Knee Orthoses

Coverage for knee orthoses requires that the item be a Medicare-covered benefit and be reasonable and necessary for the beneficiary’s knee condition, with specific HCPCS-coded orthoses covered only when beneficiary-specific clinical criteria are met (e.g., ambulatory status, documented instability, recent injury/surgery, contracture with ≥10° passive ROM, or documented need for custom fabrication). Mandatory documentation (SWO/WOPD, proof of delivery, physical exam/joint laxity tests, and justification for custom fabrication) and adherence to coding and addition-code rules are required; numerous specific additions and codes are limited or denied (e.g., L1847/L1848 inflatable bladder, certain addition codes, K0672 replacement limits, L2999 coding for contractures).

"An item is covered only if it meets Medicare benefit category eligibility, is reasonable and necessary for diagnosis/treatment or to improve functioning of a malformed body member, and meets all ot..."