesthesia (e.g., diabetic neuropathy). Functional devices realign or assist the neuromusculoskeletal system by providing dynamic or static support. Static orthoses are rigid and are used to support weakened or paralyzed body parts in a particular position. Dynamic orthoses are used to facilitate body motion to allow optimal function. Page 2 of 14 Coverage Position Number: 0150 Orthoses can also be classified by anatomic location (e.g., foot orthoses, ankle orthoses, ankle-foot orthoses [AFO], knee-ankle-foot orthoses [KAFO]).The term “foot orthoses” typically refers to devices that are placed into shoes. Ankle orthoses are supportive devices used to provide immobilization to the ankle. AFOs have a shoe insert component as well as an ankle component. KAFOs contain a knee component, ankle component and shoe insert.

A splint is defined as an appliance for preventing movement of joints or for the fixation of a displaced or movable part.

A brace is defined as an orthosis or orthopedic appliance that supports or holds in correct position any movable part of the body and that allows for motion of that part. It must be a rigid or semi-rigid device used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. It must provide support and counterforce on the limb on which it is being used. Items that do not meet the definition of a brace are not covered.

A pre-fabricated orthosis is one that is manufactured in quantity without a specific patient in mind. A pre-fabricated orthosis can be modified (e.g., trimmed, bent or molded) for use by a specific patient and is then considered a custom-fitted orthosis.

[ INSERT by LEEDer Group: the Multi USE Boot / Night Splint with Flex-E-Core Technology can be bent and molded. Mulit Use Boot / Night Splint by LEEDer Group.]

An orthosis that is made from pre-fabricated components is considered a pre-fabricated orthosis. Any orthosis that does not meet the standard definition of custom-fabricated is considered to be a pre-fabricated device. HCPCs codes representing pre-fabricated orthoses are L1901, L1902, L1906, L1910, L1930, L1951, L1971, L2035, L2112-L2116, L2036-L2108 and L2126-L2128.

A custom-fabricated orthosis is one that is specifically made for an individual patient starting with the most basic materials that may include plastic, metals, leather or various cloths. The construction of these devices requires substantial labor such as cutting, bending, molding and sewing, and may even involve the use of some pre-fabricated components. A molded-to-patient model orthosis is a type of custom-fabricated device for which an impression of the specific body part is made (e.g., by means of a plaster cast, or CAD-CAM technology). The impression is then used to make a specific patient model. The actual orthosis is molded from the patient-specific model. HCPCs codes representing custom fabricated orthoses are L1900, L1904, L1907, L1940-L1950, L1960-L1970, L1980-L2030, L2036-L2108 and L2126-L2128.

An unmodified, pre-fabricated orthosis is generally used in treating a condition prior to a custom-fitted orthosis (pre-fabricated orthosis that is modified by bending or molding for a specific patient). A custom-fitted orthosis is generally attempted prior to the use of custom-fabricated orthosis (individually constructed from materials).

Conditions with impaired peripheral circulation and sensation: The major foot-related conditions that increase the risk of ulcers and amputations in those with diabetes and other conditions that impair peripheral circulation, are peripheral neuropathy, altered biomechanics (caused by increased plantar pressure, bony deformities, limited joint mobility), peripheral vascular disease, skin pathology and a history of prior ulcers. When properly fitted, footwear can reduce abnormal pressures, reduce formation of calluses and ulcers and protect the foot from external trauma. Most patients with these conditions can safely wear properly-fitted commercial shoes. Pre-fabricated shoe inserts may also be used. The use of custom-fitted or custom-molded orthotic inserts are typically reserved for those patients with neuropathy and/or altered circulation who also have severe foot deformities such as Charcot arthropathy, severe arthritis, large bunions or prior amputation.

