L2628, Addition to lower extremity, pelvic control, metal frame, reciprocating hip
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Clinical documentation establishing that the equipment is necessary and reasonable and is expected to make a meaningful contribution to treatment or functional improvement.
- Documentation that education regarding use of the device was provided and the member/caregiver demonstrated understanding.
- Documentation of a trial of the requested device with evidence the member can use it safely and effectively.
- Documentation that the patient has newly diagnosed nonischemic cardiomyopathy and is undergoing a trial of optimal medical therapy.
Key Coverage Criteria
- An ankle-foot orthosis (AFO) is consideredmedically necessaryfor ambulatory (i.e., able to walk, independently or with assistance) individuals with weakness or deformity of the foot and ankle who require stabilization for medical reasons and have the potential to benefit functionally.
- Knee-ankle-foot orthoses (KAFOs) are consideredmedically necessaryfor ambulatory individuals for whom an ankle-foot orthosis is appropriate and additional knee stability is required.
- AFOs and KAFOs that are custom-fabricated are consideredmedically necessaryfor ambulatory individuals when medically necessary criteria are otherwise met andone or moreof the following criteria are met:
- The individual could not be fit with a prefabricated AFO;or
- The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months);or
- There is a need to control the knee, ankle, or foot in more than one plane;or
2 Active Policies
ANTHEM-CG-DME-22, CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses
AMBETTER-CP.MP.107, Durable Medical Equipment and Orthotics and Prosthetics Guidelines
Related Codes
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