Knee Orthoses

Summary of Evidence Analysis of Evidence Coding Information CPT/HCPCS Codes General Information Associated Information Sources of Information Bibliography Revision History Information Associated Documents Attachments Related Local Coverage Documents Related National Coverage Documents Public Versions Keywords Local Coverage Determination (LCD) Knee Orthoses L33318 Expand All | Collapse All  Email Document  Download  Add to basket Contractor Information Contractor Name Contract Type Contract Number Jurisdiction States Indiana Kentucky Michigan Minnesota Ohio Wisconsin Arkansas Colorado Florida Georgia Louisiana Mississippi New Mexico North Carolina Oklahoma Puerto Rico South Carolina Tennessee Texas Virgin Islands Virginia West Virginia Delaware District of Columbia Maine Maryland Massachusetts New Hampshire New Jersey New York - Entire State Pennsylvania Rhode Island Vermont American Samoa Arizona California - Entire State Guam Hawaii Idaho Iowa Kansas Missouri - Entire State Montana Nebraska Nevada North Dakota Northern Mariana Islands Oregon South Dakota Utah Washington Wyoming LCD Information Document Information LCD ID L33318 LCD Title Knee Orthoses Proposed LCD in Comment Period N/A Source Proposed LCD DL33318 Original Effective Date For services performed on or after 10/01/2015 Revision Effective Date For services performed on or after 01/25/2026 Revision Ending Date N/A Retirement Date N/A Notice Period Start Date 12/11/2025 Notice Period End Date 01/24/2026 CPT codes, descriptions, and other data only are copyright 2025 American Medical Association. All Rights Reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are n

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions. In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement: The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section. The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section. Refer to the Supplier Manual for additional information on documentation requirements. Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD. For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity. For knee orthoses definitions of off-the-shelf and custom fitted, refer to the CODING GUIDELINES section in the LCD-related Policy Article. PREFABRICATED KNEE ORTHOSES (L1810, L1812, L1820, L1821, L1830, L1831, L1832, L1833, L1836, L1843, L1845, L1847, L1848, L1850, L1851, L1852): A knee flexion contracture is a condition in which there is shortening of the muscles and/or tendons with the resulting inability to bring the knee to 0 degrees extension or greater (i.e., hyperextension) by passive range of motion. (0 degrees knee extension is when the femur and tibia are in alignment in a horizontal plane). A knee extension contracture is a condition in which there is shortening of the muscles and/or tendons with the resulting inability to bring the knee to 80 degrees flexion or greater by passive range of motion. A contracture is distinguished from the temporary loss of range of motion of a joint following injury, surgery, casting, or other immobilization. A knee orthosis with joints (L1810, L1812) or knee orthosis with condylar pads and joints with or without patellar control (L1820, L1821) are covered for ambulatory beneficiaries who have weakness or deformity of the knee and require stabilization. If an L1810, L1812, L1820 or L1821 is provided but the criteria above are not met, the orthosis will be denied as not reasonable and necessary. A knee orthosis with a locking knee joint (L1831) or a rigid knee orthosis (L1836) is covered for beneficiaries with flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture) (r efer to the Group 1 ICD-10 Codes in the LCD-related Policy Article ). If an L1831 or L1836 orthosis is provided but the criterion above is not met, the orthosis will be denied as not reasonable and necessary. There is no proven clinical benefit to the inflatable air bladder incorporated into the design of code L1847 or L1848; therefore, claims for code L1847 or L1848 will be denied as not reasonable and necessary. An immobilizer knee orthosis without joints (L1830) is covered for a beneficiary who has had a recent injury to or a surgical procedure on the knee(s) (refer to the Group 2 or Group 4 ICD-10 Codes in the LCD-related Policy Article). A knee orthosis with adjustable knee joints (L1832, L1833) is covered if one of the following criteria is met: The beneficiary has had a recent injury to or a surgical procedure on the knee(s) (refer to the Groups 2 or Group 4 ICD-10 Codes in the LCD-related Policy Article); or, The beneficiary is ambulatory and has knee instability (refer to the Group 4 ICD-10 Codes in the LCD-related Policy Article). A prefabricated Swedish type knee orthosis (L1850) is covered for a beneficiary who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee, congenital or acquired (refer to the Group 5 ICD-10 Codes in the LCD-related Policy Article). For a knee orthosis with adjustable knee joints or a prefabricated Swedish type knee orthosis (L1832, L1833, L1850), objective knee instability must be supported by documentation of the beneficiary’s physical examination including the joint laxity test(s) performed (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section in the LCD-related Policy Article). A knee orthosis with single or double upright, adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment (L1843, L1845, L1851, L1852) is covered if one of the following criteria (1-3) is met: The beneficiary is ambulatory and has objective knee instability that must be supported by documentation of a physical examination including the joint laxity test(s) performed (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section in the LCD-related Policy Article; refer to the Group 4 ICD-10 Codes in the LCD-related Policy Article); or, The beneficiary has had a recent injury to or a surgical procedure on the knee(s) (refer to the Groups 2 or Group 4 ICD-10 Codes in the LCD-related Policy Article); or, The beneficiary has a documented (see the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section in the LCD-related Policy Article) diagnosis of medial or lateral tibiofemoral osteoarthritis (refer to the Group 6 ICD-10 Codes in the LCD-related Policy Article), and meets all criteria (a-d): a. The beneficiary is ambulatory; and, b. The beneficiary is experiencing pain or reduction in their mobility and/or function secondary to the medial or lateral tibiofemoral osteoarthritis; and, c. The knee orthosis provides either varus or valgus adjustment; and, d. The beneficiary expresses a willingness to use the knee orthosis. Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the above criteria for coverage. “Addition” codes are grouped into four (4) categories in relation to knee orthosis base codes. Eligible for separate payment Not reasonable and necessary Not separately payable Incompatible The following table lists addition codes which describe components or features that can be and frequently are physically incorporated in the specified prefabricated base orthosis. Addition codes may be separately payable if: They are provided with the related base code orthosis; and The base orthosis is reasonable and necessary; and The addition is reasonable and necessary. Addition codes will be denied as not reasonable and necessary if the base orthosis is not reasonable and necessary or the addition is not reasonable and necessary. Base Code Addition Codes - Eligible for Separate Payment L1810 None L1812 None L1820 None L1821 None L1830 None L1831 None L1832 L2397, L2795, L2810 L1833 L2397, L2795, L2810 L1836 None L1843 L2385, L2395, L2397 L1845 L2385, L2395, L2397, L2795 L1847 None L1848 None L1850 L2397 L1851 L2385, L2395, L2397 L1852 L2385, L2395, L2397, L2795 The following table lists addition codes which describe components or features that can be physically incorporated in the specified prefabricated base orthosis but are considered not reasonable and necessary. These addition codes, if they are billed with the related base code, will be denied as not reasonable and necessary. Base Code Addition Codes - Not Reasonable and Necessary L1810 L2397 L1812 L2397 L1820 L2397 L1821 L2397 L1830 L2397 L1831 L2397, L2795 L1832 L2405, L2415, L2492, L2785 L1833 L2405, L2415, L2492, L2785 L1836 L2397 L1843 L2405, L2492, L2785 L1845 L2405, L2415, L2492, L2785 L1847 L2397, L2795 L1848 L2397, L2795 L1850 L2275 L1851 L2405, L2492, L2785 L1852 L2405, L2415, L2492, L2785 Refer to the related Policy Article for information on addition codes that are considered not separately payable or incompatible with prefabricated knee orthosis base codes. CUSTOM FABRICATED KNEE ORTHOSES (L1834, L1840, L1844, L1846, L1860): A custom fabricated orthosis is covered when there is a documented physical characteristic which requires the use of a custom fabricated orthosis instead of a prefabricated orthosis. Examples of situations which meet the criterion for a custom fabricated orthosis include, but are not limited to: Deformity of the leg or knee; Size of thigh and calf; Minimal muscle mass upon which to suspend an orthosis. Although these are examples of potential situations where a custom fabricated orthosis may be appropriate, suppliers must consider prefabricated alternatives such as pediatric knee orthoses in beneficiaries with small limbs, straps with additional length for large limbs, etc. If a custom fabricated orthosis is provided but the medical record does not