Neurologic and neuromuscular conditions: Certain neurologic and muscle control conditions such as stroke, neoplasms, hemiplegia, cerebral palsy, myelomeningocele and atrophic or dystrophic conditions may produce lower extremity spasticity or hyperactivity of muscles, hypotonicity of certain muscles and neuromuscular imbalances. Gait functioning, balance and foot/ankle positioning may be impacted. Custom-fitted and custom-molded foot orthoses and ankle-foot orthoses (AFOs) are used in ambulatory patients to control or correct foot joints, counteract internal deforming forces, compensate for weakness, correct or eliminate pathologic positioning, improve balance, improve gait functioning and reduce excessive plantar flexion.

Page 3 of 14 Coverage Position Number:
0150 Plantar fasciitis (Heel Pain Syndrome):
Plantar fasciitis is an inflammation of the heel of the foot typically resulting from trauma to the deep tissue of the foot (i.e., plantar fascia). Conditions involving heel pain are referred to by many names, including heel spurs, heel spur syndrome, plantar fasciitis, heel pain syndrome, painful-heel syndrome, calcaneodynia, subcalcaneal bursitis and stone bruise. Pre-fabricated orthoses have been shown to be adequate for the majority of patients with plantar fasciitis or other heel pain syndromes. Custom-molded foot orthoses are used when more conservative measures fail. The intended goals of strapping and orthosis use are to minimize pathologic forces of the gait cycle, attempt to restore the desired biomechanical function of the foot and support the medial and lateral longitudinal arch. Pre-made orthotic devices used for the treatment of heel-pain syndrome include heel lifts, heel protectors, heel cushions and dynamic insoles. Pre-made, posterior night splints are also used for plantar fasciitis and Achilles tendonitis.

It has not been shown through well-designed clinical trials that custom-molded orthoses made of materials such as medium-density polyethylene closed cell foam thermoplastic material (Plastazote®) are equal or superior to pre-fabricated shoe inserts in relieving patients’ symptoms. In a prospective randomized trial, Pfeffer, et al. (1999, n=200) compared nonoperative treatments for proximal plantar fasciitis. The authors concluded that, when used in conjunction with a stretching program, a prefabricated shoe insert is more likely to produce improvement in symptoms as part of the initial treatment of proximal plantar fasciitis than a custom polypropylene orthotic device. A systematic evaluation of the evidence for effectiveness of various treatments for plantar heel pain conducted by Cochrane (2003, 2004) concluded “although there is limited evidence for the effectiveness of local corticosteroid therapy, the effectiveness of other frequently employed treatments in altering the clinical course of plantar heel pain has not been established in comparative studies. Well-designed and well-conducted randomized studies are required.” Based on a review of the current published, scientific, peer-reviewed literature, custom-fitted and custom-fabricated foot orthoses have not been shown to be equal or superior to pre-fabricated orthoses for the treatment of heel-pain syndromes and related conditions. The use of custom-fitted and custom-fabricated foot orthoses for these conditions is not considered medically necessary.

Foot deformities:
Some foot deformities cause malalignment of feet and/or ankles and pathologic foot positioning, thereby causing impaired gait, balance and pain. Deformities that are significant may require modification of footwear in order to maintain normal alignment, gait patterns and balance. Commercially available, properly fitted footwear is adequate for most of these patients. Pre-fabricated orthoses may also be used. Adult flatfoot or pes planus is a condition that may be acquired or congenital in nature. Pre-fabricated arch supports with properly fitted, commercially available footwear provide adequate support for most patients with flat feet. There is not sufficient evidence in the published, peer-reviewed, scientific literature to demonstrate that custom foot orthoses are equal or superior to standard, properly fitted, commercially available footwear or over the counter pre-fabricated supports for patients with congenital or acquired foot deformities, such as bunions or pes planus.

