MEDICAL POLICY

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APPENDIX
HISTORY

Knee Braces

Number 1.03.501

Effective Date October 14, 2013

Revision Date(s) 10/14/13; 07/24/13; 06/10/13; 07/12/12; 07/12/11; 09/14/10; 08/11/09; 08/12/08; 08/14/07; 09/12/06; 09/13/05; 09/14/04; 07/13/04; 01/01/04; 12/11/03; 12/10/02; 10/08/02; 05/14/02; 10/09/01; 09/11/01; 11/05/99; 06/25/98

Replaces 1.03.02

Policy

Custom-made unloader knee braces, also called custom-molded knee orthoses, may be considered medically necessary as a treatment for patients with painful osteoarthritis involving the medial or lateral compartment of the knee. (See Policy Guidelines, and Benefit Application)

Off-the-shelf (custom-fitted) functional knee braces, also called ready-made or prefabricated knee orthoses, may be considered medically necessary for patients with knee instability due to injury (including patients who have had surgery for the injury) or for patients with painful osteoarthritis of the medial compartment of the knee. (See Policy Guidelines, and Benefit Application)

Custom-made functional knee braces are considered not medically necessary. However, the medical necessity of a custom-made knee brace may be considered on an individual basis for patients with abnormal limb contour, knee deformity, or large size, all of which may prevent the use of an off-the-shelf (custom-fitted) model. (See Policy Guidelines, and Benefit Application)

Prophylactic knee braces are considered not medically necessary.

A custom-made knee brace for any condition other than those listed is considered a “Special or extra cost convenience feature” that is excluded under the durable medical equipment/medical supplies benefit in most contracts. (See Member Contract, Policy Guidelines, and Benefit Application )

Related Policies

7.01.15

Meniscal Allograft and Other Meniscus Implants

7.01.549

Knee Arthroscopy in Adults

Policy Guidelines

When needed; clinical information, including a radiology report, may be requested to document the medical condition that requires the use of a knee brace.

Terminology and Coding information

The HCPCS terminology regarding custom-made and off-the-shelf knee braces may be unclear. In general, the term “custom-made” describes a brace that is made for one patient according to precise measurements or molds/casts of the individual patient. Thus, a custom-made brace is only used by one specific patient. According to the HCPCS codes, the following terms describe “custom-made” braces:

  • Custom fabricated; or
  • Molded-to-patient model.

According to the HCPCS codes, off-the-shelf knee brace models are described as “custom fitted”. These braces are prefabricated or mass-produced and come pre-sized, i.e., small, medium, large, etc. The brace can be modified easily to meet the patient’s rehabilitation need without the wait for a custom-made brace that requires special molds/casts and detailed fitting. The orthotist may provide the initial functional assessment and fit, as well as make simple adjustments to the off-the-shelf brace(s) to enable same day use, in many cases.

Unloader knee braces include, but may not be limited to, Generation II Unloader, Donjoy Monarch, and the Orthotech Montana. These knee braces may be coded as HCPCS code L-1844.

Table 1. Examples of Custom-made Functional Knee Braces (not all inclusive)

Manufacturer

Brand Name

DonJoy

CE 200, Defiance, Monarch

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, MKS2PCL

Zimmer

Sports Caster I, Sports Caster II

The following HCPCS codes describe custom braces that may be used for an abnormal limb contour, knee deformity, or a large size knee, that prevent the use of an off-the-shelf knee brace.

L1834

L1846

L1840

L1847

L1844

L1860

The following HCPCS codes describe custom braces that may be used for osteoarthritis of the knee.

