Knee Orthoses - Policy Article

Revision Effective Date: 01/25/2026
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary.” to “Documentation must be sufficiently detailed to include, but is not limited to, a detailed description of why the modifications are necessary and what modifications were performed at the time of fitting the orthosis to the beneficiary.,” as clarification
Revised: Custom fabricated language from “For custom fabricated orthoses” to “For a custom fabricated orthosis,” as clarification


04/09/2026: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/25/2026
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Documentation requirements for HCPCS codes L1832, L1833, L1843, L1844, L1845, L1846, L1850, L1851, L1852
GENERAL REQUIREMENTS:
Added: HCPCS code L1820 to items coded as custom-fitted
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Added: HCPCS codes L1830 and L1834 to Group 4 Paragraph
Added: Group 6 Paragraph, which is “For HCPCS codes L1843, L1844, L1845, L1846, L1851 and L1852:”
Added: Group 6 Codes, which are ICD-10-CM Codes M17.0, M17.11, M17.12, M17.2, M17.31, M17.32, M17.4, M17.5, M17.9


12/11/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 10/01/2025
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY:
Removed: ICD-10-CM code G35 from Group 4 Codes, due to ICD-10-CM code updates
Added: ICD-10-CM codes G35.A, G35.B0, G35.B1, G35.B2, G35.C0, G35.C1, G35.C2, G35.D to Group 4 Codes, due to ICD-10-CM code updates


09/18/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2025
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: “Based on Social Security Act §1834(h)(5), for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by the treating practitioner.” as clarification


04/03/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2025
CODING GUIDELINES:
Revised: Long descriptor for HCPCS code E1810
Added: “E1813 (DYNAMIC ADJUSTABLE KNEE EXTENSION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL), or E1814 (DYNAMIC ADJUSTABLE KNEE FLEXION ONLY DEVICE, INCLUDES SOFT INTERFACE MATERIAL)” to language for all claims for devices that contain a concentric adjustable torsion mechanism in the knee joint for any condition other than an assistive function to joint extension motion


01/16/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 10/01/2024
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Code L1821 to the referenced prefabricated orthoses
CODING GUIDELINES:
Added: A row to the table that pertains to corresponding sets of HCPCS codes; the added row contains “L1820” in Column I and “L1821” in Column II
Revised: Long descriptor for HCPCS code L1820
Added: Coding guideline information for code L1821
Added: A row to the prefabricated knee orthoses table that contains base codes and addition codes that describe components or features that can be physically incorporated into the base orthosis but that are considered to be included in the allowance for the orthosis; the added row contains “L1821” as the Base Code and “L2390, L2750, L2780, L2810, L4002” as the Addition Codes – Not Separately Payable
Added: A row to the chart that reflects the reasonable useful lifetime of prefabricated knee orthoses; the row includes “L1821” as the Code and “1 Year” as the Reasonable Useful Lifetime


10/17/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 10/01/2024
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Code L1821 to the referenced prefabricated orthoses
CODING GUIDELINES:
Added: A row to the table that pertains to corresponding sets of HCPCS codes; the added row contains “L1820” in Column I and “L1821” in Column II
Revised: Long descriptor for HCPCS code L1820
Added: Coding guideline information for code L1821
Added: A row to the prefabricated knee orthoses table that contains base codes and addition codes that describe components or features that can be physically incorporated into the base orthosis but that are considered to be included in the allowance for the orthosis; the added row contains “L1821” as the Base Code and “L2390, L2750, L2780, L2810, L4002” as the Addition Codes – Not Separately Payable
Added: A row to the chart that reflects the reasonable useful lifetime of prefabricated knee orthoses; the row includes “L1821” as the Code and “1 Year” as the Reasonable Useful Lifetime


10/17/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/23/2024
CODING VERIFICATION REVIEW:
Added: Coding verification review information for HCPCS code L1843, effective for DOS on or after 12/01/2024


06/06/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/23/2024
CODING VERIFICATION REVIEW:
Added: Coding verification review information for HCPCS code L1843, effective for DOS on or after 12/01/2024