Foot Orthotics:
A foot orthotic is a type of shoe insert that does not extend beyond the ankle, and may include heel wedges and arch supports. The goal of treating conditions with foot orthotics is to decrease pain and increase function. They may also correct some foot deformities and provide shock absorption to the foot. Codes representing foot orthotics provided to patients without diabetes are L3000-L3090. Prosthetic shoes are used when all or a portion of the foot is missing. A brace may or may not be attached to the prosthetic shoe. The absence of all or a portion of the foot may be the result of a congenital deformity, illness (amputation secondary to diabetic foot ulcer) or injury (traumatic amputation). Patients with minor distal amputations typically do not require special shoes. When all digits have been amputated, a forefoot filler orthosis may be used with a commercial shoe. For more extensive partial-foot amputations (e.g., mid-level Tran metatarsal, Chopart’s amputation), a prosthetic may be needed consisting of a conventional shoe with an ankle-foot orthosis (AFO), brace and a forefoot filler. A custom-fitted or custom-molded foot orthosis may be used as a replacement or substitute for missing parts of the foot (e.g., due to amputation) and when it is necessary for the alleviation or correction of illness, injury or congenital defect.

Ankle Orthotics:
An ankle orthotic is a type of orthotic used in treating acute ankle injuries such as a sprain, for rehabilitation after the initial injury and to prevent re-injury of the ankle. They are also used to treat chronically unstable ankles. Ankle orthotic options include lightweight sports plastics/Velcro models, hinged devices, lace-up devices, neoprene sleeves, ankle wraps and taping, braces, various types of casts, stabilizing shoes and air stirrups.
Page 4 of 14 Coverage Position Number: 0150

Ankle-foot Orthotics:
An AFO extends well above the ankle to the top of the calf. It requires fastening at the lower leg, just above the ankle. This device may be covered for ambulatory patients with weakness or deformity of the foot and ankle, which also require stabilization for medical reasons and when the patient has the potential to benefit functionally from use of the device.

Commonly, AFOs are used to treat disorders including but not limited to ankle dorsiflexion, plantar flexion, inversion and eversion, spastic displegia due to cerebral palsy, lower motor neuron weakness due to poliomyelitis and spastic hemiplegia in cerebral infarction. HCPCs codes representing AFO devices are L1900-L1990, L2106-L2116, L4350, L4360, and L4386.

Knee-ankle-foot orthotics:
A KAFOs is an AFO with metal uprights, a mechanical knee joint and two thigh bands. KAFOs are covered for ambulatory patients who meet criteria for an ankle-foot orthosis, and who also require additional support to the knee for stability. HCPCs codes representing KAFOs are L2000-L2039, L2126-L2136, and L4370.

Stance control orthotics:
A stance control orthosis is an orthotic knee joint or custom-fabricated KAFO that allows swing-phase knee flexion. The knee joint locks when weightbearing to provide stance phase stability, and when unweighted it unlocks to allow a swinging motion of the knee. It is proposed that the stance control components allow the patients to swing their impaired limb with sufficient ground clearance to provide a more normal gait. While there are no specific patient criteria, it is intended for use in patients with lower extremity weakness and who demonstrate some control of hip muscles. Candidates who may benefit from this type of device typically have conditions such as polio, post-polio syndrome, spinal cord injuries, multiple sclerosis, stroke or trauma. These devices may be mechanical or electronic.