L1840

L1844

L1846

 

Table 2. Examples of Off-The-Shelf Functional or Rehabilitation Knee Braces (not all inclusive)

Manufacturer

Brand Name

Bauerfeind

Moss Gen U Short

Bledsoe

Force 1, Force 2, Force 3, Proshifter ACL, Proshifter Contact

Comfy Splints

Comfy Standard Knee, Comfy Goniometer Knee, Spring-loaded Goniometer Knee, Comfy Lite Knee, Torq Knee

Deroval

Three-D

DonJoy

Gold Point, Legend, Point Supersport, Playmaker, Monarch

Innovation

MVP

Medical Designs

Lorus

Mueller Sports

Magna-Lite Prefit

Omni Scientific

Spectrum, OS-5

Orthomedics

Ecko

Orthotech

Contender, Controller

Spademan

ACL Sport

Townsend

Off-shelf

Vixie Enterprise

MKS2 OTS

Zinco

Lehrman Multilig, MSO

The following HCPCS codes describe off-the-shelf functional knee braces.

L1800

L1825

L1836

E1810

L1810

L1830

L1843

 

L1815

L1831

L1845

 

L1820

L1832

L1850

 

Note: Skin protectors like brace sleeves are considered medically necessary supplies when used in conjunction with knee braces/knee orthoses.

Description

Knee braces may be custom made or available off-the-shelf in a variety of sizes. Knee braces may be intended for rehabilitation, to reduce pain, or to prevent injury in either stable or unstable knees.

Background

Knee braces typically consist of 3 components:

  1. a superstructure (usually a rigid shell),
  2. a hinge,
  3. a strap system.

The superstructure extends proximally and distally to a hinge centered on the knee axis of motion. The strapping system secures the brace to the limb.

Knee braces can be subdivided into 4 categories that are based on their intended use:

  • Prophylactic knee braces are those that 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 injuries.
  • Rehabilitation knee braces are designed to 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 to limit range of motion. Rehabilitation braces are commonly used for 6 to 12 weeks after injury. Rehabilitation braces are usually purchased off-the-shelf and not custom-made.
  • Functional knee braces are designed to 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 injury 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.
  • Unloader knee braces are specifically 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. Unloader knee braces may also be used for osteoarthritis of the lateral compartment of the knee by bracing the knee in the varus position.

Scope

Medical policies are systematically developed guidelines that serve as a resource for Company staff when determining coverage for specific medical procedures, drugs or devices. Coverage for medical services is subject to the limits and conditions of the member benefit plan. Members and their providers should consult the member benefit booklet or contact a customer services representative to determine whether there are any benefit limitations applicable to this service or supply.

Benefit Application

Some member contracts exclude medical equipment and supplies that are “Special or extra cost convenience features.” Please check the member contract for benefit exclusions.

There are a variety of HCPCS codes describing knee braces. Some describe knee braces according to their specific function, while others describe knee braces according to their composition/construction, leading to overlapping HCPCS codes. (See Policy Guidelines).

For example:

Code L1840 describes a derotation, medial lateral, anterior cruciate ligament, custom-fabricated to patient model knee brace; i.e., a description of the function of the knee brace. (See Policy Guidelines).

Code L1858 describes a brace of consisting of molded plastic, polycentric knee joint, with pneumatic knee pads; i.e., a description of the composition of the knee brace. Certain sports knee braces, such as the CTI or Defiance braces, could be accurately described by either code. (See Policy Guidelines).

Rationale

This policy was originally created in 1998 and has been updated periodically with searches of the MEDLINE database. The most recent literature review was performed through August 2013.

At the time this policy was created in 1998 no data in the published peer-reviewed literature showed that custom-made functional knee braces offered any benefit over off-the-shelf braces in terms of activities of daily living. Many of the custom-made functional knee braces were designed specifically for participation in elective sports and thus would be considered not medically necessary. (1, 2) Research on unloader knee braces for osteoarthritis had focused on the custom-made knee braces and there were minimal data on off-the-shelf unloader knee braces, although several case series suggested that unloader knee braces were associated with a reduction in pain in patients with painful osteoarthritis of the medial compartment. (3)

Osteoarthritis

In 1999, Kirkley and colleagues reported on a controlled trial that randomized 119 patients with medial compartment osteoarthritis to receive standard medical management, medical management plus a polychloroprene (Neoprene) sleeve, or medical management plus an unloader knee brace. (4) Compared to the control group, the unloader knee brace was associated with a significant improvement in quality of life and function. In comparing the unloader knee brace with the neoprene sleeve, there was a significant difference in functional outcomes favoring the unloader knee, but no significant difference in terms of quality of life measures.