06/06/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/23/2024
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: “Fabrication of an orthosis using CAD/CAM or similar technology without the creation of a positive model with minimal self-adjustment at delivery is considered as OTS.”
CODING GUIDELINES:
Added: “Use of an additive manufacturing technique, CAD/CAM, or a similar manufacturing technique is not the sole requirement for a product to be designated as custom fabricated.”
Removed: “An orthosis that is fabricated from a mold, CAD/CAM, or similar technology but without the creation of a positive model is considered a prefabricated orthosis.”
Added: “Additive Manufacturing” with a description
Added: “Additive manufacturing is an acceptable custom fabrication technique as long as it adheres to the CMS DMEPOS Quality Standards, Appendix C.”
Removed: “Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient is considered as OTS if the final fitting upon delivery to the patient requires minimal self-adjustment not requiring expertise as described in this section.”
Removed: “Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient is considered as custom fitted if the final fitting at the time of delivery to the patient requires more than minimal self-adjustment requiring expertise as described in this section.”


03/07/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/23/2024
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: “Fabrication of an orthosis using CAD/CAM or similar technology without the creation of a positive model with minimal self-adjustment at delivery is considered as OTS.”
CODING GUIDELINES:
Added: “Use of an additive manufacturing technique, CAD/CAM, or a similar manufacturing technique is not the sole requirement for a product to be designated as custom fabricated.”
Removed: “An orthosis that is fabricated from a mold, CAD/CAM, or similar technology but without the creation of a positive model is considered a prefabricated orthosis.”
Added: “Additive Manufacturing” with a description
Added: “Additive manufacturing is an acceptable custom fabrication technique as long as it adheres to the CMS DMEPOS Quality Standards, Appendix C.”
Removed: “Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient is considered as OTS if the final fitting upon delivery to the patient requires minimal self-adjustment not requiring expertise as described in this section.”
Removed: “Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient is considered as custom fitted if the final fitting at the time of delivery to the patient requires more than minimal self-adjustment requiring expertise as described in this section.”


