Humana Commercial Clinical Policy

Humana Orthotics Form

Effective Date

10/01/2023

Last Reviewed

NA

Original Document

  Reference



Description

Orthotics are devices that may be utilized to support, align, prevent or correct deformities or to improve the function of movable parts of the body. Orthotics include, but may not be limited to, braces (devices that support a weak joint or joints), splints (rigid devices used to immobilize an injury), casts (devices used to immobilize fractured body parts) and supports.

Orthotics may be classified as:
  • Over-the-counter (OTC) – off-the-shelf – Devices that are not modified or changed from the original product. These items are generally available without a prescription and typically not covered under the Plan.

Page: 1 of 68
Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045
Page: 2 of 68

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Prefabricated – Devices that are generally premade; however, may require a fitting or adjustment to fit the individual.
  • Custom fabricated – Devices that involve substantial work such as cutting, bending, molding or sewing. An impression of the body part may also be made to form a model from which the orthotic is molded.

Examples of orthotics include, but may not be limited to:

  • Air splints
  • Cervical collars (eg, postsurgical)
  • Clavicle splints (eg, figure eight splint)
  • Finger splints (eg, volar plate or tendon avulsions)
  • Knee immobilizers (eg, internal derangement, ligament sprains, postsurgical)
  • Lumbar braces
  • Orthopedic shoes
  • Serial casting/plaster splinting
  • Torsion bar braces
  • Unloader braces, such as for the knee or back
  • Wrist splints (eg, carpal tunnel syndrome)

Alternative types of orthotics include, but may not be limited to:

  • Cranial orthotics are designed to improve plagiocephaly without synostosis or deformational plagiocephaly, which is a condition found in infants whose heads show an asymmetrical flattening caused by uneven external pressures on the skull. This may be part of the postoperative treatment plan following surgical correction of craniosynostosis, which is a condition that results from premature fusion of one or more cranial sutures. The two types of cranial orthotics, a cranial band or soft-shell helmet, are custom made and custom fitted to the infant’s head.
  • Pectus carinatum (PC) orthotic compression bracing uses a customized chest wall brace which applies direct, constant pressure to the protruding area of the chest with the goal of reshaping the chest and sternum. The brace has front and back compression pads that are attached to aluminum bars which are bound together by a tightening mechanism. Regular monitoring and adjustment are generally required.
  • A scoliosis brace is utilized to help the individual’s scoliosis curve from getting worse in hopes of avoiding surgical treatment. Scoliosis braces are typically rigid and cover the front and back of the upper body. Generally, thoracolumbrosacral/lumbosacral (TLSO/LSO) braces are utilized. Other braces that have been introduced include tension-based braces (eg, SpineCor) and thermoplastic braces that purportedly have pressure and expansion areas built in to provide correction from three different anatomical planes (eg, Wood Cheneau Rigor brace).

Page: 3 of 68
Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

(Refer to Coverage Limitations section)Intrepid Dynamic Exoskeleton Orthosis (IDEO) is a custom molded device that was reportedly developed for individuals who have suffered massive tissue, nerve and bone damage to supposedly return capabilities to the injured ankle. Purportedly, the individual can return to a high level of activity, such as running. The IDEO device is molded out of lightweight black carbon that includes a foot plate and a strut that runs up the back of the calf to a cuff that is situated just below the knee. Reportedly, when force is applied to the foot plate, the strut bends. As the individual steps down, it bends the foot plate, transferring energy forward. The ExoSym brace resembles the IDEO orthosis; however, it is purportedly lighter and stronger than the original version.

(Refer to Coverage Limitations section)Microprocessor activated mobility devices combine electronic components with specialized orthotic braces to reportedly provide assistance in walking to individuals with back injuries or leg muscle weakness. Examples of microprocessor activated devices include, but may not be limited to, the C-Brace Orthotronic Mobility System or the Sensor Walk Stance Control knee brace.

(Refer to Coverage Limitations section)Myoelectric orthotic devices were reportedly designed for upper limb deficiencies. They purportedly enable individuals who have been afflicted by a stroke or other neuromuscular conditions to self-initiate movement of a partially paralyzed arm using their own muscle signals. Supposedly, when the user tries to bend the affected limb, sensors in the brace detect the muscle signal, which activates the motor to move the arm in the desired direction. Examples of this brace include, but may not be limited to, the MyoPro myoelectric limb orthosis and the Myomo e100.

Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045
Page: 4 of 68

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Orthotic full body garments (eg, TheraTogs) are elasticized undergarments that include straps that are reportedly used for individuals with sensorimotor impairments. The garment along with the strapping purportedly improves stability, movement as well as postural alignment.

(Refer to Coverage Limitations section)Wearable robotic exoskeletons have been developed to reportedly help individuals ambulate despite partial or complete paraplegia. The devices include fitted braces for the legs and upper body with motorized hip and knee joints, a backpack containing a computer and rechargeable batteries, an array of upper body motion sensors and a computer based wireless control system worn on the individual’s wrist. Crutches are also used to provide the user with additional stability when walking, standing or rising from a chair.

Typically, these devices are indicated for use by people with paraplegia due to spinal cord injuries at levels T7 to L5 when accompanied by a specially trained caregiver and for individuals with spinal cord injuries at levels T4 to T6 where the device is limited to use in rehabilitation institutions.62,64,69 Examples of these types of devices include, but may not be limited to, the following:

  • Alalante
  • EksoGT and EksoNR systems (for use only in rehabilitation institutions)
  • Indego powered exoskeleton
  • Keeogo Dermoskeleton system
  • ReWalk Personal System
  • ReWalk Restore

Generally, the use of these devices requires that individuals are able to stand using an assistive device (eg, standing frame) and their hands and shoulders are able to support crutches or a walker.62,64,69 (Refer to Coverage Limitations section)

Mechanical stretching devices include low load prolonged duration stretch (LLPS) devices, patient actuated serial stretch (PASS) devices and static progressive stretch (SPS) devices. In most cases, mechanical stretching devices are proposed as an adjunct treatment to physical therapy (PT) and/or exercise. These devices may also be referred to as dynamic devices, which mean they allow some controlled motion. Stretching devices are not orthotics. (For information regarding mechanical stretching devices, please refer to Continuous Passive Motion and Mechanical Stretching Devices Medical Coverage Policy)

Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045
Page: 5 of 68

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Coverage Determination

Any state mandates for orthotics take precedence over this medical coverage policy.

Humana members may be eligible under the Plan for the following orthotics, which includes braces, splints and supports that that are prescribed by a physician and are used to support, align, prevent or correct deformities.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Knee orthosis
    • 11810, L1820, L1831, L1832, L1834,
    • 11840, L1843, L1844, L1845, L1846, 11847, L1860
  • Knee-ankle-foot orthosis
    • 12000, L2010, L2020, L2030, L2034,
    • L2035, L2036, L2037, L2038, L2126,
    • L2128, L2132, L2134, L2136
  • Legg perthes orthosis
    • L1700, L1710, L1720, L1730, L1755
  • Lumbar orthosis
    • LO626, LO627
  • Lumbar-sacral orthosis
    • 0629, LO630, L0631, LO632, L0633,L0634, L0635, LO636, L0637, L0638, LO639, LO640
  • Sacroiliac orthosis
    • LO624
    • LO622,
  • Scoliosis orthosis
    • L1300, L1310
  • Shoulder orthosis
    • L3671, L3674, L3677
  • Shoulder-elbow-wrist-hand orthosis Thoracic-lumbar-sacral orthotic
    • 13960, L3961, L3962, L3967, L3971, L3978
    • 13973, L3975, L3976, L3977, 10220, LO452, L0454, LO456, LO458, L0460, LO462, L0464, LO466, LO468, L0470, LO472, L0480, LO482, L484, L0486, LO488, L0490, LO491, LO492,
    • 11200
  • Upper extremity fracture orthosis
    • L3980, L3981, L3982, L3984
  • Walking boot (when used in lieu of a cast)
    • L4360, L4361, L4386, L4387
  • Wrist-hand orthosis
    • L3905, L3906, L3915
  • Wrist-hand-finger orthosis
    • 13806, L3807, L3808, L3900, L3901, 13904, L3931
  • Addition to cervical-thoracic-lumbar- sacral orthotic
    • 11010, L1020, L1025, L1030, L1040, L1050, L1060, L1070, L1080, L1085, L1120
    • L1090, L1100, L1110,
  • Addition to knee joint orthosis
    • 12405, L2415, L2425, L2430, L2492
  • Addition to lower extremity fracture orthosis
    • 12180, L2182, L2184, L2186, L2188, 12190, L2192
  • Addition to lower extremity orthosis
    • L2200, L2210, L2220, L2230, L2232, L2240, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330,

Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045
Page: 7 of 68

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Addition to thoracic-lumbar-sacral orthosis
    • L2397, L2500, L2510, L2520, L2525,
    • L2850, L2861 L1210, L1220, L1230, L1240, L1250, L1260, L1270, L1280, L1290
  • Addition to upper extremity joint, wrist or elbow orthosis
    • L3891, L3956
  • Addition to upper extremity orthosis
    • L3995
  • Orthotic and prosthetic supply
    • L9900

Humana members may be eligible under the Plan for chest wall deformities treatment for pectus carinatum by orthotic compression bracing when the following criteria are met:

  • Brace is custom made for the individual (L1499); AND
  • Diagnosed with mild to moderate pectus carinatum; AND
  • Documented physical functional impairment* (eg, cardiac or respiratory insufficiency); AND
  • Individual motivated to adhere to treatment; AND
  • Skeletal growth is incomplete*Functional impairment is defined as a direct and measurable reduction in physical performance of an organ or body part.

Humana members may be eligible under the Plan for cranial orthotics (cranial banding, soft shell helmets) when the following criteria are met:

Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045
Page: 8 of 68

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • Absence of hydrocephalus; AND
  • 18 months of age or younger; AND
  • Custom made and custom fitted for the individual (S1040, L0112);AND EITHER of the following:
  • Part of the postoperative treatment plan following surgical correction of craniosynostosis; OR
  • Positional plagiocephaly that has not adequately responded to a 2 month trial of repositioning and/or physical therapy

Humana members may be eligible under the Plan for shoes for the following indications:

  • Specially constructed shoes that are an integral part of a leg brace (the shoe cannot be removed from the brace without making the shoe unusable) (L3140, L3150, L3160, L3224, L3225); OR
  • Cast boots or shoes requested by the surgeon following a surgical procedure or treatment of a fracture (L3208, L3209, L3211, L3260); OR
  • One pair of custom-made or custom-fit arch supports or shoes per calendar year ONLY for members with hammer toe (L3010, L3070, L3080, L3090, L3215, L3216, L3217, L3219, L3221, L3222, L3230, L3251, L3252, L3253, L3254, L3255, L3257, L3265, L3500, L3510, L3520, L3530, L3540, L3550, L3560, L3570, L3580, L3590, L3595, L3600, L3610, L3620, L3630, L3640, L3649) OR with sensory or vascular abnormalities of the feet due to diabetes mellitus (A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, A5514)

Humana members may be eligible under the Plan for repair (L4205, L4210) or replacement (L0861, L4000, L4002, L4010, L4020, L4030, L4040, L4045, L4050,

Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045
Page: 9 of 68

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version.

Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • L4055, L4060, L4070, L4080, L4090, L4100, L4110, L4130, L4392, L4394) of an orthotic device, when not excluded by certificate, for any of the following indications:
    • Repair that will return function to the orthotic when an anatomical change* or reasonable wear and tear renders the orthotic nonfunctional; OR
    • Replacement of an orthotic for any of the following:
      • Anatomical change*; OR
      • Reasonable wear and tear render the orthotic nonrepairable and nonfunctional; OR
      • Reasonable useful lifetime wear and tear replaced every 5 years unless otherwise stated in Appendix A
  • *Anatomical change refers to significant growth in a child or adolescent, major weight loss or gain, or other body changes that result in a poor fit or function of an orthotic device.
  • Telecommunication or wireless transmission for monitoring compliance is considered integral to the primary device/procedure and not separately reimbursable.