In a 2005 Cochrane review of braces and othoses for treating osteoarthritis of the knee, Brouwer et al. concluded that there was limited evidence in favor of an unloader knee brace. (5) In 2006, Brouwer and colleagues reported a randomized multicenter trial of 117 patients that compared off-the-shelf unloading braces and conservative therapy with conservative therapy alone for unicompartmental (valgus or varus) osteoarthritis of the knee. (6) The addition of a brace resulted in a slight increase in reported walking distances at three, six, and 12 months (effect size of 0.4), with trends for improvement in subjective pain (-0.63 on a 10-point visual analogue scale) and knee function (3 points on a 100-point Hospital for Special Surgery score). Quality of life did not differ between the two groups. The authors noted that adherence to the brace was low, with 16 of 60 patients (27%) discontinuing by three months and another nine (15%) stopping treatment by 12 months. Patient-reported reasons for discontinuing use of the unloading brace were lack of benefit and adverse effects (i.e., skin irritation, bad fit).

Another study from 2006 compared custom and off-the-shelf bracing for varus gonarthrosis. (7) Ten patients wore each type of braces for four-to-five weeks (about nine hours per day) in a randomized order. Pain scores were reduced from 197 mm (500 mm maximum) to 71 mm with the custom brace and 120 mm with the off-the-shelf brace. Stiffness was reduced from 91 mm (200 mm maximum) to 36 mm with the custom brace and 63 mm with the off-the-shelf brace. Function was improved from 664 mm (1700 mm maximum) to 248 mm with the custom brace, whereas the off-the-shelf brace did not significantly affect function. Kinematic analysis showed a reduction in peak knee adduction moments during gait and stair-stepping and reduced varus angulation by 1.5° compared with baseline with the custom brace. The off-the-shelf brace did not reduce the varus angle.

A French clinical practice guideline committee evaluated evidence on the use of braces in knee osteoarthritis in 2009. (8) The review found mainly low quality evidence in support of valgus knee braces for symptomatic medial femoro-tibial osteoarthritis with short- and mid-term reduction of pain and disability. Side effects included venous thromboembolic events. No additional controlled trials were identified in a 2010 review of bracing in the management of knee osteoarthritis. (9)

A 2010 study compared use of insoles or off-the-shelf braces for medial knee osteoarthritis in a randomized trial of 91 patients with medial compartmental knee osteoarthritis. (10) Pain severity, measured by a 10 point visual analog scale (VAS), improved by 0.9 in the insole group and 1.0 for the brace group in intent-to-treat analysis. Function on the Western Ontario and McMaster Osteoarthritis Index (WOMAC) improved by 4.2 and 4.0 points out of 100, respectively. There was no significant effect on the hip-knee-ankle angle for either device. Compliance was 45% for the brace group, with a mean wearing time of 39 hours (SD 32 hours). After six months of use, neither insoles nor off-the-shelf braces resulted in clinically significant changes in varus angle, pain, or function.

In 2011, Hunter et al. reported a randomized trial of patellofemoral bracing for the treatment of patellofemoral osteoarthritis. (11) Eighty subjects completed 6 weeks with a BioSkin Q Brace with the patellar realigning strap applied, and 6 weeks with the realigning strap removed. There was a 6-week interval between the 2 conditions and the order of treatment was randomized. They found no effect of treatment on VAS knee pain and no significant difference between the groups for WOMAC pain, function, or stiffness outcomes.

Ligamentous Instability of the Knee

Soma and colleagues compared the performance of custom-made and off-the-shelf functional knee braces from four manufacturers in 2004. (11) As a group, the custom-made knees braces restrained anterior displacement better than the off-the-shelf models by a mean difference of 0.84 mm. The clinical significance of this minimal, but statistically significant, difference is questionable.

