Q4001, Service for ordering/referring physician qualifies as a service exemption
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- For fracture-related devices, documentation of fracture type, encounter (initial/subsequent), and healing status as appropriate (coding for subsequent encounters for healing/pathologic fractures is referenced) should be included.
- For replacement or component items (e.g., K0672 removable soft interface), documentation that the request is for replacement only and justification for replacement must be maintained.
- For proprietary or novel devices that the policy lists as 'not covered' (e.g., Levitation 2, Cymedica QB1, S3 Brace, adjustable click systems), documentation of medical necessity will not change non-coverage unless policy is updated; such items are excluded regardless of submitted documentation.
- The orthosis or prosthesis must be provided within six months of the date of prescription.
Key Coverage Criteria
- Knee braces (children/congenital): Q65.81 - Q65.9; Q66.8; Q68.2; Q72.00 - Q72.93; Q74.1 - Q74.2 - Congenital deformities/reduction defects of lower limb including knee
- An orthosis (orthopedic brace) and/or prosthesis is medically necessary when: care is prescribed by a physician, nurse practitioner, podiatrist or other health professional who is qualified to prescribe orthotics and/or prosthetics according to State law; and the orthosis or prosthesis will significantly improve or restore physical functions required for mobility related activities of daily living (MRADL's); and the member’s participating physician or licensed health care practitioner has determ [...]
- Lumbar orthosis, lumbar-sacral orthosis, and thoracic-lumbar-sacral orthosis are medically necessary for any of the following indications: to facilitate healing following an injury to the spine or related soft tissues; to facilitate healing following a surgical procedure on the spine or related soft tissue; to reduce pain by restricting mobility of the trunk; or to support weak spinal muscles and/or a deformed spine.
- Custom-fitted back brace (prefabricated back brace modified to fit a specific member) is medically necessary where there is a failure, contraindication or intolerance to an unmodified, prefabricated (off-the-shelf) back brace.
- Custom-fitted back brace is medically necessary as the initial brace after surgical stabilization of the spine following traumatic injury.
- Back braces: M08.1 - Juvenile ankylosing spondylitis
1 Active Policy
AETNA-CPB-0009, Orthopedic Casts, Braces and Splints
Related Codes
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