Medical policy: Ankle-Foot and Knee-Ankle-Foot Orthoses

Policy number: MP 6.062

Clinical benefit

  • Minimize safety risk or concern.
  • Minimize harmful or ineffective interventions.
  • Assure appropriate level of care.
  • Assure appropriate duration of service for interventions.
  • Assure that recommended medical prerequisites have been met.
  • Assure appropriate site of treatment or service.

Effective date: 10/1/2026

Policy

Ankle-foot orthoses (AFOs) and knee-ankle-foot orthoses (KAFOs) and associated additions are considered medically necessary when the specific medical necessity criteria, listed below for each type, are met if a covered benefit:

For non-ambulatory individuals a static or dynamic positioning ankle-foot orthosis (L4396 or L4397) may be medically necessary if either ALL of criteria 1-4 or criterion 5 is met:

  1. Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and
  2. Reasonable expectation of the ability to correct the contracture; and
  3. Contracture is interfering or expected to interfere significantly with the patient’s functional abilities; and
  4. Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.
  5. The patient has plantar fasciitis.

If code L4396 or L4397 are medically necessary, a replacement interface (L4392) is covered as long as the patient continues to meet indications and other coverage rules for the splint. Coverage of a replacement interface is limited to a maximum of one (1) per six months per lower extremity. Additional interfaces will be denied as investigational.

For ambulatory individuals’ ankle-foot orthoses described by codes L1900-L1990, L2106-L2116, L4350, L4360, L4361, L4386, L4387 and L4631 or knee-ankle-foot orthoses (KAFO) described by codes L2000-L2005, L2010-L2038, L2126-L2136, and L4370 may be medically necessary with patients with:

  1. Weakness or deformity of the foot and ankle or foot, ankle and knee, who require stabilization for medical reasons; and
  2. Have the potential to benefit functionally.

Ankle-foot orthoses and knee-ankle-foot orthoses that are custom-fabricated are medically necessary for ambulatory patients when the basic coverage criteria listed above and ONE of the following criteria are met:

  1. The patient could not be fit with a prefabricated ankle-foot orthosis, or
  2. The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than six months), or
  3. There is a need (not prophylactic) to control the knee, ankle or foot in more than one plane, or
  4. The patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury, or
  5. The patient has a healing fracture, which lacks normal anatomical integrity or anthropometric proportions.

If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria (number 1-5 above) for a custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as investigational.

An inversion/eversion correction device (A9285) is denied as investigational because it does not act as a brace; that is, it does not support a weak or deformed body member or restrict or eliminate motion in a diseased or injured part of the body. There is insufficient evidence to support a general conclusion regarding the health outcomes or benefits associated with this item.

Concentric adjustable torsion style mechanisms used to assist knee joint extension are coded as L2999 and are covered; and therefore, medically necessary for members who require knee extension assist in the absence of any co-existing joint contracture.

Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion are coded as L2999 and are covered for members who require ankle plantar or dorsiflexion assist in the absence of any co-existing joint contracture.

Additions to an AFO/KAFO are considered medically necessary and, therefore, covered, when the AFO/KAFO is considered medically necessary according to the criteria listed in this policy.

Electronic KAFOs (L2006) (e.g., the Sensor Walk Electronic KAFO, C-Brace Orthotronic Mobility System) are considered experimental and investigational as there is insufficient evidence to support a general conclusion regarding the health outcomes or benefits associated with this item.

All other uses of ankle-foot and knee-ankle-foot orthoses not described above (for example when worn only during elective activities, such as sports for prevention or reduction of injury) will be denied as investigational as there is insufficient evidence to support a general conclusion supporting the health outcomes or benefits associated with this item.

Replacement of a complete orthosis or component of an orthosis due to loss, significant change in the patient’s condition, or irreparable accidental damage may be covered if the device is still medically necessary. The reason for the replacement must be documented in the supplier’s record. Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are denied as investigational.

The provider requesting/ordering the DME should be a provider with whom the member has established a relationship and is involved in the ongoing care of the member and the condition for which the DME/orthotic is prescribed.

Cross-references

  • MP 6.012 Knee Braces
  • MP 6.028 Foot Orthotics and Other Podiatric Appliances
  • MP 6.039 Mechanical Stretching Devices for Contracture and Joint Stiffness

Product variations

This policy is only applicable to certain programs and products administered by Capital Blue Cross and subject to benefit variations. Please see additional information below.

