Knee Orthoses

Revision Effective Date: 01/25/2026
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Removed: “A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in the LCD-related Policy Article.”
Removed: “Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 are also covered for a beneficiary who is ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 Codes in the LCD-related Policy Article.”
Revised: “A knee orthosis, Swedish type, prefabricated (L1850) is covered for a beneficiary who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee, congenital or acquired (refer to the Group 5 ICD-10 Codes in the LCD-related Policy Article).” to “A prefabricated Swedish type knee orthosis (L1850) is covered for a beneficiary who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee, congenital or acquired (refer to the Group 5 ICD-10 Codes in the LCD-related Policy Article).”
Removed: “For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test).”
Added: “An immobilizer knee orthosis without joints (L1830) is covered for a beneficiary who has had a recent injury to or a surgical procedure on the knee(s) (refer to the Group 2 or Group 4 ICD-10 Codes in the LCD-related Policy Article).”
Added: “A knee orthosis with adjustable knee joints (L1832, L1833) is covered if one of the following criteria is met:" and information pertaining to the criterion of a recent injury to or a surgical procedure on the knee(s) and the criterion of the beneficiary being ambulatory and having knee instability
Added: “For a knee orthosis with adjustable knee joints or a prefabricated Swedish type knee orthosis (L1832, L1833, L1850), objective knee instability must be supported by documentation of the beneficiary’s physical examination including the joint laxity test(s) performed (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section in the LCD-related Policy Article).”
Added: “A knee orthosis with single or double upright, adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment (L1843, L1845, L1851, L1852) is covered if one of the following criteria (1-3) is met:" and information pertaining to the criterion of the beneficiary being ambulatory and having objective knee instability, the criterion of a recent injury to or a surgical procedure on the knee(s), and a criterion of the beneficiary having a documented medial or lateral tibiofemoral osteoarthritis and meeting all criteria (a-d)
Revised: “Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied if only pain or a subjective description of joint instability is documented.” to “Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage.”
SUMMARY OF EVIDENCE:
Added: Information related to knee orthoses for osteoarthritis, pain, mobility and function
ANALYSIS OF EVIDENCE (RATIONALE FOR DETERMINATION):
Added: Information related to knee orthoses for osteoarthritis, pain, mobility and function
BIBLIOGRAPHY:
Added: Information related to knee orthoses for osteoarthritis, pain, mobility and function
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments (A60371)

Revision Effective Date: 01/01/2025
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Added: “regardless of any co-existing condition(s)” and codes “E1813 and/or E1814” to the description of concentric adjustable torsion style mechanisms used for the treatment of contractures


01/16/2025: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.

Revision Effective Date: 10/01/2024
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Added: Code L1821 to prefabricated knee orthoses
Added: A row to the prefabricated knee orthoses table that contains base codes and addition codes that are not eligible for separate payment; this added row contains “L1821” as the Base Code and “None” in regard to Addition Codes – Eligible for Separate Payment
Added: A row to the prefabricated knee orthoses table that contains base codes and addition codes which can be physically incorporated into the base orthosis but that are not considered reasonable and necessary; this added row contains “L1821” as the Base Code and “L2397” as the Addition Codes – Not Reasonable and Necessary
HCPCS CODES:
Revised: Long descriptor for code L1820 in Group 1 Codes
Added: Code L1821 to Group 1 Codes


10/17/2024: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because the revisions are non-discretionary updates per CMS HCPCS coding determinations.

Revision Effective Date: 01/01/2020
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Format of HCPCS code references, from code spans to individually-listed HCPCS
Removed: Statement to refer to ICD-10 Codes that are Covered section in the LCD-related PA
 Added: Statement to refer to ICD-10 codes in the LCD-related Policy Article
Revised: Order information as a result of Final Rule 1713
CODING INFORMATION:
Removed: Field titled “Bill Type”
Removed: Field titled “Revenue Codes”
Removed: Field titled “ICD-10 Codes that Support Medical Necessity”
Removed: Field titled “ICD-10 Codes that DO NOT Support Medical Necessity”
Removed: Field titled “Additional ICD-10 Information”
GENERAL DOCUMENTATION REQUIREMENTS:
Revised: Prescriptions (orders) to SWO


02/27/2020: Pursuant to the 21st Century Cures Act , these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).