A 2007 systematic review of 12 randomized controlled trials of bracing for rehabilitation following anterior cruciate ligament (ACL) reconstruction “found no evidence supporting the routine use of functional or rehabilitative bracing in a patient with a reconstructed ACL. In particular no study demonstrated a clinically important finding of improved range of motion, decreased pain, improved graft stability or decreased complications and reinjuries.” (12)

In 2008, Birmingham and colleagues reported a randomized controlled trial comparing use of an off-the-shelf functional knee brace or neoprene sleeve beginning six-weeks after ACL reconstruction. (13) Out of 150 patients randomized to a brace or sleeve after surgery, 127 (85%) completed 24-month follow-up. Compliance was similar for the two groups and three patients from each group had graft failures and revision surgeries. Confidence in the knee was rated higher for the brace (70 versus 55 out of 100), as was the rating of help in returning to sport (66 versus 53). No other outcome measures differed between the groups, including the ACL-quality of life questionnaire, highest activity level, satisfaction with the brace/sleeve, side-to-side laxity, or functional tests. As this report described evaluators as blinded to the patient’s group allocation, it does not appear that the patients were wearing the brace or sleeve at the time of functional testing.

Patellofemoral Pain Syndrome

In 2008, Warden et al reported a meta-analysis of 16 randomized or quasi-randomized studies assessing patellar taping or bracing effects on chronic knee pain. (14) Thirteen trials investigated taping or bracing for anterior knee pain and three investigated taping for osteoarthritis. The authors concluded there was limited evidence to demonstrate the efficacy of patellar bracing. They reported high heterogeneity between study outcomes and significant publication bias in the studies.

Summary

Evidence of efficacy of off-the-shelf bracing is limited for osteoarthritis of the medial compartment, ligamentous instability, or patellofemoral pain.

Technology Assessments, Guidelines and Position Statements

The American Academy of Orthopaedic Surgeons (AAOS) provided a 2009 clinical practice guideline on the nonarthroplasty treatment of osteoarthritis of the knee. (15) The AAOS was unable to make a recommendation for or against the use of a brace with a varus- or valgus- directing force for patients with medial or lateral unicompartmental osteoarthritis of the knee, based on limited evidence for the effectiveness of knee braces. (4, 6)

The Osteoarthritis Research Society International (OARSI) 2008 treatment guidelines recommend the following: “In patients with knee OA and mild/moderate varus or valgus instability, a knee brace can reduce pain, improve stability and diminish the risk of falling.” This guideline is based in part on the Brower study previous referenced in which there was a small but significant effect with unloading knee braces for patients with mild or moderate varus or valgus instability. (6) In this study, the patients had medial or lateral osteoarthritis and the unloading knee brace was adapted to each kind of compartment. A slightly better effect was shown for the varus group.

