CG-OR-PR-02 Prefabricated and Prophylactic Knee Braces

This policy addresses prefabricated (off-the-shelf/custom-fitted) functional or rehabilitation knee braces and prophylactic knee braces. Prefabricated functional/rehabilitation braces are covered when any of these criteria are met: documented ACL or PCL tears or functional instability with non-surgical management; Grade II/III MCL or LCL sprains requiring hinged support for ambulation; after PCL or posterolateral reconstruction (including after knee dislocation); or during post‑operative recovery after ACL repair. Not covered: prophylactic knee braces for any indication; and prefabricated functional/rehabilitation braces when criteria are not met (including after knee surgery such as total knee arthroplasty unless ligament insufficiency is documented); individuals with size variations may be fitted with adjusted prefabricated braces (e.g., extra‑large straps).

"Prefabricated functional or rehabilitation knee braces are consideredmedically necessaryfor individuals whenanyof the following criteria are met:"