03/07/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 07/20/2023
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Language that describes prefabricated and custom fabricated orthoses
Removed: Reasonable and useful lifetime (RUL) language and chart of knee orthoses codes with RUL guidelines
Removed: Language pertaining to noncoverage of L-coded additions when the base orthosis is noncovered
Removed: “Brace sleeves (A9270) used in conjunction with orthoses are noncovered because 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).”
Removed: Repair information
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: “General Requirements”
Added: “The supplier must include on the claim line the diagnosis code(s) for HCPCS codes L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852 and L1860.”
Added: “For a custom-fabricated orthosis, there must be documentation in the supplier's records to support the medical necessity of that type of device rather than a prefabricated orthosis. This information must be available upon request.”
Revised: "prescribing practitioner" to "treating practitioner"
Removed: “The beneficiary’s condition (diagnosis code) that necessitates the need for the knee orthosis must be included on the claim.”
Added: Prefabricated orthoses HCPCS codes to language that pertains to coding of prefabricated orthoses
Revised: "This information will be corroborated by the functional evaluation in the orthotist’s or prosthetist’s records.” to “This information will be corroborated by the functional evaluation in the orthotist’s records and the method of custom fabrication should adhere to the DMEPOS Quality Standards, Appendix C.”
MODIFIERS:
Removed: “(refer to the CODING GUIDELINES section for additional information)” pertaining to RT and LT modifiers
Added: RT and LT modifier information (relocated from the CODING GUIDELINES section)
MISCELLANEOUS:
Added: Language pertaining to information for inclusion in claims for codes L4205 and L4210
CODING GUIDELINES:
Removed: "Definitions," language pertaining to terms used to describe devices in the Policy Article, and brace definition language
Revised: “Custom Fabricated” to “CUSTOM FABRICATED”
Added: “Custom-fabricated additions are appropriate only for custom-fabricated base orthotics and should not be billed with prefabricated base orthotics” (relocated from the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section)
Added: Updated language that describes custom fabricated orthoses, molded-to-patient-model custom fabrication, and positive model of the patient
Added: “PREFABRICATED” and language that describes prefabricated orthoses
Revised: “More than minimal self-adjustment is defined as changes made to achieve an individualized fit of the item that requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthotics in compliance with all applicable Federal and State licensure and regulatory requirements.” to “In contrast to “minimal self-adjustment,” “more than minimal self-adjustment” is defined as changes made to achieve an individualized fit during the final fitting at the time of delivery of the item that requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthotics in compliance with all applicable Federal and State licensure and regulatory requirements.”
Added: “Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient is considered as custom fitted if the final fitting at the time of delivery to the patient requires more than minimal self-adjustment requiring expertise as described in this section.”
Removed: “However, for certain types of orthoses, the HCPCS code narrative that best describes the product does not make a distinction between prefabricated orthoses that are provided as custom-fit or OTS. These code narratives are correct and must be used for Medicare billing, without regard to how the product is provided to the beneficiary at the final delivery.” (Effective March 11, 2021)
Added: “Corresponding HCPCS Code Sets”
Revised: “parallel” to “corresponding” in regard to HCPCS codes
Removed: “(e.g., L1832, L1833, L1845, L1846, L1847, and L1848)” from the sentence that pertains to corresponding sets of HCPCS codes
Added: HCPCS codes L1810, L1812, L1832, L1833, L1843, L1845, L1847, L1848, L1851, L1852 to a table that pertains to corresponding sets of HCPCS codes
Added: Information that pertains to the coding of a prefabricated orthosis when a corresponding HCPCS code set is not available and the unique HCPCS code describes a custom fitted item, including “Code the product using the unique HCPCS code, if the product was custom fitted at the time of delivery to the beneficiary” and “Code the product using a miscellaneous HCPCS code, if the product was not custom fitted at delivery to the beneficiary and, instead, was provided as OTS to the beneficiary. The miscellaneous HCPCS code for billing of knee orthoses is HCPCS code L2999.” (Effective March 11, 2021)
Revised: “Elastic and Similar Stretchable Materials” to “ELASTIC AND SIMILAR STRETCHABLE MATERIALS”
Added: “KNEE ORTHOSES”
Removed: “(respectively)” from the description of codes L1843, L1844, L1845, L1846, L1851 and L1852
Added: “LOWER EXTREMITY ADDITIONS” and language that describes custom-fabricated additions
Revised: “Not medically necessary” to “Not reasonable and necessary” in regard to the four (4) categories into which addition codes are grouped
Added: Reasonable and useful lifetime (RUL) language and chart of knee orthoses codes with RUL guidelines (relocated from the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section)
Added: Language pertaining to noncoverage of L-coded additions when the base orthosis is noncovered (relocated from the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section)
Added: “CONCENTRIC TORSION JOINTS” and “REPAIR/REPLACEMENT”
Revised: “dynamic adjustable knee extension/flexion device” to “DYNAMIC ADJUSTABLE KNEE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL”
Removed: “Code L4002 (REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE) is for billing of replacement component(s) and is not payable at initial issue of a base orthosis. When code L4002 is billed at the time of initial issue of a base orthosis, it will be denied as not separately payable.”
Removed: RT and LT modifier information
Added: Reasonable and useful lifetime (RUL) language and chart of knee orthoses codes with RUL guidelines (relocated from the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section)
Added: “Addition codes K0672, L2390, L2750, L2780, L4002 are for billing of replacement component(s) and are not payable at initial issue of a base orthosis. When code L4002 is billed at the time of initial issue of a base orthosis, it will be denied as not separately payable.”
Added: “Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. Replacement components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L2999. Items that have unique codes must not be billed using a NOC code.”