References

  1. Liu SH, Mirzayan R. Functional knee bracing. Clin Ortho Rel Research 1995; 317:273-281.
  2. Beynnon BD, Pope MH, Wertheimer CM et al. The effect of functional knee-braces on strain on the anterior cruciate ligament in vivo. J Bone Joint Surg Am 1992; 74(9):1298-312.
  3. Matsuno H, Kadowaki KM, Tsuji H. Generation II knee bracing for severe medial compartment osteoarthritis of the knee. Arch Phys Med Rehabil 1997; 78(7):745-9.
  4. Kirkley A, Webster-Bogaert S, Litchfield R et al. The effect of bracing on varus gonarthrosis. J Bone Joint Surg Am 1999; 81(4):539-48.
  5. Brouwer RW, Jakma TS, Verhagen AP et al. Braces and orthoses for treating osteoarthritis of the knee. Cochrane Database Syst Rev 2005; (1):CD004020.
  6. Brouwer RW, van Raaij TM, Verhaar JA et al. Brace treatment for osteoarthritis of the knee: a prospective randomized multi-centre trial. Osteoarthritis Cartilage 2006; 14(8):777-83.
  7. Draganich L, Reider B, Rimington T et al. The effectiveness of self-adjustable custom and off-the-shelf bracing in the treatment of varus gonarthrosis. J Bone Joint Surg Am 2006; 88(12):2645-52.
  8. Beaudreuil J, Bendaya S, Faucher M et al. Clinical practice guidelines for rest orthosis, knee sleeves, and unloading knee braces in knee osteoarthritis. Joint Bone Spine 2009; 76(6):629-36.
  9. Rannou F, Poiraudeau S, Beaudreuil J. Role of bracing in the management of knee osteoarthritis. Curr Opin Rheumatol 2010; 22(2):218-22.
  10. van Raaij TM, Reijman M, Brouwer RW et al. Medial Knee Osteoarthritis Treated by Insoles or Braces: A Randomized Trial. Clin Orthop Relat Res 2010.
  11. Soma CA, Cawley PW, Liu S et al. Custom-fit versus premanufactured braces. Orthopedics 2004; 27(3):307-10.
  12. Wright RW, Fetzer GB. Bracing after ACL reconstruction: a systematic review. Clin Orthop Relat Res 2007; 455:162-8.
  13. Birmingham TB, Bryant DM, Giffin JR et al. A randomized controlled trial comparing the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate ligament reconstruction. Am J Sports Med 2008; 36(4):648-55.
  14. Warden SJ, Hinman RS, Watson MA, Jr. et al. Patellar taping and bracing for the treatment of chronic knee pain: a systematic review and meta-analysis. Arthritis Rheum 2008; 59(1):73-83.
  15. Richmond J, Hunter D, Irrgang J et al. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg 2009; 17(9):591-600.
  16. Zhang, W, Moskowitz RW, Nuki G et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16:137-162.
  17. Hunter DJ, Harvey W, Gross KD et al. A randomized trial of patellofemoral bracing for treatment of patellofemoral osteoarthritis. Osteoarthritis Cartilage 2011; 19(7) 792-800.

Coding

Codes

Number

Description

CPT

   

ICD-9 Procedure

   

ICD-9 Diagnosis

715.0

Osteoarthrosis, generalized

 

715.1

Localized, primary

 

715.2

Localized, secondary

 

715.3

Localized, not specified whether primary or secondary

 

715.8

Involving, or with mention of more than one site, but not specified as generalized

 

715.9

Unspecified whether generalized or localized

 

717

Internal derangement of knee

 

717.0

Old bucket handle tear of medial meniscus

 

717.1

Derangement of anterior horn of medial meniscus

 

717.2

Derangement of posterior horn of medial meniscus

 

717.3

Other and unspecified derangement of medial meniscus

 

717.4

Derangement of lateral meniscus

 

718.86

Other joint derangement, not elsewhere classified, lower leg

 

836

Dislocation of knee

 

836.0

Tear of medial cartilage or meniscus of knee, current

 

836.1

Tear of lateral cartilage or meniscus of knee, current

 

836.2

Other tear of cartilage or meniscus of knee, current

 

836.3

Dislocation of patella, closed

 

836.4

Dislocation of patella, open

 

836.5

Other dislocation of knee, closed

 

836.6

Other dislocation of knee, open

 

844

Sprains and strains of knee and leg

 

844.0

Lateral collateral ligament of knee

 

844.1

Medial collateral ligament of knee

 

844.2

Cruciate ligament of knee

 

844.3

Tibiofibular (joint) (ligament), superior

 

844.8

Other specified sites of knee and leg

 

844.9

Unspecified site of knee and leg

 

959.7

Other and unspecified injury of knee, leg, ankle, and/or foot

HCPCS

E1810

Dynamic adjustable knee extension/flexion device, includes soft interface material

 

E1811

Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories

 

E1812

Dynamic knee, extension/flexion device with active resistance control

 

L1810

Knee orthosis (KO); elastic with joints, prefabricated, includes fitting and adjustment

 

L1820

Knee orthosis (KO); Elastic with condylar pads and joints, with or without patellar control, prefabricated, including fitting and adjustments

 

L1830

Knee orthosis (KO); Immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustments

 

L1831

Knee orthosis (KO); Locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment

 

L1832

Knee orthosis (KO); Adjustable knee joints, (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustment

