CGS and Noridian, the Durable Medical Equipment Medicare Administrative Contractors, updated the Dear Physician letter for AFOs and KAFOs.
The letter describes coverage requirements, as well as the necessary medical necessity documentation for AFOs not used during ambulation, AFOs and KAFOs used during ambulation, and custom-fabricated AFOs and KAFOs.
The coverage requirements read as follows:
Ankle-foot orthoses and KAFOs are covered under the Medicare braces benefit (Social Security Act §1861(s)(9)). For coverage under this benefit, the orthosis must:
- be a rigid or semi-rigid device; and
- be used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.
Items that are not sufficiently rigid to be capable of providing the necessary immobilization or support to the body part for which it is designed do not meet the statutory definition of the braces benefit. Items that do not meet the definition of a brace are statutorily noncovered, no benefit.
To read the revised letter, visit the CGS website.