The Stance Control Orthotic Knee Joint (Horton SCOKJ) and the Free Walk Stance Control Knee Ankle System (Otto Bock) are currently available in the United States and function as mechanical devices. The Horton SCOTJ is a knee joint that is fabricated into a custom KAFO. This device has a switch allowing the patient to select an automatic mode for stance control, an unlocked position for motion associated with free-swinging KAFO, and a locked extension for use with climbing. The Free Walk (Otto Bock) is an entire KAFO system, a single-upright KAFO with a foot-plate design. This device has an automatic lock initiated by knee extension. An electronic device, the Becker 9001 E-Knee is one that can be programmed to lock at any degree of flexion and unlock in response to various conditions. It is a computer-controlled, foot-force activated, electromechanical orthotic knee joint. Based on review of the published, peer-reviewed, scientific literature it has not been shown that stance control orthotic devices are superior to standard knee-ankle-foot orthoses. There are no studies evaluating the degenerative changes in the contralateral limb and lower back with use of a standard device compared to use of a stance control orthotic to support long-term outcomes. L-code additions to AFOs or KAFOs (L2180-L2550, L2750-L2830) are not covered if either the base orthosis is not medically necessary or the specific addition is not medically necessary. AFOs and KAFOs used for ambulatory patients for the treatment of edema and/or for the prevention or treatment of pressure ulcers are not covered. Walking boots (L4360 and L4386) are AFOs that may be used to relieve pressure on the sole of the foot or used for patients with foot ulcers and are noncovered for those conditions. Walking boots may be covered when used to treat orthopedic conditions or postoperatively for orthopedic surgery. Ankle flexion contracture is a condition where the muscles and/or tendons that plantarflex the ankle are shortened resulting in an inability to bring the ankle to 0° by passive range of motion. At 0° flexion, the ankle is perpendicular to the lower leg. Foot drop is a condition where there is a weakness and/or lack of use of the muscles that dorsiflex the ankle but there is the ability to bring the ankle to 0° by passive range of motion. An ankle-foot orthosis used in non-ambulatory patients may be either an ankle contracture splint, night splint or a foot drop splint. Ankle contracture splints (L4396) are not covered when they are used solely for the prevention or treatment of a heel pressure ulcer. Foot drop splints (L4398) and/or replacement interface (L4393) are recumbent positioning devices and are not covered in a non-ambulatory patient or when used solely for the prevention or treatment of heel pressure ulcers. These types of devices are not used to support a weak or deformed body part, or to restrict or eliminate motion in a diseased or injured part of the body (i.e., they do not meet the definition of a brace). HCPCs codes representing ankle-foot orthoses worn when the patient is ambulatory are L1900-L1990, L2106-L2116, L4350, L4360 and L4386.

An ankle-contraction splint is a prefabricated ankle-foot orthosis that has all of the following characteristics:

  • designed to accommodate an ankle with a plantar flexion contracture of up to 45°
  • applies dorsiflexion force up to the ankle
  • for use by a patient who is non-ambulatory
  • has a soft interface.

A foot drop splint/recumbent positioning device is a prefabricated ankle-foot orthosis which has all of the following characteristics:

  • designed to maintain the foot at a fixed position of 0° (i.e., perpendicular to the lower leg)
  • not designed to accommodate an ankle with a plantar flexion contracture
  • used by a patient who is non-ambulatory
  • has a soft interface

If an AFO is to be used for a non-ambulatory patient for the treatment of 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 the professional staff (in a nursing facility) or caregiver (at home). An ankle-contracture splint is not considered medically necessary for the treatment of a fixed contracture and/or in patients who demonstrate foot drop without an ankle-flexion contracture. The effectiveness of components of the ankle-contracture splint used to correct positioning of the knee or hip is not well established in the peer-reviewed literature.

University of California Berkeley Laboratory (UCBL) Orthosis:
This orthosis is a variant of the traditional pre-fabricated arch support and was originally designed to maintain a flexible, paralytic valgus, foot deformity in the corrected position. It is used to treat flatfoot, plantar fasciitis, calcaneal spurs, posterior tibial tendon dysfunction and rheumatoid arthritis. This orthosis is cast in a semi-weight-bearing position. The efficacy of the UCBL for the treatment of any of these conditions has not been demonstrated through well-designed, randomized, controlled clinical trials. Socks (L2840, L2850) used in conjunction with orthoses are not covered items.

Orthotics that are used to prevent injury in an otherwise uninjured body part is solely preventive and is therefore considered not medically necessary for the treatment of disease or injury.

Orthotics that are used only for participation in sports are considered not medically necessary. Participation in sports is considered an elective activity.

Identical, spare orthotics purchased only for the patient’s convenience are considered not medically necessary and are not covered.

