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Date Printed: June 23, 2017: 11:38 AM

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09-L0000-01

Original Effective Date: 08/15/00

Reviewed: 07/17/15

Revised: 01/01/17

Subject: Knee Braces

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Updates  
           

DESCRIPTION:

The three components common to almost all knee braces include a rigid shell, a hinge, and a strap system. The shell extends proximally and distally to a hinge that is centered on the knee axis of motion. The strapping system secures the brace to the leg.

Knee braces can be subdivided into four categories that are based on the intended use:

  1. Prophylactic braces attempt to prevent or reduce the severity of knee ligament injuries. These braces are primarily designed to prevent injuries to the medial collateral ligament, which is among the most common athletic knee injury.
  2. Rehabilitation braces allow protected motion of injured knees that have been treated operatively or non-operatively. These braces allow for controlled joint motion and typically consist of hinges that can be locked into place for the purpose of limiting range of motion. Rehabilitation braces are commonly used for 6 to 12 weeks after injury and are usually purchased off-the-shelf and are not custom-made.
  3. Functional braces assist or provide stability for unstable knees during activities of daily living or sports and may be either “off-the-shelf” or “custom-made”. Derotation braces are typically used after injuries to ligaments and have medial and lateral bars with varying hinge and strap designs. These derotation braces are designed to permit significant motion and speed; in many instances the braces are worn only during elective activities, such as sports. Braces made of graphite, titanium, or other lightweight materials are specifically designed for high-performance sports. Functional knee braces have also been used in patients with osteoarthritis in order to decrease the weight on painful joints.
  4. Unloader knee braces are designed to reduce the pain and disability associated with osteoarthritis of the medial compartment of the knee by bracing the knee in the valgus position in order to unload the compressive forces on the medial compartment.

The HCPCS coding terminology regarding “custom-made” and “off-the-shelf” knee braces can be confusing. Please see the DEFINITIONS section of this policy for applicable description.

POSITION STATEMENT:

Off-the-shelf (custom-fitted) functional knee braces meet the definition of medical necessity in members with knee instability due to injury (including members who have had surgery for the injury) or in members with painful osteoarthritis of the medial compartment of the knee.

Examples of off-the-shelf (custom-fitted) functional knee braces may include:

Manufacturer

Brand Names

Bauerfeind

Moss Gen U Short

Bledsoe

Force I, Force 2, Force 3, Proshifter ACL, Proshifter Contact

Deroyal

Three-D

DonJoy

Gold Point, Legend, 4 Point Supersport, Playmaker, Monarch

Innovation

MVP

Medical Designs

Lorus

Mueller Sports

Magna-Lite Prefi t

Omni Scientific

Spectrum, OS-5

Orthomedics

Ecko II

Orthotech

Contender, Controller

Spademan

ACL Sport

Townsend

Off-shelf

Vixie Enterprise

MKS2 OTS

Zinco

Lehrman Multilig, MSO

Custom-made unloader knee braces meet the definition of medical necessity as a treatment for members with painful osteoarthritis involving the medial compartment of the knee.

Examples of unloader knee braces may include:

Manufacturer

Brand Names

Generation II

Unloader

Donjoy

Monarch

Orthotech

Montana

Custom-made functional knee braces do not meet the definition of medical necessity, as there is no data in the published peer-reviewed literature supporting custom-made functional knee braces offer any benefit over off-the-shelf braces in terms of activities of daily living (e.g., sporting activities). However, the medical necessity of a custom-made knee brace may be an individual consideration when: the member has met the criteria for an off the shelf (custom-fitted) knee brace and is unable to be fitted with a prefabricated brace as a result of any of the following: abnormal limb contour, (disproportionate size and shape) knee deformity, or large size, all of which would preclude the use of an off-the-shelf (custom-fitted) model. The following information may be required documentation to support medical necessity: Physician history and physical, physician operative reports and physician progress notes.