FEP PPO - Refer to FEP Medical Policy Manual.

Description/Background

An orthosis (orthotic), which may also be called a brace or splint, is a rigid or semi-rigid device that supports a weak or deformed body part or restricts or eliminates motion in a diseased or injured part of the body. An orthosis can be either prefabricated or custom-fabricated. An orthosis can also be used to treat plantar fasciitis, which is an inflammation of the broad band of fibrous tissue that runs along the bottom surface of the foot. Caused by excessive stretching, plantar fasciitis often leads to heel pain, heel spurs, and/or arch pain if left untreated.

An ankle-foot orthosis (AFO) extends well above the ankle (usually near the top of the calf) and is fastened around the lower leg above the ankle. AFOs differ from therapeutic shoes and supportive devices for the foot (e.g., shoe inserts, arch supports), which are placed within the shoe and do not extend above the ankle.

A knee-ankle-foot orthosis (KAFO) supports the knee as well as the ankle and foot.

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.

Definitions

N/A

Disclaimer

Capital Blue Cross’ medical policies are used to determine coverage for specific medical technologies, procedures, equipment, and services. These medical policies do not constitute medical advice and are subject to change as required by law or applicable clinical evidence from independent treatment guidelines. Treating providers are solely responsible for medical advice and treatment of members. These policies are not a guarantee of coverage or payment. Payment of claims is subject to a determination regarding the member’s benefit program and eligibility on the date of service, and a determination that the services are medically necessary and appropriate. Final processing of a claim is based upon the terms of contract that applies to the members’ benefit program, including benefit limitations and exclusions. If a provider or a member has a question concerning this medical policy, please contact Capital Blue Cross’ Provider Services or Member Services.

Coding information

Note: This list of codes may not be all-inclusive*, and codes are subject to change at any time. The identification of a code in this section does not denote coverage as coverage is determined by the terms of member benefit information. In addition, not all covered services are eligible for separate reimbursement.

Investigational; therefore, not covered:

HCPCS code
Description

L2006

Knee ankle foot device, any material, single or double upright, swing and stance phase microprocessor control with adjustability, includes all components (e.g., sensors, batteries, charger), any type of activation, with or without ankle joint(s), custom fabricated

Not medically necessary; therefore, not covered:

HCPCS code
Description

A9285

Inversion/eversion correction device

Covered when medically necessary for limited diagnosis:

HCPCS code
Description

L4392

Replacement, soft interface material, static AFO

L4396

Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L4397

Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf

Diagnosis for L4392, L4396, and L4397

ICD-10-CM diagnosis code
Description

M24.571

Contracture, right ankle

M24.572

Contracture, left ankle

M24.574

Contracture, right foot

M24.575

Contracture, left foot

M67.A

Plantar fasciitis

M67.A0

Plantar fasciitis, foot

M67.A01

Plantar fasciitis, right foot

M67.A02

Plantar fasciitis, left foot

M67.A09

Plantar fasciitis, unspecified foot

M72.2

Plantar fascial fibromatosis

M72.20

Plantar fascial fibromatosis, unspecified foot

M72.21

Plantar fascial fibromatosis, right foot

M72.22

Plantar fascial fibromatosis, left foot

Covered when medically necessary:

HCPCS code
Description

L1900

Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf band, custom fabricated

L1902

Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf

L1904

Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated

L1906

Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf

L1907

Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated

L1910

Ankle-foot orthotic (AFO), posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment

L1920

Ankle-foot orthotic (AFO), single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated

L1930

Ankle-foot orthotic (AFO), plastic or other material, prefabricated, includes fitting and adjustment

L1932

Ankle-foot orthosis (AFO), rigid anterior tibial section, total carbon fiber or equal material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1933

Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, off-the-shelf

L1940

Ankle-foot orthotic (AFO), plastic or other material, custom fabricated

L1945

Ankle-foot orthotic (AFO), plastic, rigid anterior tibial section (floor reaction), custom fabricated

L1950

Ankle-foot orthotic (AFO), spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated

L1951

Ankle-foot orthosis, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1952

Ankle foot orthosis, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, off-the-shelf