document why that item is medically necessary instead of a prefabricated orthosis, the custom fabricated orthosis will be denied as not reasonable and necessary. Custom fabricated orthoses (L1834, L1840, L1844, L1846, L1860) are not reasonable and necessary in the treatment of knee contractures in cases where the beneficiary is nonambulatory. A custom fabricated knee immobilizer without joints (L1834) is covered if criteria 1 and 2 are met: The coverage criteria for the prefabricated orthosis code L1830 are met; and The general criterion defined above for a custom fabricated orthosis is met. If an L1834 orthosis is provided and both criteria 1 and 2 are not met, the orthosis will be denied as not reasonable and necessary. A custom fabricated derotation knee orthosis (L1840) is covered for instability due to internal ligamentous disruption of the knee ( refer to the Group 3 ICD-10 Codes in the LCD-related Policy Article ). A custom fabricated knee orthosis with an adjustable flexion and extension joint (L1844, L1846) is covered if criteria 1 and 2 are met: The coverage criteria for the prefabricated orthosis codes L1843, L1845, L1851 and L1852 are met; and The general criterion defined above for a custom fabricated orthosis is met. If an L1844 or L1846 orthosis is provided and both criteria 1 and 2 are not met the orthosis will be denied as not reasonable and necessary. A custom fabricated knee orthosis with a modified supracondylar prosthetic socket (L1860) is covered for a beneficiary who is ambulatory and has knee instability due to genu recurvatum - hyperextended knee ( refer to the Group 5 ICD-10 Codes in the LCD-related Policy Article ). The following table lists addition codes which describe components or features that can be and frequently are physically incorporated in the specified custom fabricated base orthosis. Addition codes may be separately payable if: They are provided with the related base code orthosis; and The base orthosis is reasonable and necessary; and The addition is reasonable and necessary. Addition codes will be denied as not reasonable and necessary if the base orthosis is not reasonable and necessary or the addition is not reasonable and necessary. Base Code Addition Codes - Eligible for Separate Payment L1834 L2795 L1840 L2385, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2755, L2785, L2795 L1844 L2385, L2390, L2395, L2397, L2405, L2492, L2755, L2785 L1846 L2385, L2390, L2395, L2397, L2405, L2415, L2492, L2755, L2785, L2795, L2800 L1860 None The following table lists addition codes which describe components or features that can be physically incorporated in the specified custom fabricated base orthosis but are considered not reasonable and necessary. These addition codes, if they are billed with the related base code, will be denied as not reasonable and necessary. Base Code Addition Codes - Not Reasonable and Necessary L1834 L2397, L2800 L1840 L2275, L2800 L1844 None L1846 None L1860 L2397 Refer to the related Policy Article for information on addition codes that are considered not separately payable or incompatible with custom fabricated knee orthosis base codes. MISCELLANEOUS: Heavy duty knee joint codes (L2385, L2395) are covered only for beneficiaries who weigh more than 300 pounds. Coverage of a removable soft interface (K0672) is limited to a maximum of two (2) per year beginning one (1) year after the date of service for initial issuance of the orthosis. Additional replacement interfaces will be denied as not reasonable and necessary. Refer to the Coding Guidelines section in the LCD related Policy Article for information on denial of removable soft interfaces that are billed separately at the time of initial issue of the orthosis. Concentric adjustable torsion style mechanisms used to assist knee joint extension are coded as L2999 and are covered for beneficiaries who require knee extension assist in the absence of any co-existing joint contracture. Concentric adjustable torsion style mechanisms used for the treatment of contractures, regardless of any co-existing condition(s), are coded as E1810, E1813, and/or E1814 and are covered under the Durable Medical Equipment benefit ( refer to the CODING GUIDELINES section in the LCD-related Policy Article ). Claims for devices incorporating concentric adjustable torsion style mechanisms used for the treatment of any joint contracture and coded as L2999 will be denied as incorrect coding. GENERAL A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary. For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section. For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary. An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded. Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.