Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article
A52457
Medicare covers rigid or semi-rigid ankle-foot orthoses (AFO) and knee-ankle-foot orthoses (KAFO) when they support a weak/deformed body member or restrict/eliminate motion for a diseased/injured part and when Local Coverage Determination reasonable-and-necessary criteria are met. Specific HCPCS codes and billing rules apply: non-rigid supports, certain pressure-ulcer–only uses, specified garments/devices, and incorrect coding (custom vs OTS) are noncovered or denied; Final Rule 1713 requires a face-to-face encounter and Written Order Prior to Delivery for specified items. Supplier documentation (diagnosis codes on claims, justification for custom vs prefabricated, evidence of minimal vs more-than-minimal adjustment, and orthotist/prosthetist records) is required and services like CAD/CAM, evaluation, and fitting are bundled into the orthosis allowance.
"Ankle-foot orthoses (AFO) and knee-ankle-foot orthoses (KAFO) are covered when they are rigid or semi-rigid devices used to support a weak or deformed body member or to restrict or eliminate motion..."