12/07/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 07/20/2023
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Language that describes prefabricated and custom fabricated orthoses
Removed: Reasonable and useful lifetime (RUL) language and chart of knee orthoses codes with RUL guidelines
Removed: Language pertaining to noncoverage of L-coded additions when the base orthosis is noncovered
Removed: “Brace sleeves (A9270) used in conjunction with orthoses are noncovered because 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).”
Removed: Repair information
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: “General Requirements”
Added: “The supplier must include on the claim line the diagnosis code(s) for HCPCS codes L1830, L1831, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1845, L1846, L1850, L1851, L1852 and L1860.”
Added: “For a custom-fabricated orthosis, there must be documentation in the supplier's records to support the medical necessity of that type of device rather than a prefabricated orthosis. This information must be available upon request.”
Revised: "prescribing practitioner" to "treating practitioner"
Removed: “The beneficiary’s condition (diagnosis code) that necessitates the need for the knee orthosis must be included on the claim.”
Added: Prefabricated orthoses HCPCS codes to language that pertains to coding of prefabricated orthoses
Revised: "This information will be corroborated by the functional evaluation in the orthotist’s or prosthetist’s records.” to “This information will be corroborated by the functional evaluation in the orthotist’s records and the method of custom fabrication should adhere to the DMEPOS Quality Standards, Appendix C.”
MODIFIERS:
Removed: “(refer to the CODING GUIDELINES section for additional information)” pertaining to RT and LT modifiers
Added: RT and LT modifier information (relocated from the CODING GUIDELINES section)
MISCELLANEOUS:
Added: Language pertaining to information for inclusion in claims for codes L4205 and L4210
CODING GUIDELINES:
Removed: "Definitions," language pertaining to terms used to describe devices in the Policy Article, and brace definition language
Revised: “Custom Fabricated” to “CUSTOM FABRICATED”
Added: “Custom-fabricated additions are appropriate only for custom-fabricated base orthotics and should not be billed with prefabricated base orthotics” (relocated from the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section)
Added: Updated language that describes custom fabricated orthoses, molded-to-patient-model custom fabrication, and positive model of the patient
Added: “PREFABRICATED” and language that describes prefabricated orthoses
Revised: “More than minimal self-adjustment is defined as changes made to achieve an individualized fit of the item that requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthotics in compliance with all applicable Federal and State licensure and regulatory requirements.” to “In contrast to “minimal self-adjustment,” “more than minimal self-adjustment” is defined as changes made to achieve an individualized fit during the final fitting at the time of delivery of the item that requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthotics in compliance with all applicable Federal and State licensure and regulatory requirements.”
Added: “Use of CAD/CAM or similar technology to create an orthosis without a positive model of the patient is considered as custom fitted if the final fitting at the time of delivery to the patient requires more than minimal self-adjustment requiring expertise as described in this section.”
Removed: “However, for certain types of orthoses, the HCPCS code narrative that best describes the product does not make a distinction between prefabricated orthoses that are provided as custom-fit or OTS. These code narratives are correct and must be used for Medicare billing, without regard to how the product is provided to the beneficiary at the final delivery.” (Effective March 11, 2021)
Added: “Corresponding HCPCS Code Sets”
Revised: “parallel” to “corresponding” in regard to HCPCS codes
Removed: “(e.g., L1832, L1833, L1845, L1846, L1847, and L1848)” from the sentence that pertains to corresponding sets of HCPCS codes
Added: HCPCS codes L1810, L1812, L1832, L1833, L1843, L1845, L1847, L1848, L1851, L1852 to a table that pertains to corresponding sets of HCPCS codes
Added: Information that pertains to the coding of a prefabricated orthosis when a corresponding HCPCS code set is not available and the unique HCPCS code describes a custom fitted item, including “Code the product using the unique HCPCS code, if the product was custom fitted at the time of delivery to the beneficiary” and “Code the product using a miscellaneous HCPCS code, if the product was not custom fitted at delivery to the beneficiary and, instead, was provided as OTS to the beneficiary. The miscellaneous HCPCS code for billing of knee orthoses is HCPCS code L2999.” (Effective March 11, 2021)
Revised: “Elastic and Similar Stretchable Materials” to “ELASTIC AND SIMILAR STRETCHABLE MATERIALS”
Added: “KNEE ORTHOSES”
Removed: “(respectively)” from the description of codes L1843, L1844, L1845, L1846, L1851 and L1852
Added: “LOWER EXTREMITY ADDITIONS” and language that describes custom-fabricated additions
Revised: “Not medically necessary” to “Not reasonable and necessary” in regard to the four (4) categories into which addition codes are grouped
Added: Reasonable and useful lifetime (RUL) language and chart of knee orthoses codes with RUL guidelines (relocated from the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section)
Added: Language pertaining to noncoverage of L-coded additions when the base orthosis is noncovered (relocated from the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section)
Added: “CONCENTRIC TORSION JOINTS” and “REPAIR/REPLACEMENT”
Revised: “dynamic adjustable knee extension/flexion device” to “DYNAMIC ADJUSTABLE KNEE EXTENSION/FLEXION DEVICE, INCLUDES SOFT INTERFACE MATERIAL”
Removed: “Code L4002 (REPLACEMENT STRAP, ANY ORTHOSIS, INCLUDES ALL COMPONENTS, ANY LENGTH, ANY TYPE) is for billing of replacement component(s) and is not payable at initial issue of a base orthosis. When code L4002 is billed at the time of initial issue of a base orthosis, it will be denied as not separately payable.”
Removed: RT and LT modifier information
Added: Reasonable and useful lifetime (RUL) language and chart of knee orthoses codes with RUL guidelines (relocated from the NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section)
Added: “Addition codes K0672, L2390, L2750, L2780, L4002 are for billing of replacement component(s) and are not payable at initial issue of a base orthosis. When code L4002 is billed at the time of initial issue of a base orthosis, it will be denied as not separately payable.”
Added: “Some replacement items have unique Healthcare Common Procedure Coding System (HCPCS) codes. Replacement components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L2999. Items that have unique codes must not be billed using a NOC code.”