Evaluation of the patient, measurement and/or casting, and fitting of the orthoses are included in the allowance for the orthosis.
There is no separate reimbursement for these services.
Coding/Billing Information
Note: This list of codes may not be all-inclusive. Covered when medically necessary: Page 6 of 14 Coverage Position Number: 0150 CPT® Codes Description
HCPCS Codes Description

* L3000 Foot insert, removable, molded to patient model, “UCB” type, Berkeley shell, each * L3001 Foot insert, removable, molded to patient model, Spenco, each * L3002 Foot insert, removable, molded to patient model, Plastazote or equal, each * L3003 Foot insert, removable, molded to patient model, silicone gel, each * L3010 Foot insert, removable, molded to patient model, longitudinal arch support, each * L3020 Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each * L3030 Foot insert, removable, formed to patient foot, each * L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each * L3040 Foot, arch support, removable, premolded, longitudinal, each * L3050 Foot, arch support, removable, premolded, metatarsal, each * L3060 Foot, arch support, removable, premolded, longitudinal/metatarsal, each * L3070 Foot, arch support, nonremovable, attached to shoe, longitudinal, each * L3080 Foot, arch support, nonremovable, attached to shoe, metatarsal, each * L3090 Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each * L1900 AFO, spring wire, dorsiflexion assist calf band, custom fabricated * L1901 Ankle orthosis, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra) * L1902 AFO, ankle gauntlet, prefabricated, includes fitting and adjustment * L1904 AFO, molded ankle gauntlet, custom fabricated * L1906 AFO, multiligamentus ankle support, prefabricated, includes fitting and adjustment * L1907 Afo, supramalleolar with straps, with or without interface/pads, custom fabricated * L1910 AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment * L1920 AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated * L1930 AFO, plastic or other material, prefabricated, includes fitting and adjustment * L1940 AFO, plastic or other material, custom-fabricated * L1945 AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated * L1950 AFO, spiral, (Institute of Rehabilitative Medicine type), plastic, custom-fabricated * L1951 AFO, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, includes fitting and adjustment * L1960 AFO, posterior solid ankle, plastic, custom fabricated * L1970 AFO, plastic, with ankle joint, custom fabricated * L1971 AFO, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment * L1980 AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar “BK” orthosis), custom fabricated * L1990 AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar “BK” orthosis), custom fabricated * L2000 KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar “AK” orthosis), custom fabricated * L2010 KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar “AK” orthosis), without knee joint, custom fabricated * Page 7 of 14 Coverage Position Number: 0150 * L2020 KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar “AK” orthosis), custom fabricated * L2030 KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar “AK” orthosis), without knee joint, custom fabricated * L2035 KAFO, full plastic, static, (pediatric size), prefabricated, includes fitting and adjustment * L2036 KAFO, full plastic, double upright, free knee, custom fabricated * L2037 KAFO, full plastic, single upright, free knee, custom fabricated * L2038 KAFO, full plastic, without knee joint, multiaxis ankle, (Lively orthosis or equal), custom fabricated * L2039 KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, custom fabricated * L2106 AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated * L2108 AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated * L2112 AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment * L2114 AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment * L2116 AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment * L2126 KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated * L2128 KAFO, 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 * 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 * 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, nonmolded lacer * L2330 Addition to lower extremity, lacer molded to patient model * L2335 Addition to lower extremity, anterior swing band * L2340 Addition to lower extremity, pretibial shell, molded to patient model * Page 8 of 14 Coverage Position Number: 0150 * L2350 Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for “PTB,” “AFO” orthoses) * 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 * 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, lock; drop, stance or swing phase, each joint * 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 * L2435 Addition to knee joint, polycentric joint, 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, nonmolded * 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 * L2760 Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth) * L2768 Orthotic side bar disconnect device, per bar * L2770 Addition to lower extremity orthosis, any material, per bar or joint * L2780 Addition to lower extremity orthosis, noncorrosive 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, kneecap, medial or lateral pull * 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 * L2860 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism, each * L4010 Replace trilateral socket brim * L4350 Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment * L4360 Walking boot, pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment * Page 9 of 14 Coverage Position Number: 0150 * 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 ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment * L4398 Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment * L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock * L5847 Addition, endoskeletal knee-shin system, microprocessor control feature, stance phase

