Ankle-Foot Orthoses (AFOs), Knee Ankle-Foot Orthoses (KAFOs), and Hip Knee-Ankle-Foot Orthoses (HKAFOs) - DME.MU.203.A

Evicore covers medically necessary AFOs, KAFOs, and HKAFOs (prefabricated and custom when indicated) for ambulatory, minimally/non‑ambulatory, and pediatric (≤18) patients for specific conditions (e.g., plantar flexion contractures, plantar fasciitis, lower‑extremity weakness or deformity requiring stabilization), and excludes preventive uses, edema‑only indications, fabric/elastic supports, certain foot‑drop devices in nonambulatory patients, duplicative devices/additions, and AFOs for knee osteoarthritis. Coverage requires specific clinical documentation of ambulatory status, functional impairment and expected benefit, condition‑specific findings (e.g., ≥10° dorsiflexion and use with active stretching for positioning AFOs; plantar fasciitis exam; inability to fit prefabricated device/condition >6 months for custom fabrication) and strict replacement criteria (recent provider visit/care plan, growth/change, loss/theft, or irreparable/warranty‑expired damage).