Note: The criteria for orthotics are not consistent with the Medicare National Coverage Policy and therefore may not be applicable to Medicare members. Refer to the CMS website for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for orthotics for any indications other than those listed above or for the following orthotics (list may not be all inclusive):

Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045
Page: 10 of 68

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

  • maternity lumbar supports/belly bands, rib belts, trusses and wrist supports) that can be provided or prescribed by a health care practitioner but are also available without a written order or prescription (generally excluded by certificate) (A4467, A4565, A4566, A4570, A9285, E0942, E0944, E0945, K1015, L0113, L0450, L0455, L0457, L0467, L0469, L0621, L0623, L0625, L0628, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L0970, L0972, L0974, L0976, L0980, L0982, L0984, L1812, L1830, L1833, L1836, L1848, L1850, L1851, L1852, L1902, L1906, L1930, L3100, L3170, L3650, L3660, L3670, L3675, L3678, L3710, L3761, L3762, L3809, L3908, L3912, L3916, L3918, L3924, L3925, L3927, L3930, L4350, L4370, L4396, L4397, L4398, L8300, L8310, L8320, L8330, S8450, S8451, S8452)
  • Arch supports (foot orthotics) (generally excluded by certificate) (L3040, L3050, L3060)
  • Braces used only for activities other than normal daily living including, but may not be limited to, braces used for sports and industrial back braces
  • Heel wedges, lifts or shoe inserts (generally excluded by certificate) (L3000, L3001, L3002, L3003, L3020, L3030, L3031, L3300, L3310, L3320, L3330, L3332, L3334, L3340, L3350, L3360, L3370, L3380, L3390, L3400, L3410, L3420, L3430, L3440, L3450, L3455, L3460, L3465, L3470, L3480, L3485)
  • Orthopedic shoes, except as outlined in Coverage Determination section (generally excluded by certificate) (A5500, A5501, A5503, A5504, A5505, A5506, A5507, A5508, A5510, A5512, A5513, A5514, L3201, L3202, L3203, L3204, L3206, L3207, L3212, L3213, L3214)
  • Prophylactic knee brace
  • Repair or replacement of orthotics due to abuse, misuse or neglect
  • Treatment of flat, strained, unbalanced, unstable or weak feet (generally excluded by certificate) (K1015, L1910)

These are generally excluded by certificate OR NOT medically necessary as defined in the member’s individual certificate. Please refer to the member’s individual certificate for the specific definition.

Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045
Page: 11 of 68

Humana's documents are updated regularly online.

When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.

Humana members may NOT be eligible under the Plan for the following orthotic devices:

  • C-Brace Orthotronic Mobility System (L2006)
  • DDS 500 Lumbar Traction LSO
  • E- Mag Active Knee Joint System
  • ExoSym brace
  • IDEO device
  • Myoelectric upper extremity orthotic devices (L8701, L8702)
  • Orthotic full body garments (eg, TheraTogs)
  • Sensor Walk Stance Control knee brace
  • Tension based scoliosis orthotic (eg, SpineCor System Dynamic Corrective Brace) (L1005)
  • Wearable robotic exoskeletons (eg, Atalante, EksoGT system, EksoNR system, Indego powered exoskeleton, Keeogo Dermoskeleton system, ReWalk Personal System, ReWalk ReStore) (E1399, K1007)
  • Wood Cheneau Rigo scoliosis brace (L0999)

These are considered experimental/investigational as they are not identified as widely used and generally accepted for the proposed uses as reported in nationally recognized peer-reviewed medical literature published in the English language.

Humana members may NOT be eligible under the Plan for cranial orthotics for any indications other than those listed above. This is considered experimental/investigational as it is not identified as widely used and generally accepted for any other proposed use as reported in nationally recognized peer-reviewed medical literature published in the English language.

Background

Additional information about injuries and/or disorders that may necessitate the use of braces, supports or splints may be found from the following websites:

  • American Academy of Orthopaedic Surgeons
  • National Library of Medicine

Medical Alternatives

Physician consultation is advised to make an informed decision based on an individual’s health needs.

Any CPT, HCPCS or ICD codes listed on this medical coverage policy are for informational purposes only. Do not rely on the accuracy and inclusion of specific codes. Inclusion of a code does not guarantee coverage and or reimbursement for a service or procedure.

Orthotics Effective Date: 10/01/2023
Revision Date: 10/01/2023
Review Date: 03/01/2023
Policy Number: HUM-0330-045
Page: 12 of 68

Humana's documents are updated regularly online. When printed, the version of this document becomes uncontrolled. Do not rely on printed copies for the most up-to-date version. Refer to Medical and Pharmacy Coverage Policies to verify that this is the current version before utilizing.