ICD-9-CM Diagnosis Codes Description

* 250.60 Type II (non-insulin dependent type) or unspecified type diabetes mellitus with neurological manifestations, not stated as uncontrolled * 250.62 Type II (non-insulin dependent type) or unspecified type diabetes mellitus with neurological manifestations, uncontrolled * 250.63 Type I (insulin dependent type) diabetes mellitus with neurological manifestations, uncontrolled * 250.70 Type II (non-insulin dependent type) or unspecified type diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled * 250.71 Type I (insulin dependent type) diabetes mellitus with peripheral circulatory disorders, not stated as uncontrolled * 250.72 Type II (non-insulin dependent type) or unspecified type diabetes mellitus with peripheral circulatory disorders, uncontrolled * 250.73 Type I (insulin dependent type) diabetes mellitus with peripheral circulatory disorders, uncontrolled * 335.20 Amyotrophic lateral sclerosis * 335.21 Progressive muscular atrophy * 335.22 Progressive bulbar palsy * 335.29 Other motor neuron diseases * 336.9 Unspecified disease of spinal cord * 337.0 Idiopathic peripheral autonomic neuropathy * 341.8 Other demyelinating diseases of central nervous system * 342.10 Spastic hemiplegia affecting unspecified side * 342.11 Spastic hemiplegia affecting dominant side * 342.12 Spastic hemiplegia affecting nondominant side * 343.0 Diplegic infantile cerebral palsy * 343.1 Hemiplegic infantile cerebral palsy * 355.8 Unspecified mononeuritis of lower limb * 356.0 Hereditary peripheral neuropathy * 356.1 Peroneal muscular atrophy * 356.2 Hereditary sensory neuropathy * 356.3 Refsum’s disease * 356.4 Idiopathic progressive polyneuropathy * 356.8 Other specified idiopathic peripheral neuropathy * 357.0 Acute infective polyneuritis * 357.1 Polyneuropathy in collagen vascular disease * 357.2 Polyneuropathy in diabetes * 357.3 Polyneuropathy in malignant disease * 357.4 Polyneuropathy in other diseases classified elsewhere * Page 10 of 14 Coverage Position Number: 0150 * 358.00 Myasthenia gravis without (acute) exacerbation * 359.0 Congenital hereditary muscular dystrophy * 359.1 Hereditary progressive muscular dystrophy * 359.2 Myotonic disorders * 438.20 Hemiplegia affecting unspecified side due to cerebrovascular disease * 438.21 Hemiplegia affecting dominant side due to cerebrovascular disease * 438.22 Hemiplegia affecting nondominant side due to cerebrovascular disease * 438.40 Monoplegia of lower limb affecting unspecified side due to cerebrovascular disease * 438.41 Monoplegia of lower limb affecting dominant side due to cerebrovascular disease * 440.20 Atherosclerosis of native arteries of the extremities, unspecified * 440.21 Atherosclerosis of native arteries of the extremities with intermittent claudication * 440.22 Atherosclerosis of native arteries of the extremities with rest pain * 440.23 Atherosclerosis of native arteries of the extremities with ulceration * 443.0 Raynaud’s syndrome * 443.1 Thromboangiitis obliterans (Buerger’s disease) * 443.89 Other peripheral vascular disease * 443.9 Unspecified peripheral vascular disease * 713.5 Arthropathy associated with neurological disorders * 726.71 Achilles bursitis or tendinitis * 726.72 Tibialis tendinitis * 726.73 Calcaneal spur * 728.71 Plantar fascial fibromatosis * 735.0 Hallux valgus (acquired) * 735.1 Hallux varus (acquired) * 735.2 Hallux rigidus * 735.3 Hallux malleus * 735.4 Other hammer toe (acquired) * 735.5 Claw toe (acquired) * 735.8 Other acquired deformity of toe * 735.9 Unspecified acquired deformity of toe * 736.70 Unspecified deformity of ankle and foot, acquired * 736.71 Acquired equinovarus deformity * 736.72 Equinus deformity of foot, acquired * 736.73 Cavus deformity of foot, acquired * 736.74 Claw foot, acquired * 736.75 Cavovarus deformity of foot, acquired * 736.76 Other acquired calcaneus deformity * 741.00 Spina bifida with hydrocephalus, unspecified region * 741.93 Spina bifida without mention of hydrocephalus, lumbar region * 754.50 Congenital talipes varus * 754.51 Congenital talipes equinovarus * 754.52 Congenital metatarsus primus varus * 754.53 Congenital metatarsus varus * 754.60 Congenital talipes valgus * 754.61 Congenital pes planus * 754.62 Talipes calcaneovalgus * 754.69 Other congenital valgus deformity of feet * 754.70 Unspecified talipes * 754.71 Talipes cavus