L1960

Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated

L1970

Ankle-foot orthotic (AFO), plastic with ankle joint, custom fabricated

L1971

Ankle-foot orthosis, plastic or other material with ankle joint, with or without dorsiflexion assist, prefabricated, includes fitting and adjustment

L1972

Ankle foot orthosis, plastic or other material with ankle joint, with or without dorsiflexion assist, prefabricated, off-the-shelf

L1980

Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar ‘BK’ orthotic), custom fabricated

L1990

Ankle-foot orthotic (AFO), double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar ‘BK’ orthotic), custom fabricated

L2000

Knee-ankle-foot orthotic (KAFO), single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ‘AK’ orthotic), custom fabricated

L2005

Knee-ankle-foot orthotic (KAFO), any material, single or double upright, stance control, automatic lock and swing phase release, any type of activation, includes ankle joint, any type, custom fabricated

L2010

Knee-ankle-foot orthotic (KAFO), single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ‘AK’ orthotic), without knee joint, custom fabricated

L2020

Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar ‘AK’ orthotic), custom fabricated

L2030

Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar ‘AK’ orthotic), without knee joint, custom fabricated

L2034

Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion knee, medial-lateral rotation control, with or without free motion ankle, custom fabricated

L2035

Knee-ankle-foot orthotic (KAFO), full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment

L2036

Knee-ankle-foot orthotic (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated

L2037

Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated

L2038

Knee-ankle-foot orthotic (KAFO), full plastic, with or without free motion knee, multi-axis ankle, custom fabricated

L2106

Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, thermoplastic type casting material, custom fabricated

L2108

Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, custom fabricated

L2112

Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, soft, prefabricated, includes fitting and adjustment

L2114

Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, semi-rigid, prefabricated, includes fitting and adjustment

L2116

Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture orthotic, rigid, prefabricated, includes fitting and adjustment

L2126

Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, thermoplastic type casting material, custom fabricated

L2128

Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, custom fabricated

L2132

Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, soft, prefabricated, includes fitting and adjustment

L2134

Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, semi-rigid, prefabricated, includes fitting and adjustment

L2136

Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, rigid, prefabricated, includes fitting and adjustment

L2180

Addition to lower extremity fracture orthotic, plastic shoe insert with ankle joints

L2182

Addition to lower extremity fracture orthotic, drop lock knee joint

L2184

Addition to lower extremity fracture orthotic, limited motion knee joint

L2186

Addition to lower extremity fracture orthotic, adjustable motion knee joint, Lerman type

L2188

Addition to lower extremity fracture orthotic, quadrilateral brim

L2190

Addition to lower extremity fracture orthotic, waist belt

L2192

Addition to lower extremity fracture orthotic, hip joint, pelvic band, thigh flange, and pelvic belt

L2200

Addition to lower extremity, limited ankle motion, each joint

L2210

Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

L2220

Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint

L2230

Addition to lower extremity, split flat caliper stirrups and plate attachment

L2232

Addition to lower extremity orthotic, rocker bottom for total contact ankle-foot orthotic (AFO), for custom fabricated orthotic only

L2240

Addition to lower extremity, round caliper and plate attachment

L2250

Addition to lower extremity, foot plate, molded to patient model, stirrup attachment

L2260

Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)

L2265

Addition to lower extremity, long tongue stirrup

L2270

Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus pad

L2275

Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

L2280

Addition to lower extremity, molded inner boot

L2300

Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable

L2310

Addition to lower extremity, abduction bar, straight

L2320

Addition to lower extremity, non-molded lacer, for custom fabricated orthotic only

L2330

Addition to lower extremity, lacer molded to patient model, for custom fabricated orthotic only

L2335

Addition to lower extremity, anterior swing band

L2340

Addition to lower extremity, pretibial shell, molded to patient model

L2350

Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses)

L2360

Addition to lower extremity, extended steel shank

L2370

Addition to lower extremity, Patten bottom

L2375

Addition to lower extremity, torsion control, ankle joint and half solid stirrup

L2380

Addition to lower extremity, torsion control, straight knee joint, each joint

L2385

Addition to lower extremity, straight knee joint, heavy-duty, each joint

L2387

Addition to lower extremity, polycentric knee joint, for custom fabricated knee-ankle-foot orthotic (KAFO), each joint