12/07/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 07/20/2023
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY
:
Revised: ICD-10-CM Code range in the Group 2 and Group 4 Codes, from “S83.221A - S83.222A” to “S83.221A - S83.222S”


07/20/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 07/20/2023
ICD-10-CM CODES THAT SUPPORT MEDICAL NECESSITY
:
Revised: ICD-10-CM Code range in the Group 2 and Group 4 Codes, from “S83.221A - S83.222A” to “S83.221A - S83.222S”


07/20/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “equipment” to “orthosis”
Revised: “Knee Orthosis” to “Knee orthosis (KO)”
Revised: “Braces Benefit” to “braces benefit”
Revised: “knee orthoses” to “KO”
Revised: “coding guideline” to “CODING GUIDELINES section”
Revised: “(See definitions below.)” to “(See definitions in the CODING GUIDELINES section below.)”
Revised: “(See Policy Specific Documentation Requirements section below)” to “(See the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS” section below)”
Revised: “CAD-CAM” to “computer-aided design/computer-added manufacturing (CAD/CAM)”
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Revised: “provides” to “provide”
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “these items” to “orthoses”
Revised: “off-the-shelf” to “OTS”
Revised: “Coding Guidelines” to “CODING GUIDELINES section below”
Added: “(as defined in the CODING GUIDELINES section below)”
MODIFIERS:
Revised: “KX, GA, and GZ MODIFIERS” to “KX, GA, GZ, LT and RT MODIFIERS:”
Revised: “knee orthoses” to “the KO”
Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
MISCELLANEOUS:
Added: “MISCELLANEOUS” section regarding billing of custom fabricated items without a specific HCPCS code
Added: Billing information for all orthoses with the same date of service on the same claim
CODING GUIDELINES:
Revised: “Braces Benefit “ to “braces benefit”
Added: “See “more than minimal self-adjustment” definition below for additional information.” to paragraph referencing the term “minimal self-adjustment”
Revised: “custom-fit” to “custom fitted”
Revised: “off-the-shelf (OTS)” to “OTS”
Revised: Language describing parallel code set availability for identical types of products
Added: “(e.g., L1832, L1833, L1845, L1846, L1847 and L1848)” to language describing parallel code set availability for identical types of products
Added: Language describing kits
Added: Long HCPCS descriptions to coding guidelines for L1810, L1812, L1820, L1830, L1831, L1847, L1848, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1851, L1845, L1846, L1852, L1850, L1860, L2755, L2820, L2830, L2320, L2330, L4002
Revised: “Durable Medical Equipment” to “durable medical equipment”
Revised: codes” to “code”
Revised: “Braces” to “braces”
Removed: Coding verification review information in reference to HCPCS codes L1845 and L1852
CODING VERIFICATION REVIEW:
Added: Section header and PDAC coding verification review information
Revised: PDAC coding verification review information for HCPCS code L1845, to include effective for DOS on or after 07/01/2008
Revised: PDAC coding verification review information for HCPCS code L1852, to include effective for DOS on or after 01/01/2017
Added: PDAC coding verification review information for HCPCS codes L1832, L1833, and L1851, effective for DOS on or after 10/10/2022


