L1858
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Key Coverage Criteria
- Prefabricated functional or rehabilitation knee braces are consideredmedically necessaryfor individuals whenanyof the following criteria are met:
- Documented anterior or posterior cruciate ligament tears or functional instability episodes due to cruciate ligament insufficiency when non-surgical treatment is elected;or
- Grade II or III medial collateral or lateral collateral ligament sprain to support ambulation when the use of a hinged brace allows for controlled joint motion;or
- Posterior cruciate or posterior lateral reconstruction, including reconstruction after knee dislocation;or
- Recent surgery for anterior cruciate ligament repair in the post-operative recovery phase;or
- Recent surgery for meniscal cartilage repair in the post-operative recovery phase;or
1 Active Policy
ANTHEM-GL-A047994 — CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces
Related Codes
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