L4130 — Replace pretibial shell
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- A Standard Written Order (SWO) must be received by the supplier before a claim is submitted; claims billed without a completed SWO will be denied.
- For DMEPOS base items that require a Written Order Prior to Delivery (WOPD), the supplier must have a signed SWO/WOPD before delivery; delivery without a WOPD will result in claim denial.
- For base items with separately billed options/accessories/supplies, the WOPD must list the base item (and may list associated items); separate billing for accessories without a WOPD listing the base item will be denied.
- For AFO used to treat plantar-flexion contracture, pre-treatment passive range-of-motion must be measured with a goniometer and documented in the medical record.
Key Coverage Criteria
- An item is covered only if it is in a Medicare benefit category, is reasonable and necessary for diagnosis/treatment or to improve functioning of a malformed body member, and meets all other Medicare statutory and regulatory requirements.
- Static or dynamic positioning AFOs (L4396 or L4397) not used during ambulation are covered when all of the following are met: plantar-flexion contracture with passive dorsiflexion >= 10 degrees (nonfixed), reasonable expectation contracture can be corrected, contracture significantly interferes or is expected to interfere with function, and device is used as a component of a therapy program including active stretching.
- Static or dynamic positioning AFOs (L4396 or L4397) not used during ambulation are covered for beneficiaries with plantar fasciitis.
- AFOs described by codes (e.g., L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1933, L1940, L1945, L1950, L1951, L1952, L1960, L1970, L1971, L1980, L1990, L2106, L2108, L2112, L2114, L2116, L4350, L4360, L4361, L4386, L4387, L4631) are covered for ambulatory beneficiaries with weakness or deformity of the foot/ankle who require stabilization for medical reasons and have potential to benefit functionally.
- KAFOs described by codes (e.g., L2000, L2005, L2010, L2020, L2030, L2034-L2038, L2126, L2128, L2132, L2134, L2136, L4370) are covered for ambulatory beneficiaries who meet AFO criteria and additionally require knee stability.
- Custom-fabricated AFOs/KAFOs are covered for ambulatory beneficiaries who meet basic coverage criteria and meet at least one of: cannot be fit with a prefabricated AFO; condition expected to be permanent or >6 months; need to control knee/ankle/foot in more than one plane; documented neurological/circulatory/orthopedic status requiring custom fabrication to prevent tissue injury; or a healing fracture lacking normal anatomical integrity or anthropometric proportions.
3 Active Policies
L33686 — Ankle-Foot/Knee-Ankle-Foot Orthosis
J19
AMBETTER-CP.MP.107 — Durable Medical Equipment and Orthotics and Prosthetics Guidelines
ANTHEM-CG-DME-22 — CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses
Related Codes
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