The first section of the AFO/KAFO LCD addresses coverage of AFOs that are not used during ambulation. The only nonambulatory AFOs that are eligible for coverage are those described by L4396, and they are only covered when they are being used to treat a non-fixed ankle contracture or plantar fasciitis. When being used to treat contracture, the following four specific coverage criteria must be met: 1. The patient has plantar flexion contracture of the ankle (ICD-9 diagnosis code 718.47) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a non-fixed contracture). 2. The practitioner has reasonable expectation that the device can correct the contracture. 3. The contracture is interfering or expected to interfere significantly with the beneficiary’s functional abilities.
4. The device is used as a component of a therapy program, which includes active stretching of the involved muscles and/or tendons.
Documentation of knee instability alone does not meet the coverage criteria for an AFO. All four criteria must be met and documented in the patient’s medical record in order for Medicare to cover an AFO used to treat contracture. The LCD goes on to indicate that a maximum of one replacement soft interface described by L4392 may be covered every six months. When a static AFO is used to treat plantar
fasciitis, the only policy requirement is that documentation supports the diagnosis. The next section of the LCD addresses AFOs and KAFOs used during ambulation. The LCD states that AFOs are covered for ambulatory patients with “weakness or deformity of the foot and ankle, who require stabilization for medical reasons, and have the potential to benefit functionally.” It then goes on to state that “KAFOs are covered for ambulatory patients for whom an AFO is covered and for whom additional knee stability is required.” It is extremely important that the patient’s medical records, including those of the referring physician, contain documentation of the specific medical condition that is causing the weakness or deformity of the foot and ankle for which the AFO or KAFO has been prescribed.
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OCTOBER 2013 O&P Almanac
American Orthotic & Prosthetic Association (AOPA) - October 2013 Issue - O&P Almanac