TRICARE Manuals - Display Chap 8 Sect 3.1 (Change 52, Sep 20, 2019)

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Chapter 8

Section 3.1

Orthoses (Braces And Splints)

Issue Date: September 20, 1990

Authority: 32 CFR 199.4(d)(3)(viii)

Revision: C-38, January 4, 2019

1.0 HCPCS Procedure Codes

Level II Codes L0112 - L4631

2.0 DESCRIPTION

2.1 The term orthotics refers to the study and practice of bracing (such as leg, arm, back, and neck braces), not to the actual device.

2.2 Orthoses are devices, such as braces or splints, that are applied externally to the body to support, align, prevent or correct deformities, improve the function of movable parts of the body, or restrict or eliminate motion in a diseased or injured part of the body. These items modify the functional and structural characteristics of the neuromuscular and musculoskeletal systems.

2.2.1 There are specific HCPCS codes that identify orthoses. Examples of orthoses include but are not limited to:

• Spinal (thoracic, cervical, lumbar, sacral);

• Lower limb (hip, knee, ankle-foot, knee-foot-ankle, and hip-knee-ankle-foot, plus the orthopedic shoe(s) that are an integral part of the brace);

• Upper limb (shoulder, elbow, wrist-hand-finger);

• Splints for extremities;

• Braces for leg, arm, neck, back and shoulder.

2.2.2 A custom fabricated orthosis brace is one that is individually made for a specific patient. No other patient would be able to use the brace. A custom brace is based on clinically derived and rectified castings, tracings, measurements, and/or other images (such as X- rays) of the body part. The fabrication may involve using calculations, templates, and components. This process requires the use of basic materials including, but not limited to, plastic, metal, leather, or cloth in the form of uncut or unshaped sheets, bars, or other basic forms and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling and finishing prior to fitting on the patient.

2.2.3 A custom fitted orthosis brace is one that is prefabricated and that requires fitting and adjustment. For example, the brace must be trimmed, bent, molded (with or without heat), or otherwise modified for a specific patient to provide an individualized fit. Modifications must result in alterations to the brace beyond simple adjustments made by bending, trimming, and/or molding, installation of add-on components, or assembly.

Note: An orthosis leg brace involving the foot extends above the ankle and is made of metal or other durable rigid material that immobilizes, restricts movement in a given direction, controls mobility, assists with movement, reduces weight-bearing forces or holds body parts in correct position.

2.3 Orthotic footwear (shoes) are designed to affect changes in foot or feet position and alignment, which are not an integral part of a leg brace (i.e., not attached). Orthopedic shoes attached to a leg brace means the brace is permanently affixed to the shoe as an integral part. The shoe attachment is necessary for the device to function.

3.0 POLICY

3.1 Orthoses must be medically necessary to diagnose or treat a covered condition, must be U.S. Food and Drug Administration (FDA)-approved and must be provided by a TRICARE authorized provider. See examples in paragraph 2.2.1 that may be covered. This list is not inclusive.

3.1.1 Lower limb orthosis. A lower limb orthosis, which fits inside the shoe, extends outside the shoe and up the lower extremity with a primary purpose of bracing may be covered.

3.1.2 Post-operative ambulatory boots. Surgical boots prescribed by a surgeon following a surgical procedure or treatment for a fracture that restricts or eliminates motion in the injured foot are covered.

3.2 Orthopedic footwear and other supportive devices. Orthopedic shoes including inserts (or custom molded) and heel/sole are covered only when one or both shoes are an integral part of a leg brace, and medically necessary for the proper functioning of the brace. Coverage is allowed when neither the shoe nor the brace is usable separately. See paragraph 2.3 for further description.

3.2.1 Examples of covered orthopedic shoes include, but are not limited to, the following codes if the shoe is an integral part of a covered leg brace: codes L1900, L1920, L1980-L2030, L2050, L2060, L2080, or L2090, and Oxford shoes (L3224 and L3225).

3.2.2 Any related modifications, which include inserts and heel/sole are covered when the shoe(s) is an integral part of the brace.

3.3 Repair and replacement. Covered orthoses that are worn, damaged or outgrown may be repaired or replaced once a year. For beneficiaries under the age of 18, outgrown orthoses may be replaced earlier than one year with appropriate documentation from the physician or other TRICARE-authorized allied health professional. Shoes attached to orthopedic leg braces may be replaced when outgrown or worn out. Repair of an appliance will not be authorized when cost of the repair equals or exceeds the cost of a new appliance.

3.4 Costs

3.4.1 Covered orthoses and supportive devices include the initial purchase and fitting of such devices and supplies. Cost of casting, molding, fittings and adjustments are included as well.

3.4.2 The cost of the initial orthopedic shoes (including inserts and other related supplies) and leg brace(s) are not separate, but are included as part of the cost of the brace.

3.5 The Dynamic Orthotic Cranioplasty (DOC) Band Post-Op device is covered for adjunctive use for infants from three to eighteen months of age whose synostosis has been surgically corrected, but who still have moderate to severe cranial deformities including plagiocephallic-, brachycephalic-, and scaphocephalic-shaped heads (HCPCS code S1040).

3.6 Related TRICARE Policies.

• For therapeutic shoes including inserts and modifications for diabetics, see Section 8.2.

• Orthoses for the Extended Care Health Option (ECHO) Program, see Chapter 9, Sections 7.1, 15.1, and 17.1. TRICARE Systems Manual (TSM), Chapter 2, Section 6.2, TED Edit 2-160-05R, list codes covered under ECHO.

• Orthoses for Active Duty Service Members (ADSMs) and the Supplemental Health Care Program (SHCP), see TRICARE Operations Manual (TOM), Chapter 17, Section 3.

4.0 EXCLUSIONS

The following types of orthoses are excluded from TRICARE coverage:

4.1 Orthopedic shoes, unless one or both shoes are an integral part of a covered brace.

4.2 Arch supports and shoe inserts designed to effect conformational changes in the foot or foot alignment.

4.3 Over-The-Counter (OTC) custom-made or built-up shoes.

4.4 Exercise/relaxation/comfort/sporting items or sporting devices. Orthoses provided solely for use during sports-related activities in the absence of an acute injury or other indicated medical condition.

4.5 Orthoses for tired or fatigued feet or whose sole purpose is for restraint.

4.6 Orthoses for pes planus (flat feet) or plantar fasciitis, or other similar diagnoses.

4.7 A foot-drop splint and recumbent positioning devices (L4398), and replacement interface (L4394) in a patient with foot drop who is non-ambulatory, as these items are not medically necessary.

4.8 A static or dynamic positioning Ankle-Foot Orthosis (AFO) and replacement interface if the contracture is fixed or for beneficiaries with foot-drop but without an ankle flexion contracture; or a component of a static and dynamic AFO that is used to address positioning of the knee or hip (L4396 and L4397 are excluded as not medically necessary).

4.9 Cranial orthosis (DOC Band) and cranial molding helmets are not covered for the treatment of nonsynostotic positional plagiocephaly (deformational plagiocephaly, plagiocephaly without synostosis) or for the treatment of craniosynostosis before surgery.

4.10 Comfort or convenience items.

4.11 Intrepid Dynamic Exoskeletal Orthosis (IDEO).

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