Ankle foot orthoses (AFO), plastic or metal

Foot anomalies, cerebral palsy, hemiplegia, spina bifida, club foot, arthrogryposis, and arthropathy associated with extremity conditions

Dynamic splints

Case-by-case basis using the following criteria to be submitted by the physician:

•The client's condition to be treated with the dynamic splint.

•The client's current course of therapy to date, for the condition to be treated.

•The rationale for the use of the dynamic splint at this time, including:

a. Quality of care considerations such as improved outcome

b. Potential cost-effectiveness

•The likelihood that the family/client will comply with the use of the dynamic splint

Foot orthoses

Foot anomalies, tibial torsion, club foot, varus deformities of feet, cerebral palsy, spina bifida, arthrogyposis, and arthritic conditions. Medical justification is needed for valgus deformity of the feet

Hip knee ankle foot orthoses (HKAFO) and knee ankle foot orthoses (KAFO)

Spina bifida, cerebral palsy, paraplegia, late effects of cerebrovascular accident (CVA), spinal cord lesions, arthrogryposis, club foot, varus deformities of feet, genu varus and genu valgus if due to growth deformity, and arthropathy associated with hematological disorder

Hip orthoses (HO)

Dislocated hip, cerebral palsy, spina bifida, and congenital deformities of the hip

Inhibitive casting

Cerebral palsy or any central nervous system deficit resulting in increased muscle tone in the extremities

Knee orthoses (KO), knee immobilizer

Arthropathy associated with hematological disorders related to lower extremity conditions

Protective helmets

Neoplasms of the brain, subarachnoid hemorrhage, subdural hemorrhage, hemophilia, epilepsy (if not well controlled), and cerebral palsy (severe)

Reciprocating gait orthoses (RGOs)

RGOs may be a benefit for children with spina bifida or similar functional disabilities

Authorization requests must include a statement from the prescribing physician indicating the medical necessity, such as:

•A PT plan

•A statement that the family is expected to comply with the treatment plan

Removable shoe insert, UCB (University of California at Berkeley) type

Case-by-case basis using one of the following criteria to be submitted by the physician:

•Client must have a valgus deformity and significant congenital pes planus (75461), which is symptomatic for pain

•Client may have a structural problem that results in significant pes planus

•Client may have an acute plantar fasciitis

•Client may have a diagnosis of hemophilia

Spinal orthoses (SO), collars, corsets, and body jackets (TLSO, LSO, and LLSO)

Scoliosis, spinal injuries, paraplegia, kyphosis, neurofibromatosis, cerebral palsy, spina bifida, and spinal tumor

Thoracic-hip, knee, and ankle orthoses (THKAO), parapodium, and swivel walker

Spina bifida, spinal injuries, spinal tumor, cerebral palsy, and paraplegia

Upper extremity orthoses, shoulder, elbow, wrist, hand, finger, and mobile arm support

Cerebral palsy, spinal cord injury, brachial plexus lesions, nerve lesions, paralysis, juvenile rheumatoid arthritis, and reduction deformities