Revision Effective Date: 01/01/2019
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Removed: Statement to refer to diagnosis code section below
Added:Refer to Covered ICD-10 Codes in the LCD-related Policy Article
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Moved: All diagnosis codes to the LCD-related Policy Article diagnosis code section per CMS instruction
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Moved: Statement about noncovered diagnosis codes moved to LCD-related Policy Article noncovered diagnosis code section per CMS instruction

Revision Effective Date: 10/16/2017
Coverage Indications, Limitations, and/or Medical Necessity:
Updated: References to ICD 10 code lists to reflect accurate title of the list
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: ICD 10 codes S76.111 (A,D,S), S76.112 (A,D,S), S76.121 (A,D,S) and S76.122 (A,D,S) to Group 2 and Group 4 codes
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Updated: language under to add “justify”
DATE (09/07/2017): At this time 21st Century Cures Act will apply to new and revised LCDs that restrict coverage which requires comment and notice. This revision is not a restriction to the coverage determination; and, therefore not all the fields included on the LCD are applicable as noted in this policy.

Revision Effective Date: 01/01/2017
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Removed: Standard Documentation Language
Added: New reference language and directions to Standard Documentation Requirements
Deleted: K0901 and K0902
Added: L1851 and L1852
Added: General Requirements
HCPCS CODES:
Deleted: A4466, K0901 and K0902
Added: A4467, L1851 and L1852
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Deleted: K0901 and K0902 from Group 4 Paragraph
Added: L1851 and L1852 to Group 4 Paragraph
Added: ICD-10 Codes M21.861 and M21.862 to Group 5 –Effective 10/01/2015
DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: General Documentation Requirements
Added: New reference language and directions to Standard Documentation Requirements
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: Standard Documentation Language
Added: Directions to Standard Documentation Requirements
Removed: Information under Miscellaneous and Appendices
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements article

Revision Effective Date: 10/01/2016
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: ICD-10 Codes G57.03 & G57.23 to Group 4 per ICD-10 annual update
Deleted: ICD-10 Codes T84.042A, T84.043S from Groups 2 and 4 per ICD-10 annual update

Revision Effective Date: 07/01/2016
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Replaced: ICD-10 Code M21.869 with Q68.2 in Group 5 - Effective 10/01/2015
DOCUMENTATION REQUIREMENTS:
Revised: Standard documentation language - Start date instructions - Effective 04/28/2016

Effective July 1, 2016 oversight for DME MAC LCDs 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 LCDs.

Revision Effective Date: 06/02/2016
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: HCPCS Codes L1832 and L1833 to Group 2 Diagnoses
Added: Initial, Subsequent, and Sequela ICD-10s to Group 2 and Group 4
Removed: ICD-10 Non-specific femur codes S72.426B & S72.426C – entered in error
DOCUMENTATION REQUIREMENTS:
Revised: Standard Documentation language (Effective 04/28/2016)

Revision Effective Date: 05/01/2015
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Added: HCPCS L1833 to Prefabricated Knee Orthoses denial statement, clerical error

Revision Effective Date:  05/01/2015
COVERAGE INDICATIONS, LIMITATIONS AND/OR MEDICAL NECESSITY:
Revised: Standard Documentation Language to add covered prior to a beneficiary’s Medicare eligibility
DOCUMENTATION REQUIREMENTS:
Added: Continued Need and Continued Use
Revised: Standard language to add who can enter date of delivery date on the POD
Added: Instructions for Equipment Retained from a Prior Payer
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Updated: Documentation responsibilities for prefabricated vs. custom fabricated devices to reflect revision of April 2015 bulletin article
Revised: Repair to beneficiary-owned DMEPOS
Revised: Instructions for HCPCS L2999

Revision Effective Date: 10/01/2015
COVERAGE INDICATIONS, LIMITATIONS, and/or MEDICAL NECESSITY:
Added: Codes K0901 and K0902 to Prefabricated Knee Orthoses section
Added: Base Codes K0901 and K0902 to Addition Codes tables
Added: Codes K0901 and K0902 to the requirement (1) for custom fabricated knee orthosis with an adjustable flexion and extension joint
HCPCS CODES:
Added: Codes K0901 and K0902
ICD-9 CODES THAT SUPPORT MEDICAL NECESSITY:
Added: Codes K0901 and K0902 to Group 4 Codes

Revision Effective Date: 10/01/2014
COVERAGE INDICATIONS, LIMITATIONS, and/or MEDICAL NECESSITY:
Added: Reference to Group 4 diagnosis for coverage of recent injury or surgical procedure on knees

Revision Effective Date: 10/01/2014
COVERAGE INDICATIONS, LIMITATIONS, and/or MEDICAL NECESSITY:
Restored: HCPCS to appropriate Diagnoses Group that Support Medical Necessity
DOCUMENTATION REQUIREMENTS:
Removed: Continued Need and Continued Use, not relevant to this policy