LOINC Codes:

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Physician operative note

28573-4

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim.

Examples of custom-made functional knee braces include:

Manufacturer

Brand Names

DonJoy

CE 2000, Defiance

Generation II

GII Sports Brace

Innovation Sports

CTI Classic, CTII Superlight, CTI Standard, CTI Pro Sport

Lennox Hill

Regular, Light, Spectralite

MedTechna

Can Am

Mueller Sports Medicine

Magnum Competition

Omni Scientific

Elite, TS-7

Orthotech

Oti Performer

Spademan

Custom

Sutter

Talon

Townsend Design

Air Custom, Original

Vixie Enterprise

MKS2 Custom, MKS2 PCL

Zimmer Sports

Caster I, Sports Caster II

Prophylactic knee braces do not meet the definition of medical necessity and are generally considered contract exclusions.

BILLING/CODING INFORMATION:

HCPCS Coding:

There are a variety of HCPCS codes describing knee braces. While some describe knee braces according to their specific function, others describe knee braces according to their composition, which leads to overlapping of the HCPCS codes. Certain sports knee braces, such as the CTI or Defiance braces, could be accurately described by either code, and the choice of the code used probably depends on the level of reimbursement associated with each.

The following codes describe knee braces that meet the definition of medical necessity and are eligible for coverage:

L1810

Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1812

Knee orthosis, elastic with joint, prefabricated, off-the-shelf

L1820

Knee orthosis, elastic with condylar pads and joints, prefabricated, includes fitting and adjustment

L1830

Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf

L1831

Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment

L1832

Knee orthosis, adjustable knee joints, (unicentric or polycentric) positional orthosis, rigid support, prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1833

Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the-shelf

L1836

Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf

L1843

Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, (unicentric or polycentric) medial-lateral and rotation control, with or without varus/valgus adjustment, pre-fabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1844

Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, (unicentric or polycentric) medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated (only considered medically necessary in patient with osteoarthritis)

L1845

Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint, (unicentric or polycentric) medial-lateral and rotation control, custom fitted prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.

L1847

Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s)prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.

L1848

Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf

L1850

Knee orthosis, Swedish type prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.

L1851

Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

L1852

Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

The following codes describe custom-made functional knee braces that do not generally meet the definition of medical necessity and therefore would not be eligible for coverage:

L1834

Knee orthosis, without knee joint, rigid, custom fabricated

L1840

Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated

L1846

Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint, (unicentric or polycentric) medial-lateral and rotation control, custom fabricated

L1860

Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (SK)

REIMBURSEMENT INFORMATION:

As with all covered orthotic devices, reimbursement for a knee brace is based on the lesser of either the established allowance or the actual cost shown on the invoice. Medically necessary additions to knee braces (e.g., L2397, L2395, L2820, and L2830) are separately reimbursable.

Replacement of a previously covered knee brace is limited to the following conditions:

1. Reasonable and useful lifetime (RUL) has been exceeded (see chart below) OR

2. When still within the RUL:

The following chart reflects the reasonable useful lifetime of prefabricated knee orthoses:

L1810

1 year

L1812

1 year

L1820

1 year

L1830

1 year

L1831

2 years

L1832

2 years

L1833

2 years

L1836

3 years

L1843

3 years

L1845

3 years

L1850

2 years

Reimbursement for the repair is not to exceed the allowance for the cost of a new device.

Reimbursement for travel time and for professional services associated with preparation and fitting is included in the basic allowance for the orthotic device.

PROGRAM EXCEPTIONS:

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

The following Durable Medical Equipment Regional Carrier (DMERC) Local Coverage Determination (LCD) was reviewed on the last guideline reviewed date and is located at cgsmedicare.com: Knee Orthosis (L22664).

The following DMERC Local Coverage article was reviewed on the last guideline reviewed date and is located at cgsmedicare.com: Knee Orthoses-Policy Article (A47270).

DEFINITIONS:

Custom-fabricated: see definition for “custom-made”.

