Medical Coverage Policy - AAOS

1 Orthotics Medical Coverage Policy Effective Date: 01/01/2012 Revision Date: 01/01/2012 Review Date: 04/28/2011 Policy Number: CLPD-0330-013 Page: 1 of 56 Change Summary: Updated Provider Claims Codes When printed, the version of this document becomes uncontrolled because Humana's documents are updated regularly. Do not rely on printed copies for the most up-to-date version. Refer to to verify this is the current version before each use. Disclaimer Description Coverage Determination Background Medical Alternatives Provider Claims Codes Medical Terms References Disclaimer State and federal law, as well as contract language, including definitions and specific inclusions/ exclusions, take precedence over clinical Policy and must be considered first in determining eligibility for Coverage .

2 Coverage may also differ for our Medicare and/or Medicaid members based on any applicable Centers for Medicare & Medicaid Services (CMS) Coverage statements including National Coverage Determinations (NCD), Local Medical Review Policies (LMRP), and/or Local Coverage Determinations. See the CMS web site at The member's health plan benefits, in effect on the date services are rendered, must be used. clinical Policy is not intended to preempt the judgment of the reviewing Medical Director or dictate to providers how to practice medicine. Providers are expected to exercise their Medical judgment in rendering the most appropriate care. Identification of selected brand names of devices, tests, and procedures in a Medical Coverage Policy are for reference only and is not an endorsement of any one device, test or procedure over another.

3 clinical technology is constantly evolving, and we reserve the right to review and update this Policy periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any shape or form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Humana Inc. Description Orthotics are devices that are utilized to support, align, prevent, or correct deformities or to improve the function of movable parts of the body. Orthotics includes braces (devices that support a weak joint or joints), splints (rigid devices used to immobilize an injury), casts (devices used for immobilization of body parts for fractures), supports and other devices. There are two classifications of orthotics: over-the-counter and custom-made.

4 Custom made or custom fitted involves substantial work such as cutting, bending, molding or sewing. For custom molded orthoses, an impression of the specific body part is made and is used to make a model. The orthosis is molded from that model. Over-the-counter orthotics are available without a prescription and are not custom-fitted for the individual. These are generally not covered under the Plan. Orthopedic shoes are shoes used to prevent or correct disorders of the bones, joints, muscles, ligaments, and cartilage of the legs and feet. Orthotics Effective Date: 01/01/2012 Revision Date: 01/01/2012 Review Date: 04/28/2011 Policy Number: CLPD-0330-013 Page: 2 of 56 When printed, the version of this document becomes uncontrolled because Humana's documents are updated regularly.

5 Do not rely on printed copies for the most up-to-date version. Refer to to verify this is the current version before each use. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Coverage Determination Any state mandates for orthotics would take precedence over this clinical Policy . Humana members may be eligible under the Plan for orthotics, which would include braces, splints, and supports that are prescribed by a physician, if they are custom-fitted or custom-made by the physician or brace shop for the specific needs of the patient and rigid or semi-rigid in structure. The following also applies for shoes: Specially constructed shoes that are an integral part of a leg brace (the shoe cannot be removed from the brace without making the shoe unusable); OR Cast boots or shoes requested by the surgeon following a surgical procedure or treatment of a fracture; OR One pair of custom made or custom fitted arch supports or shoes per calendar year ONLY for members with hammer toe or with sensory or vascular abnormalities of the feet due to diabetes mellitus.

6 Examples of orthotics include, but may not be limited to: Air splints. Cervical collars post-surgery Denis-Browne or torsion bar braces. Figure-eight splints for clavicle fractures. Finger splints for volar plate or tendon avulsions. Knee immobilizers for internal derangements and ligament sprains. Lumbar braces with metal stays, custom-fitted. Serial casting and plaster splinting. Wrist splints for carpal tunnel syndrome. Substitute casts, splints, trusses, crutches, and non-dental braces, when required by growth or a change in Medical condition and their replacement when irreparable. V-Loc unloader back brace (must be utilized for activities of daily living, not just for sporting activities). Note: This criteria for orthotics is not consistent with the Medicare National Coverage Policy , and therefore may not be applicable to Medicare members.

7 Orthotics Effective Date: 01/01/2012 Revision Date: 01/01/2012 Review Date: 04/28/2011 Policy Number: CLPD-0330-013 Page: 3 of 56 When printed, the version of this document becomes uncontrolled because Humana's documents are updated regularly. Do not rely on printed copies for the most up-to-date version. Refer to to verify this is the current version before each use. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Refer to the CMS web site at for additional information. Coverage Limitations Humana members may NOT be eligible under the Plan for the following types of supports (list may not be all inclusive) as they are generally excluded by contract or not considered medically necessary.

8 Any over-the-counter devices such as arch supports, wrist supports, knee supports and heel cups because they are not custom fitted or custom made Braces used only for activities other than normal daily living, this includes braces used for sports Fabric supports Heel wedges, lifts or shoe inserts Lumbar sacral supports, industrial back braces Mechanical stretch devices, which includes static progressive (SP) stretch (Dynasplint, low-load prolonged-duration stretch (LLPS) (Joint Active Systems, and patient-actuated serial stretch (PASS) devices (Extensionaters and Flexionaters). Please refer to the Continuous Passive Motion and Mechanical Stretching Devices Medical Coverage Policy for additional Coverage information on these devices Repair and replacement of orthotics SpineCor System Dynamic Corrective Brace Orthotics Effective Date: 01/01/2012 Revision Date: 01/01/2012 Review Date: 04/28/2011 Policy Number: CLPD-0330-013 Page: 4 of 56 When printed, the version of this document becomes uncontrolled because Humana's documents are updated regularly.))

9 Do not rely on printed copies for the most up-to-date version. Refer to to verify this is the current version before each use. See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on this subject may not be included. This document is for informational purposes only. Background You can learn more about injuries and/or disorders that may constitute the use of braces, supports or splints from the following sites: American Academy of Orthopedic Surgeons American Academy of Pediatrics - American College of Foot and Ankle Surgeons National Diabetes Information Clearinghouse National Institute of Neurological Disorders and Stroke - National Library of Medicine - Medical Alternatives To make the best health decision for your individual needs, consult your physician.

10 Provider Claims Codes All provider claims codes surrounding this topic may not be included in the following table: CPT Codes Description Comments 97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes 97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes Orthotics Effective Date: 01/01/2012 Revision Date: 01/01/2012 Review Date: 04/28/2011 Policy Number: CLPD-0330-013 Page: 5 of 56 When printed, the version of this document becomes uncontrolled because Humana's documents are updated regularly. Do not rely on printed copies for the most up-to-date version. Refer to to verify this is the current version before each use.