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Medical Policy: 01.03.01
Original Effective Date: November 1995
Reviewed: September 2011
Revised: February 2004
Benefit Application
Benefit determinations are based on the applicable contract language in effect at the time the
services were rendered. Exclusions, limitations or exceptions may apply. Benefits may vary
based on contract, and individual member benefits must be verified. Wellmark determines medical
necessity only if the benefit exists and no contract exclusions are applicable. This medical
policy may not apply to FEP. Benefits are determined by the Federal Employee Program.
This Medical Policy document describes the status of medical technology at the time the document
was developed. Since that time, new technology may have emerged or new medical literature may
have been published. This Medical Policy will be reviewed regularly and be updated as scientific
and medical literature becomes available.
Description:
Knee braces are useful in the treatment of knee ligament injuries, primarily anterior cruciate ligament injuries. They may be used by the patients who have not had surgical treatment and also in post surgical patients.
Knee braces consist of three components: a superstructure (usually a rigid shell), a hinge, and a strap system. The superstructure extends proximally and distally to a hinge centered around the knee axis of motion. The strapping system secures the brace to the limb.
Knee braces can be divided into four categories:
- Prophylactic braces attempt to prevent or reduce the severity of knee ligament injuries, and are primarily used in recreational or organized sports.
- Rehabilitation braces are designed to allow protected motion of injured knees that have been treated operatively or non-operatively, are usually purchased off the shelf and used for 6-12 weeks after injury.
- Functional braces are designed to assist or provide stability for unstable knees during activities of daily living or vocational or avocational activities. Functional knee braces can be divided into two categories;
1. Prefabricated braces or off the shelve braces
2. Custom fabricated braces
The prefabricated functional brace comes in various sizes and fit most patients reasonably well. The custom fabricated brace, however, requires either a cast mold or extensive measurements, which are provided to the manufacturer so that the brace can be fabricated. The peer reviewed medical literature does not show significant differences in the efficacy of the two categories.
- Unloader knee braces are specifically designed to reduce the pain and disability associated with severe 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.
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Prior Approval:
Not applicable
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Policy:
One of the following criteria must be met:
- Prefabricated functional knee braces may be considered medically necessary in members with documented knee instability due to injury or after surgery or in members with painful osteoarthritis of the medial compartment of the knee.
- Custom fabricated functional knee braces may be considered medically necessary for members with documented knee instability due to injury or after surgery if abnormal limb contour, limb deformity, or large limb size preclude the use of an off-the-shelf model.
- Custom fabricated unloader knee braces may be considered medically necessary as a treatment of members with painful osteoarthritis involving the medial compartment of the knee.
- Prophylactic knee braces are considered not medically necessary.
- Functional knee braces of any kind with the primary use for recreation or sports participation are considered not medically necessary.
- Except under the conditions described above, custom fabricated functional knee braces are considered not medically necessary.
While active, this policy is no longer scheduled for routine literature review.
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Procedure Codes and Billing Guidelines:
- To report provider services, use appropriate CPT* codes, Modifiers, Alpha Numeric (HCPCS level 2) codes, Revenue codes, and/or ICD-9 diagnostic codes.
- L1800 Knee orthotic (KO), elastic with stays, prefabricated, includes fitting and adjustment
- L1815 Knee orthotic (KO), elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment
- L1825 Knee orthotic (KO), elastic knee cap, prefabricated, includes fitting and adjustment
- L1855 KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated
- L1858 KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated
- L1870 KO, double upright, thigh and calf lacers, with knee joints, custom fabricated
- L1880 KO, double upright, nonmolded thigh and calf cuffs/lacers with knee joints, custom fabricated
- L1844 to report either custom fabricated unloader knee braces (medically necessary only for diagnoses of osteoarthritis of the knee ICD-9CM range 715.06-715.96) or custom fabricated rehabilitation knee braces used in the post-operative setting.
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Selected References:
- Wojtys EM, Huston LJ. "Custom-fit: versus "off-the-shelf" ACL functional braces. American Journal of Knee Surgery 2001 Summer; 14(3): 157-62.
- Bimingham TB, Kramer JF, Kirkley A, Inglis JT, Spaulding SJ, Vandervoort AA. Knee bracing for medial compartment osteoarthritis: effects on proprioception and postural control. Rheumatology(Oxford)2001;40(3):285-289
- Martin TJ. Committee on Sports Medicine and Fitness. American Academy of Pediatrics: Technical report: knee brace use in the young athlete. Pediatrics. 2001 Aug;108(2):503-7
- Paluska SA, McKeag DB. Knee Braces: current evidence and clinical recommendations for their use. Am Fam Physician. 2000 Jan 15;61(2):411-8,423-4.
- 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.
- Kirkley A, Webster-Bogaert S, Litchfield R et al. The effect of bracing on varus gonarthrosis. JBone Joint Surg Am 1999; 81(4):539-48.
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Policy History:
Date Reason Action
September 2011 Annual review Policy renewed
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Wellmark medical policies address the complex issue
of technology assessment of new and emerging treatments, devices,
drugs, etc. They are developed to
assist in administering plan benefits and constitute neither offers of
coverage nor medical advice. Wellmark medical policies contain only a
partial, general description of plan or program benefits and do not
constitute a contract. Wellmark does not provide health care services
and, therefore, cannot guarantee any results or outcomes.
Participating providers are independent contractors in private
practice and are neither employees nor agents of Wellmark or its
affiliates. Treating providers are solely responsible for medical
advice and treatment of members. Our medical policies may be updated
and therefore are subject to change without notice.
*Current Procedural Terminology © 2010 American Medical Association. All Rights Reserved.
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