L2390

Addition to lower extremity, offset knee joint, each joint

L2395

Addition to lower extremity, offset knee joint, heavy-duty, each joint

L2397

Addition to lower extremity orthotic, suspension sleeve

L2405

Addition to knee joint, drop lock, each

L2415

Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each joint

L2425

Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint

L2430

Addition to knee joint, ratchet lock for active and progressive knee extension, each joint

L2492

Addition to knee joint, lift loop for drop lock ring

L2500

Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring

L2510

Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model

L2520

Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted

L2525

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim molded to patient model

L2526

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim, custom fitted

L2530

Addition to lower extremity, thigh/weight bearing, lacer, non-molded

L2540

Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model

L2550

Addition to lower extremity, thigh/weight bearing, high roll cuff

L2750

Addition to lower extremity orthosis, plating chrome or nickel, per bar

L2755

Addition to lower extremity orthotic, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthotic only

L2760

Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth)

L2768

Orthotic side bar disconnect device, per bar

L2780

Addition to lower extremity orthotic, noncorrosive finish, per bar

L2785

Addition to lower extremity orthosis, drop lock retainer, each

L2795

Addition to lower extremity orthosis, knee control, full kneecap

L2800

Addition to lower extremity orthotic, knee control, kneecap, medial or lateral pull, for use with custom fabricated orthotic only

L2810

Addition to lower extremity orthosis, knee control, condylar pad

L2820

Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

L2830

Addition to lower extremity orthosis, soft interface for molded plastic, above knee section

L2840

Addition to lower extremity orthotic, tibial length sock, fracture or equal, each

L2850

Addition to lower extremity orthotic, femoral length sock, fracture or equal, each

L2861

Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each

L2999

Lower extremity orthotic, not otherwise specified

L4002

Replacement strap, any orthotic, includes all components, any length, any type

L4010

Replace trilateral socket brim

L4020

Replace quadrilateral socket brim, molded to patient model

L4030

Replace quadrilateral socket brim, custom fitted

L4040

Replace molded thigh lacer, for custom fabricated orthotic only

L4045

Replace non-molded thigh lacer, for custom fabricated orthotic only

L4050

Replace molded calf lacer, for custom fabricated orthotic only

L4055

Replace non-molded calf lacer, for custom fabricated orthotic only

L4060

Replace high roll cuff

L4070

Replace proximal and distal upright for KAFO

L4080

Replace metal bands KAFO, proximal thigh

L4090

Replace metal bands KAFO-AFO, calf or distal thigh

L4100

Replace leather cuff KAFO, proximal thigh

L4110

Replace leather cuff KAFO-AFO, calf or distal thigh

L4130

Replace pretibial shell

L4205

Repair of orthotic device, labor component, per 15 minutes

L4210

Repair of orthotic device, repair or replace minor parts

L4350

Ankle control orthosis, stirrup style, rigid, includes any type of interface (e.g., pneumatic, gel), prefabricated, off-the-shelf

L4360

Pneumatic walking boot prefab

L4361

Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf

L4370

Pneumatic full leg splint, prefabricated, includes fitting and adjustment

L4386

Walking boot non-pneumatic prefab w/fit & adj

L4387

Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf

L4631

Ankle-foot orthotic, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated

*The following diagnosis codes as well as diagnosis codes for fractures of the knee, ankle and foot are applicable for reimbursement for Ankle-Foot and Knee-Ankle-Foot Orthoses: (see below)

ICD-10-CM diagnosis code*
Description

A52.16

Charcot's arthropathy (tabetic)