Experimental/Investigational/Unproven/Not Covered: CPT* Codes Description
Page 11 of 14 Coverage Position Number: 0150 HCPCS Codes Description ICD-9-CM Diagnosis Codes Description
*Current Procedural Terminology (CPT®) ©2003 American Medical Association: Chicago, IL. References

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Academy of Ambulatory Foot and Ankle Surgery. Heel spur syndrome. National Guideline Clearinghouse. Summary completed October 12, 2000, verified by Academy of Ambulatory Foot and Ankle Surgery December 8, 2000. Updated by ECRI December 19, 2003. Verified by Academy of Ambulatory Foot and Ankle Surgery December 29, 2003. Accessed June 30, 2004. Available at URL address: http://www.guideline.gov/summary/summary.aspx?doc_id=4245 * 6. Bloomgarden ZT. American Diabetes Association 60th Scientific Sessions, 2000. The Diabetic Foot. Diabetes Care 2001 May;24(5):946-51. * 7. Brunner R, Meier G, Ruepp T. Comparison of stiff and spring-type ankle-foot orthosis to improve gait in spastic hemiplegic children. Journal of Pediatric Orthopedics. 1998 Nov-Dec;18(6):719-26. * 8. Cappello T, Song KM. Determining treatment of flatfeet in children. Current Opinion in Pediatrics. 1998 Feb;10(1):77-81. * 9. Chao W, Wapner KL, Lee TH, Adams J, Hecht PJ. 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Moore JW. Prostheses, orthoses, and shoes for partial foot amputees. Clin Podiatr Med Surg. 1997 Oct;14(4):775-83. * Page 13 of 14 Coverage Position Number: 0150 * 31. Mueller MJ, Strube MJ. Therapeutic footwear: enhanced function in people with diabetes and transmetatarsal amputation. Arch Phys Med Rehabil. 1997 Sep; 78(9):952-6. * 32. Pfeffer G, Bacchetti P, Deland J, Lewis A, Anderson R, Davis W, Alvarez R, Brodsky J, Cooper P, Frey C, Herrick R, Myerson M, Sammarco J, Janecki C, Ross S, Bowman M, Smith R. Comparison of custom and prefabricated orthoses in the initial treatment of proximal plantar fasciitis. Foot Ankle Int. 1999 Apr;20(4): 214-21. * 33. Pinzur MS, Slovenkai MP, Trepman E. Guidelines for Diabetic Foot Care. Foot Ankle Int. 1999 Nov;20(11):695-702. * 34. Radtka SA, Skinner SR, Dixon DM, Johanson ME. A comparison of gait with solid, dynamic, and no ankle-foot orthoses in children with cerebral palsy. Phys Ther.1997 Apr;77(4):395-409. * 35. Ranawat CS, Positano RG. 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