This document addresses the intended use of prefabricated functional or rehabilitation knee braces and prophylactic knee braces.

Note: Please refer to the following document for additional information concerning knee braces:

• CG-OR-PR-03 Custom-made Knee Braces

Clinical Indications

Medically Necessary:

Prefabricated functional or rehabilitation knee braces are considered medically necessary for individuals when any of the following criteria are met:

1. Documented anterior or posterior cruciate ligament tears or functional instability episodes due to cruciate ligament insufficiency when non-surgical treatment is elected; or
2. Grade II or III medial collateral or lateral collateral ligament sprain to support ambulation when the use of a hinged brace allows for controlled joint motion; or
3. Posterior cruciate or posterior lateral reconstruction, including reconstruction after knee dislocation; or
4. Recent surgery for anterior cruciate ligament repair in the post-operative recovery phase; or
5. Recent surgery for meniscal cartilage repair in the post-operative recovery phase; or
6. Major ligament and bony reconstruction above the knee such as patella or quadriceps tendon repair, medial and lateral collateral ligament repair; or
7. Major fractures requiring early post-injury or post-operative motion such as patella fractures or tibial plateau fractures; or
8. Osteoarthritis of the knee (unicompartmental) who meet any of the following:
   1. High tibial osteotomy or total knee arthroplasty (replacement) candidate that may elect non-surgical treatment; or
   2. To predict the success of high tibial osteotomy versus total knee arthroplasty; or
   3. Severe patellofemoral arthrosis in conjunction with medial or lateral compartment arthrosis.

Not Medically Necessary:

Prefabricated functional or rehabilitation knee braces are considered not medically necessary for individuals who are status post knee surgery when the criteria are not met, including, but not limited to total knee arthroplasty (unless there is documented ligament insufficiency).

Prefabricated functional or rehabilitation knee braces are considered not medically necessary for non-surgical indications when the criteria are not met.

Prophylactic knee braces are considered not medically necessary for all indications.

Note: Individuals with height (tall or short stature) or weight (obesity) variations can be fitted with a prefabricated (custom-fitted) knee brace with any of the following adjustments:

• extra-large straps for an obese person
• a pediatric model for a person of short stature
• extensions for an unusually tall person