Ankle-foot orthoses (AFO) and knee-ankle foot orthoses (KAFO) are covered under the Medicare Braces Benefit. For coverage under this benefit, the orthosis must be a rigid or semi-rigid device, which is 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. Items that are not sufficiently rigid to be capable of providing the necessary immobilization or support to the body part for which it is designed do not meet the statutory definition of the Braces Benefit. Items that do not meet the definition of a brace are statutorily non covered, no benefit.
Both “off-the-shelf” (OTS) and custom-fit items are considered prefabricated braces for Medicare coding purposes. 42 CFR §414.402 establishes that correct coding of AFO and KAFO items is dependent upon whether there is a need for “minimal self-adjustment” during the final fitting at the time of delivery. (See instructions in Coding Guidelines). If a custom fit code is billed when minimal self-adjustment was provided at final delivery, or if an OTS code is billed when more than minimal self-adjustments were made at final delivery, the claims will be denied as incorrect coding with a statutory denial.
A static/dynamic Ankle-Foot Orthosis (AFO) (L4396, L4397) and replacement interface (L4392) are denied as noncovered (no Medicare benefit) when they are used solely for the prevention or treatment of a heel pressure ulcer because for these indications they are not used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace).
A foot drop splint/recumbent positioning device (L4398) and replacement interface (L4394) are denied as noncovered (no Medicare benefit) when they are used solely for the prevention or treatment of a pressure ulcer because for these indications they are not used to support a weak or deformed body member or to restrict or eliminate motion in a diseased or injured part of the body (i.e., it does not meet the definition of a brace).
Elastic or other fabric support garments (A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE)) with or without stays or panels do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Code A4467 is denied as noncovered (no Medicare benefit). Refer to the coding guideline for additional information.
A foot pressure off-loading/supportive device (A9283) is denied as noncovered (no Medicare benefit), because it does not support a weak or deformed body member or restrict or eliminate motion in a diseased or injured part of the body.
An inversion/eversion correction device (A9285) is denied as noncovered (no Medicare benefit), because it does not act as a brace; that is, it does not support a weak or deformed body member or restrict or eliminate motion in a diseased or injured part of the body.
Socks (L2840, L2850) used in conjunction with orthoses are denied as noncovered (no Medicare benefit).
Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are an integral part of a brace.
There is no separate payment if CAD-CAM technology is used to fabricate an orthosis. Reimbursement is included in the allowance of the codes for custom fabricated orthoses.
Evaluation of the beneficiary, measurement and/or casting, and fitting/adjustments of the orthosis are included in the allowance for the orthosis. There is no separate payment for these services.
Payment for ankle-foot orthoses or knee-ankle foot orthoses are included in the payment to a hospital or skilled nursing facility (SNF) if:
The orthosis is provided to a beneficiary prior to an inpatient hospital admission or Part A covered SNF stay; and,
The medical necessity for the orthosis begins during the hospital or SNF stay (e.g., after ankle, foot, or knee surgery).
A claim should not be submitted to the DME MAC in this situation.
Payment for ankle-foot orthoses or knee-ankle foot orthoses are also included in the payment to a hospital or a Part A covered SNF stay if:
The orthosis is provided to a beneficiary during an inpatient hospital or Part A covered SNF stay prior to the day of discharge; and,
The beneficiary uses the item for medically necessary inpatient treatment or rehabilitation.
A claim must not be submitted to the DME MAC in this situation.
Payment for ankle-foot orthoses or knee-ankle foot orthoses delivered to a beneficiary in a hospital or a Part A covered SNF stay is eligible for coverage by the DME MAC if:
The orthosis is medically necessary for a beneficiary after discharge from a hospital or Part A covered SNF stay; and,
The orthosis is provided to the beneficiary within two days prior to discharge to home; and,
The orthosis is not needed for inpatient treatment or rehabilitation, but is left in the room for the beneficiary to take home.