04/14/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “equipment” to “orthosis”
Revised: “Knee Orthosis” to “Knee orthosis (KO)”
Revised: “Braces Benefit” to “braces benefit”
Revised: “knee orthoses” to “KO”
Revised: “coding guideline” to “CODING GUIDELINES section”
Revised: “(See definitions below.)” to “(See definitions in the CODING GUIDELINES section below.)”
Revised: “(See Policy Specific Documentation Requirements section below)” to “(See the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS” section below)”
Revised: “CAD-CAM” to “computer-aided design/computer-added manufacturing (CAD/CAM)”
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Revised: “provides” to “provide”
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Revised: “these items” to “orthoses”
Revised: “off-the-shelf” to “OTS”
Revised: “Coding Guidelines” to “CODING GUIDELINES section below”
Added: “(as defined in the CODING GUIDELINES section below)”
MODIFIERS:
Revised: “KX, GA, and GZ MODIFIERS” to “KX, GA, GZ, LT and RT MODIFIERS:”
Revised: “knee orthoses” to “the KO”
Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
MISCELLANEOUS:
Added: “MISCELLANEOUS” section regarding billing of custom fabricated items without a specific HCPCS code
Added: Billing information for all orthoses with the same date of service on the same claim
CODING GUIDELINES:
Revised: “Braces Benefit “ to “braces benefit”
Added: “See “more than minimal self-adjustment” definition below for additional information.” to paragraph referencing the term “minimal self-adjustment”
Revised: “custom-fit” to “custom fitted”
Revised: “off-the-shelf (OTS)” to “OTS”
Revised: Language describing parallel code set availability for identical types of products
Added: “(e.g., L1832, L1833, L1845, L1846, L1847 and L1848)” to language describing parallel code set availability for identical types of products
Added: Language describing kits
Added: Long HCPCS descriptions to coding guidelines for L1810, L1812, L1820, L1830, L1831, L1847, L1848, L1832, L1833, L1834, L1836, L1840, L1843, L1844, L1851, L1845, L1846, L1852, L1850, L1860, L2755, L2820, L2830, L2320, L2330, L4002
Revised: “Durable Medical Equipment” to “durable medical equipment”
Revised: codes” to “code”
Revised: “Braces” to “braces”
Removed: Coding verification review information in reference to HCPCS codes L1845 and L1852
CODING VERIFICATION REVIEW:
Added: Section header and PDAC coding verification review information
Revised: PDAC coding verification review information for HCPCS code L1845, to include effective for DOS on or after 07/01/2008
Revised: PDAC coding verification review information for HCPCS code L1852, to include effective for DOS on or after 01/01/2017
Added: PDAC coding verification review information for HCPCS codes L1832, L1833, and L1851, effective for DOS on or after 10/10/2022


04/14/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
CODING GUIDELINES:
Added: “(CVR)” after reference to coding verification review
Added: “(PCL)” after reference to “Product Classification List”
Revised: Coding verification review information, to include incorrect coding denial language for products billed using HCPCS that require written coding verification review


03/18/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
CODING GUIDELINES:
Added: “(CVR)” after reference to coding verification review
Added: “(PCL)” after reference to “Product Classification List”
Revised: Coding verification review information, to include incorrect coding denial language for products billed using HCPCS that require written coding verification review


03/18/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Denial language for custom fitted orthoses to remove “
with a statutory denial
”


11/19/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 02/01/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Denial language for custom fitted orthoses to remove “
with a statutory denial
”


11/19/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
CODING GUIDELINES:
Revised: L1845, L1846 and L1852 rotation control to include “and posterior”
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


02/27/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
CODING GUIDELINES:
Revised: L1845, L1846 and L1852 rotation control to include “and posterior”
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”


02/27/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019
 CODING GUIDELINES:
 Clarified: Custom fit requirements


03/28/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019
 CODING GUIDELINES:
 Clarified: Custom fit requirements


03/28/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019
CODING GUIDELINES:
Revised: Coding instructions for prefabricated orthoses without distinction of OTS or custom-fit.
Revised: RT and LT modifier billing instructions (Effective 03/01/2019)
ICD-10 CODES THAT ARE COVERED:
Added: All diagnosis codes formerly listed in the LCD
ICD-10 CODES THAT ARE NOT COVERED:
Added: Notation excluding all unlisted diagnosis codes for specified HCPCS codes from coverage


02/21/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2019
CODING GUIDELINES:
Revised: Coding instructions for prefabricated orthoses without distinction of OTS or custom-fit.
Revised: RT and LT modifier billing instructions (Effective 03/01/2019)
ICD-10 CODES THAT ARE COVERED:
Added: All diagnosis codes formerly listed in the LCD
ICD-10 CODES THAT ARE NOT COVERED:
Added: Notation excluding all unlisted diagnosis codes for specified HCPCS codes from coverage


02/21/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “Spinal” to “knee”, in reference to OTS language
CODING GUIDELINES:
Update: Velcro and Kevlar to include trademark


 04/05/2018:  At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination
.

Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “Spinal” to “knee”, in reference to OTS language
CODING GUIDELINES:
Update: Velcro and Kevlar to include trademark


 04/05/2018:  At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination
.

Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Brace Benefit explanation to remove reference to “counterforce” that is no longer applicable
Revised: Prefabricated and off-the-shelf (OTS) “minimal self-adjustment” regulatory definition discussion to improve consistency with regulatory definition of minimal self-adjustment
Deleted: A4466
Added: A4467
Deleted: K0901 & K0902 from the Reasonable Useful Lifetime table
Added: L1851 & L1852 to the Reasonable Useful Lifetime table
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifiers
CODING GUIDELINES:
Removed: Reference to classification algorithm summary
Revised: OTS and custom-fit definitions to improve consistency with regulatory definition of “minimal self-adjustment”
Added: Section on coding of elastic and similar materials
Deleted: A4466
Deleted: K0901 & K0902
Added: A4467
Added: L1851
Added: L1852
Deleted: K0901 & K0902 from the Not Separately Payable table
Added: L1851 & L1852 to the Not Separately Payable table
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Brace Benefit explanation to remove reference to “counterforce” that is no longer applicable
Revised: Prefabricated and off-the-shelf (OTS) “minimal self-adjustment” regulatory definition discussion to improve consistency with regulatory definition of minimal self-adjustment
Deleted: A4466
Added: A4467
Deleted: K0901 & K0902 from the Reasonable Useful Lifetime table
Added: L1851 & L1852 to the Reasonable Useful Lifetime table
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifiers
CODING GUIDELINES:
Removed: Reference to classification algorithm summary
Revised: OTS and custom-fit definitions to improve consistency with regulatory definition of “minimal self-adjustment”
Added: Section on coding of elastic and similar materials
Deleted: A4466
Deleted: K0901 & K0902
Added: A4467
Added: L1851
Added: L1852
Deleted: K0901 & K0902 from the Not Separately Payable table
Added: L1851 & L1852 to the Not Separately Payable table
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Revision Effective Date: 10/01/2016
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Counterforce coverage requirement (does not apply to this policy)
CODING GUIDELINES:
Removed: Counterforce from the description of the brace

Revision Effective Date: 10/01/2016
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Removed: Counterforce coverage requirement (does not apply to this policy)
CODING GUIDELINES:
Removed: Counterforce from the description of the brace

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Revision Effective Date: 06/02/2016
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added:  Definitions from CMS DMEPOS Quality Standards (42 CFR 424.57) and 42 CFR 414.402
CODING GUIDELINES:
Added: Custom fabricated orthosis definitions
Added: Definition of K0672

Revision Effective Date: 06/02/2016
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added:  Definitions from CMS DMEPOS Quality Standards (42 CFR 424.57) and 42 CFR 414.402
CODING GUIDELINES:
Added: Custom fabricated orthosis definitions
Added: Definition of K0672

Revision Effective Date: 10/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Information for hospital and SNF reimbursement

Revision Effective Date: 10/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Information for hospital and SNF reimbursement

Revision Effective Date: 10/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Codes K0901 and K0902 to Correct coding of prefabricated knee orthoses
Added: Reasonable Useful Lifetime for codes K0901 and K0902
CODING GUIDELINES:
Added: Codes K0901 and K0902 to coding guidelines
Added: Base Codes K0901 and K0902 to Addition Codes table

Revision Effective Date: 10/01/2015
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Added: Codes K0901 and K0902 to Correct coding of prefabricated knee orthoses
Added: Reasonable Useful Lifetime for codes K0901 and K0902
CODING GUIDELINES:
Added: Codes K0901 and K0902 to coding guidelines
Added: Base Codes K0901 and K0902 to Addition Codes table