G60.3

Idiopathic progressive neuropathy

M12.571

Traumatic arthropathy, right ankle and foot

M12.572

Traumatic arthropathy, left ankle and foot

M14.661

Charcot's joint, right knee

M14.662

Charcot's joint, left knee

M14.671

Charcot's joint, right ankle and foot

M14.672

Charcot's joint, left ankle and foot

M19.071

Primary osteoarthritis, right ankle and foot

M19.072

Primary osteoarthritis, left ankle and foot

M19.171

Post-traumatic osteoarthritis, right ankle and foot

M19.172

Post-traumatic osteoarthritis, left ankle and foot

M21.371

Foot drop, right foot

M21.372

Foot drop, left foot

M21.541

Acquired clubfoot, right foot

M21.542

Acquired clubfoot, left foot

M24.571

Contracture, right ankle

M24.572

Contracture, left ankle

M24.574

Contracture, right foot

M24.575

Contracture, left foot

M25.271

Flail joint, right ankle and foot

M25.272

Flail joint, left ankle and foot

M25.371

Other instability, right ankle

M25.372

Other instability, left ankle

M62.471

Contracture of muscle, right ankle and foot

M62.472

Contracture of muscle, left ankle and foot

M65.871

Other synovitis and tenosynovitis, right ankle and foot

M65.872

Other synovitis and tenosynovitis, left ankle and foot

M67.01

Short Achilles tendon (acquired), right ankle

M67.02

Short Achilles tendon (acquired), left ankle

M72.2

Plantar fascial fibromatosis

M76.61

Achilles tendinitis, right leg

M76.62

Achilles tendinitis, left leg

M76.71

Peroneal tendinitis, right leg

M76.72

Peroneal tendinitis, left leg

M76.811

Anterior tibial syndrome, right leg

M76.812

Anterior tibial syndrome, left leg

M76.821

Posterior tibial tendinitis, right leg

M76.822

Posterior tibial tendinitis, left leg

Q72.811

Congenital shortening of right lower limb

Q72.812

Congenital shortening of left lower limb

Q72.813

Congenital shortening of lower limb, bilateral

Q72.892

Other reduction defects of left lower limb

Q72.893

Other reduction defects of lower limb, bilateral

Q74.2

Other congenital malformations of lower limb(s), including pelvic girdle

R26.0

Ataxic gait

S93.401A

Sprain of unspecified ligament of right ankle, initial encounter

S93.401D

Sprain of unspecified ligament of right ankle, subsequent encounter

S93.402A

Sprain of unspecified ligament of left ankle, initial encounter

S93.402D

Sprain of unspecified ligament of left ankle, subsequent encounter

S93.411A

Sprain of calcaneofibular ligament of right ankle, initial encounter

S93.411D

Sprain of calcaneofibular ligament of right ankle, subsequent encounter

S93.412A

Sprain of calcaneofibular ligament of left ankle, initial encounter

S93.412D

Sprain of calcaneofibular ligament of left ankle, subsequent encounter

S93.421A

Sprain of deltoid ligament of right ankle, initial encounter

S93.421D

Sprain of deltoid ligament of right ankle, subsequent encounter

S93.422A

Sprain of deltoid ligament of left ankle, initial encounter

S93.422D

Sprain of deltoid ligament of left ankle, subsequent encounter

S93.431A

Sprain of tibiofibular ligament of right ankle, initial encounter

S93.431D

Sprain of tibiofibular ligament of right ankle, subsequent encounter

S93.432A

Sprain of tibiofibular ligament of left ankle, initial encounter

S93.432D

Sprain of tibiofibular ligament of left ankle, subsequent encounter

S93.491A

Sprain of other ligament of right ankle, initial encounter

S93.491D

Sprain of other ligament of right ankle, subsequent encounter

S93.492A

Sprain of other ligament of left ankle, initial encounter

S93.492D

Sprain of other ligament of left ankle, subsequent encounter

S93.611A

Sprain of tarsal ligament of right foot, initial encounter

S93.611D

Sprain of tarsal ligament of right foot, subsequent encounter

S93.612A

Sprain of tarsal ligament of left foot, initial encounter

S93.612D

Sprain of tarsal ligament of left foot, subsequent encounter

S93.621A

Sprain of tarsometatarsal ligament of right foot, initial encounter

S93.621D

Sprain of tarsometatarsal ligament of right foot, subsequent encounter

S93.622A

Sprain of tarsometatarsal ligament of left foot, initial encounter

S93.622D

Sprain of tarsometatarsal ligament of left foot, subsequent encounter

S93.691A

Other sprain of right foot, initial encounter

S93.691D

Other sprain of right foot, subsequent encounter

S93.692A

Other sprain of left foot, initial encounter

S93.692D

Other sprain of left foot, subsequent encounter

