Anthem Blue Cross Connecticut CG-OR-PR-09 Microprocessor Controlled Knee-Ankle-Foot Orthosis Form

This document addresses the use of a microprocessor controlled knee-ankle-foot orthosis (for example, the C-Brace^®, Ottobock HealthCare LP, Austin, TX) that provides support for individuals with lower extremity weakness. This microprocessor controlled device is a stance and swing phase control orthosis (SSCO) intended to augment the function of individuals with peripheral or central neurologic conditions that result in weakness or paresis of the quadriceps and/or other knee extensor muscles.

Note: This device should not be confused with microprocessor controlled prosthetic devices, which are intended to replace or compensate for a missing limb or body part. For documents related to microprocessor controlled prosthetic devices see

• CG-OR-PR-05 Myoelectric Upper Extremity Prosthetic Devices
• CG-OR-PR-08 Microprocessor Controlled Lower Limb Prosthesis.

Note: Please see the following related document for additional information:

• CG-DME-22 Ankle-Foot & Knee-Ankle-Foot Orthoses

Clinical Indications

Medically Necessary:

1. Microprocessor controlled knee-ankle-foot orthoses are considered medically necessary when all of the following criteria set forth in (A) and (B) below have been met:
   1. Selection criteria:
      1. Individual is ambulatory and use of a knee-ankle-foot orthosis (KAFO) is appropriate; and
      2. Individual has adequate cardiovascular reserve and cognitive learning ability to master the higher level technology; and
      3. The provider has documented that there is a reasonable likelihood of better mobility or stability with the device instead of a KAFO; and
      4. There is documented need for ambulation in situations where the device will provide benefit (for example, regular need to ascend/descend stairs, traverse uneven surfaces or ambulate for long distances [generally 400 yards or greater cumulatively]);
         and
   2. Documentation and performance criteria:
      1. Complete multidisciplinary assessment of individual including an evaluation by a certified orthotist. The assessment must objectively document that all of the above selection criteria have been evaluated and met.

Not Medically Necessary:

The use of a microprocessor controlled knee-ankle-foot orthosis is considered not medically necessary when the criteria above have not been met.