Medicare AFO Height Requirement Rescinded

As expected, the height requirement for an AFO is being removed by medicare.

Let’s get on with helping people walk!

Below is the text from the Medicare website:

February 6, 2013

Ankle-Foot Orthoses/Knee-Ankle-Foot Orthoses LCD related Policy Article – Revised
The related Policy Article for the Ankle-Foot Orthosis/Knee-Ankle-Foot Orthosis is being revised. The Policy Article with an effective date of January 1, 2013 included Coding Guidelines for AFOs that included a height requirement. The height requirement is being removed. The effective date for the revised Policy Article is for dates of service on or after January 1, 2013.

See for yourself here:
http://www.cgsmedicare.com/jc/pubs/news/2013/0213/cope21209.html

Again, the only type of AFO that requires a PDAC Coding verification letter is the L1906. Insightful does not use that code for any of its current bracing. To verify this for yourself, please see the PDAC website listing those that are required. The link to this page is below.

https://www.dmepdac.com/review/items_requiring_coding_verification_reviews.html

Finally, keep in mind that the pretibial shell that has been offered by our competitors is essentially a custom shin guard, the argument that this provides axially unloading as medical justification is risky in our opinion.

New Medial Upright Extension

Insightful Products responds to the new 2013 Medicare Height requirement with an adjustable medial extension that allows the practitioner the ability to remove and relocate the extension to the preferred height.

Some of our competitors have suggested additional brace add-ons that also provide additional Lcodes to solve this new height requirement. These additional Lcodes must still meet the threshold of “Medical Necessity”. For instance, a pre-tibial shell is medically needed for distribution of pressure from a floor reaction, anterior stop or solid ankle design. Free motion articulated designs, by definition, do not necessitate a pre-tibial shell. Our add-on solution does not change the well established LCode descriptors and provides some additional medial/lateral stability.

PDAC letters obtained before the rule change do not necessarily make AFOs comply with the current height requirements.