References

  1. Adaptive control of an actuated-ankle-foot-orthosis. Accessed December 29, 2022.
  2. Cooke MV, Marsh JL, Clark M, et al. Treatment of severe ankle sprain: A pragmatic randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of three types of mechanical ankle support with tubular bandage. The CAST trial. Health Technol Assess. 2009; 13(13):1-144.
  3. Kobayashi T, Orendurff MS, Singer ML, Gao F, Foreman KB. Contribution of ankle-foot orthosis moment in regulating ankle and knee motions during gait in individuals post-stroke. Clin Biomech (Bristol, Avon). 2017;45:9-13.
  4. Davis PC, Bach TM, Pereira DM. The effect of stance control orthoses on gait characteristics and energy expenditure in knee-ankle-foot orthosis users. Prosthet Orthot Int. 2010; 34(2):206-215.
  5. Grissom SP, Blandon S. Treatment of upper motorneuron plantarflexion contractures by using an adjustable ankle-foot orthosis. Arch Phys Med Rehabil. 2001; 82(2):270-273.
  6. Hijmans JM, Geertzen JH, Dijkstra PU, Postema K. A systematic review of the effects of shoes and other ankle or foot appliances on balance in older people and people with peripheral nervous system disorders. Gait Posture. 2007; 25(2):316-323.
  7. Kerkhoffs GMMJ, Struijs PAA, Marti RK, et al. Different functional treatment strategies for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev. 2002;(3):CD002938.
  8. Noridian Healthcare Solutions, LLC (NHS). Ankle-Foot/Knee-Ankle-Foot Orthosis. Local Coverage Determination No. L33686. Durable Medical Equipment Medicare Administrative Carrier Jurisdiction J-A; revised January 1, 2020.
  9. Richie DH Jr. Effects of foot orthoses on patients with chronic ankle instability. J Am Podiatr Med Assoc. 2007;97(1):19-30.
  10. Deems-Dluhy S, Hoppe-Ludwig S, Mummidisetty CK, Semik P, Heinemann AW, Jayaraman A. Microprocessor Controlled Knee Ankle Foot Orthosis (KAFO) vs Stance Control vs Locked KAFO: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2021;102(2):233-244.
  11. Aboutorabi A, Bahramizadeh M, Arazpour M, et al. A systematic review of the effect of foot orthoses and shoe characteristics on balance in healthy older subjects. Prosthet Orthot Int. 2016;40(2):170-181.
  12. Choo JY, Chang MC. Effectiveness of an ankle-foot orthosis on walking in patients with stroke: a systematic review and meta-analysis. Sci Rep. 2021;11(1):15879. Published 2021 Aug 5.
  13. Aboutorabi A, Arazpour M, Ahmadi Bani M, et al. Efficacy of ankle foot orthoses types on walking in children with cerebral palsy: A systematic review. Ann Phys Rehabil Med. 2017;60(6):393-402.
  14. Ruetz A, DiBello T, Toelle C, et al. A microprocessor stance and swing control orthosis improves balance, risk of falling, mobility, function, and quality of life of individuals dependent on a knee-ankle-foot orthosis for ambulation. Disabil Rehabil. 2024;46(17):4019-4032.

Policy history

MP 6.062

08/19/2019 Administrative update. Coding reviewed no changes. Removed not medically necessary statements related to foot drop splints/recumbent positioning devices.

04/21/2020 Consensus review. Policy statements unchanged. References updated.

04/20/2021 Consensus review. Cross references and references updated. Deleted L4396 and L4397 from MN coding table. These are listed in the coding table titled “Covered when medically necessary for limited diagnosis.”

06/24/2021 Ad hoc review. HCPCS code L2006 taken off MP 6.042 and placed into this policy as E/I. Included electronic KAFOs into E/I policy statement. Deleted code L4398. Updated background.

12/29/2022 Consensus review. No changes to policy statement. Updated references. Coding reviewed, no changes.

08/23/2023 Consensus review. No changes to policy statement. Updated references. Coding reviewed, no changes.

01/18/2024 Administrative update. Added clinical benefit.

10/07/2024 Consensus review. No changes to policy statement or references. Coding reviewed, no changes.

03/13/2025 Administrative update. Added two new MN codes L1933 and L1952, and updated descriptions for L1932, L1951, and L1971, effective 04/01/2025.

07/22/2025 Consensus review. No changes to policy statement. Updated references. Coding reviewed, no changes.

11/24/2025 Administrative update. Removed Benefit Variations Section and updated Disclaimer.

09/02/2026 Administrative update. New code L1972 added, ICD10 added for L4392, L4396, L4397 effective 10/01/2026.