CG-OR-PR-03 Custom-made Knee Braces

This policy addresses custom-made (custom fabricated/molded) knee braces, particularly unloader braces. A custom-made unloader brace is medically necessary as an alternative to a prefabricated brace for unicompartmental knee osteoarthritis with or without varus/valgus deformity when any of the following apply: the individual is a candidate for high tibial osteotomy (HTO) or total knee arthroplasty (TKA) and may elect non-surgical treatment; the brace is used to help predict success of HTO vs TKA; or there is severe patellofemoral osteoarthritis with medial or lateral compartment osteoarthritis. Custom-made knee braces (functional or unloader) are not medically necessary when these criteria are not met.

"Custom-made (custom fabricated, custom molded) unloader knee braces are consideredmedically necessaryas an alternative to a prefabricated (custom-fitted) knee brace for the treatment of unicompartm..."