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2.7.2.2.2 Lower-Limb Orthoses
Lower-limb orthoses include, but are not limited to, hip orthoses (HO), Legg Perthes orthoses, knee orthoses (KO), ankle-foot orthoses (AFO), knee-ankle-foot orthoses (KAFO), hip-knee-ankle-foot orthoses (HKAFO), fracture orthoses, and reciprocating gait orthoses (RGO).
In addition to the general indication requirements, lower-limb orthoses will be considered for prior authorization with documentation of the following criteria for specific orthotic devices:
Ankle-Foot Orthoses (AFO)
AFOs used during ambulation will be considered for prior authorization for clients with documentation of all of the following:
• Weakness or deformity of the foot and ankle.
•A need for stabilization for medical reasons.
•Anticipated improvement in functioning during activities of daily living (ADLs) with use of the device.
AFOs not used during ambulation (static AFO) will be considered for prior authorization for clients with documentation of one of the following conditions:
•Plantar fasciitis.
•Plantar flexion contracture of the ankle, with additional documentation that includes all of the following:
•Dorsiflexion on pretreatment passive range of motion testing is at least ten degrees.
•The contracture is interfering or is expected to interfere significantly with the client's functioning during ADLs.
•The AFO will be used as a component of a physician-prescribed therapy plan care, which includes active stretching of the involved muscles or tendons.
•There is reasonable expectation that the AFO will correct the contracture.
Knee-Ankle-Foot Orthoses (KAFO)
KAFOs used during ambulation will be considered for prior authorization for clients with documentation that supports medical necessity for additional knee stabilization.
KAFOs that are custom-fabricated (molded-to-patient model) for ambulation will be considered for prior authorization when at least one of the following criteria is met:
•The client cannot be fit with a prefabricated AFO/KAFO.
•The condition that necessitates the orthosis is expected to be permanent or of long-standing duration (more than six months).
•There is a need to control the knee, ankle, or foot in more than one plane.
•The client has a documented neurological, circulatory, or orthopedic status that requires custom fabrication to prevent tissue injury.
•The client has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.
Reciprocating Gait Orthoses (RGO)
Reciprocating gait orthoses will be considered for prior authorization for clients with spina bifida or similar functional disabilities.
The prior authorization request must include a statement from the prescribing physician that indicates medical necessity for the RGO, the physical therapy treatment plan, and documentation that the client/family is willing to comply with the treatment plan.
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