 

L1834

Knee orthosis (KO); Without knee joint, rigid, custom fabricated

 

L1836

Knee orthosis (KO); Rigid, without joint(s), includes soft interface material, prefabricated, includes fitting and adjustment

 

L1840

Knee orthosis (KO); Derotation, medial-lateral, anterior cruciate ligament, custom-fabricated

 

L1843

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, includes fitting and adjustment

 

L1844

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, custom fabricated

 

L1845

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, includes fitting and adjustment

 

L1846

Knee orthosis (KO); 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, custom fabricated

 

L1847

Knee orthosis (KO); Double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, includes fitting and adjustment

 

L1850

Knee orthosis (KO); Swedish type, includes fitting and adjustment

 

L1860

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

Type of Service

Orthopedics

 

Place of Service

Outpatient

 

Appendix

N/A

History

Date

Reason

06/25/98

Add to Durable Medical Equipment Section - New Policy

11/05/99

Replace Policy - Description revised.

09/11/01

Replace Policy - Scheduled update

10/09/01

Replace Policy - HCPCS codes added; reviewed by Care Management staff.

05/14/02

Replace Policy - Benefits Application Section updated.

10/08/02

Replace Policy - Policy reviewed; policy statement unchanged. Additional references added.

12/10/02

Replace Policy - Policy reviewed; reimbursement for custom brace language updated.

12/09/03

Replace Policy - Policy reviewed; policy statement added concerning elective sports braces. Additional references and HCPC codes added.

01/01/04

Replace Policy - HCPC code update only.

07/13/04

Replace Policy - Policy reviewed; policy statement unchanged. Tables, Rationale and References updated.

09/01/04

Replace Policy - Policy renumbered from PR.1.03.100. No date changes.

09/14/04

Replace Policy - Policy reviewed; policy statement unchanged. Benefit Application and Rationale updated.

09/13/05

Replace Policy - Policy statement revised to indicate that custom knee braces not meeting criteria are considered an extra cost convenience feature excluded under most contract provisions. Rationale and References updated.

02/06/06

Codes updated - No other changes.

06/23/06

Update Scope and Disclaimer - No other changes.

09/12/06

Replace Policy - Policy reviewed with literature search; references added; no change in policy statement.

08/14/07

Replace Policy - Policy updated with literature review; references added. No change in policy statement.

08/12/08

Replace Policy - Policy updated with literature search; no change to the policy statement.

08/11/09

New BC - Policy updated with literature search and converted to BC version. Replaces PR.1.03.500. Policy statement reworded but essentially unchanged.

09/14/10

New PR Policy - Policy updated with literature search; references added and reordered. Policy statements changed to allow unloader bracing for “lateral” compartment of knee, in addition to medial. A new PR policy has been developed to replace BC.1.03.02

07/12/11

Replace Policy - Policy updated with literature review; reference added. 2011 update added to osteoarthritis section. No change to the policy statement.

07/20/12

Replace policy. No change in policy statement.

07/24/13

Replace policy. Policy reviewed. Minor edits for readability. A review of the literature through April 2013 did not prompt any additions to the references. Policy statement unchanged.

10/14/13

Replace policy. Removed Policy guideline stating “When the patient’s clinical condition meets the requirement for an off-the-shelf (prefabricated) knee brace but the patient prefers a custom knee brace, payment for the most common type of off-the-shelf knee brace (L1845) may be allowed toward that purchase”. Moved codes from benefit application to Policy Guidelines following the descriptions of the types of knee braces. A review of the literature through August 2013 did not prompt any additions to the references. Policy statement unchanged.


Disclaimer: This medical policy is a guide in evaluating the medical necessity of a particular service or treatment. The Company adopts policies after careful review of published peer-reviewed scientific literature, national guidelines and local standards of practice. Since medical technology is constantly changing, the Company reserves the right to review and update policies as appropriate. Member contracts differ in their benefits. Always consult the member benefit booklet or contact a member service representative to determine coverage for a specific medical service or supply. CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA).
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