Custom fitted: see definition for “off-the-shelf”.

Custom-made: generally describes a brace that is individually made according to precise measurements or molds/casts of an individual patient. Thus only the individual patient may use a custom-made brace. According to the HCPCS codes, custom-made braces may also be described as custom-fabricated or molded to patient model.

Molded to patient model: see definition for “custom made”.

Off-the-shelf (custom-fitted): knee braces that are described as “custom fitted.” The braces are custom fitted only to the extent that the patient is fitted to a limited selection of sizes (i.e., small, medium, large, etc.). The brace may also be initially fitted by an orthotist, but this involves simple adjustments of the off-the-shelf braces.

Orthotist: someone skilled in the application of appliances or apparatus used to support, align, prevent, or correct deformities or improve function of movable parts of the body.

Unloader brace: designed to reduce pain and disability associated with osteoarthritis of the medial compartment of the knee by bracing the knee in a valgus position.

Prefabricated: see definition for “off-the-shelf”.

Valgus position: bent outward.

RELATED GUIDELINES:

Orthotics, 09-L0000-03

OTHER:

None applicable.

REFERENCES:

  1. American Academy of Orthopaedic Surgeons (AAOS) Position Statement: The Use of Knee Braces (10/97, Revised 12/03).
  2. Blue Cross Blue Shield Association Medical Policy 01.03.02 – Knee Braces, archived 05/11.
  3. Brouwer RW, Jakma TSC, Verhagen AP, Verhaar JAN, Bierma-Zeinstra SMA. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD004020. DOI: 10.1002/14651858.CD004020.pub2.
  4. CGS Administrators, LLC, Local Coverage Article: KNEE ORTHOSES - Policy Article - Effective January 2015 (A47270); accessed at cgsmedicare.com 06/11/15.
  5. CGS Administrators, LLC, Local Coverage Determination (LCD): Knee Orthoses (L22664), 05/01/15; accessed at cgsmedicare.com 06/11/15.
  6. Consortium Health Plans Medical Policy 1.03.02 – Knee Braces, (11/01/99).
  7. St. Anthony’s ICD-9-CM Code Book (current edition).

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 07/17/15.

GUIDELINE UPDATE INFORMATION:

08/15/00

New Medical Coverage Guideline.

08/23/01

Reviewed – no changes.

03/15/03

Reviewed – added examples of the various types of braces; removed L1844 and L1880 from the list of covered codes; and added L1836.

01/01/04

Annual HCPCS coding update.

02/15/04

Reviewed; deleted L1885; and added E1810.

05/15/05

Revision consisting of changing investigational statement for custom-made unloader knee braces to “medically necessary”.

10/15/05

Revision consisting of addition of definition for “prefabricated”.

01/01/06

Annual HCPCS coding update: revise L1832, L1843, L1844, L1845, and L1846.

05/15/07

Revision: deleted E1810 since this code is addressed in another MCG.

09/15/07

Reviewed; modified information regarding custom-made functional braces; updated coding section; reformatted guideline; updated references.

01/01/08

Annual HCPCS coding update: removed L1855, L1858, L1870, and L1880. Added statement regarding additions to knee braces.

01/01/10

Annual HCPCS coding update: removed L1800, L1815, and L1825.

12/15/10

Revisions; related ICD-10 codes added; formatting changes.

09/15/11

Revision; formatting changes.

01/01/14

Annual HCPCS coding update: added L1812 and L1833; revised L1810, L1820, L1830, L1832, L1836, L1843, L1845, L1847, and L1850. Updated Program Exceptions section.

08/21/14

Revision: updated Program Exceptions section.

08/15/15

Revision; Position statement, billing/coding, reimbursement information, program exception, and reference sections updated; formatting changes.

01/01/17

Annual CPT/HCPCS update.Added L1851 and L1852; deleted K0901 & K0902.

Date Printed: June 23, 2017: 11:38 AM