CG-OR-PR-09 Microprocessor Controlled Knee-Ankle-Foot Orthosis

This policy addresses microprocessor-controlled knee-ankle-foot orthoses (KAFOs), such as the C-Brace. Coverage is medically necessary when all criteria are met: the individual is ambulatory and an appropriate KAFO candidate; has adequate cardiovascular reserve and cognitive ability to use the technology; the provider documents a reasonable likelihood of improved mobility or stability versus a standard KAFO; there is documented need for ambulation demands (e.g., regular stair use, uneven terrain, or long distances of roughly 400+ yards); and a complete multidisciplinary assessment, including a certified orthotist, objectively confirms these criteria. Use is not medically necessary when these requirements are not met.

"Microprocessor controlled knee-ankle-foot orthoses are consideredmedically necessarywhenallof the following criteria set forth in (A) and (B) below have been met:Selection criteria:Individual is am..."