I. Ankle and Foot Orthotics: (AFO) are considered medical necessary when One or more of the following are met:

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1 Moda Health Plan, Inc. Medical Necessity Criteria Subject: Origination Date: 05/2015 Revision Date(s): Developed By: Medical Criteria Committee Effective 07/01/2015 Ankle-Foot Orthotics (AFO) Page 1 of 14 Approved: Mary Engrav, MD Date: 06/24/2015 Description: An ankle-foot orthosis (AFO) is an orthosis or that can brace that encumbers the ankle and foot. AFOs are externally applied and intended to control position and motion of the ankle, compensate for weakness, or correct deformities. AFOs can be used to support weak limbs, or to position a limb with contracted muscles into a more normal position. They are also used to immobilize the ankle and lower leg in the presence of arthritis or, and to correct foot drop; an AFO is also known as a foot-drop brace. Ankle-foot orthoses are the most commonly used orthoses, making up about 26% of all orthoses provided in the United States.[9] An AFO is generally constructed of lightweight polypropylene-based plastic in the shape of an "L", with the upright portion behind the calf and the lower portion running under the foot. They are attached to the calf with a strap, and are made to fit inside accommodative shoes. The unbroken "L" shape of some designs provides rigidity, while other designs (with a jointed ankle) provide different types of control. There are two types of AFOs. 1. An off-the-shelf or prefabricated AFO matched in size to the end user and the 2. custom manufacture of an individualized AFO from a positive model, obtained from a negative cast or the use of computer-aided imaging, design, and milling designed for use to only accommodate the end user. Criteria: CWQI: HCS-0121 (This criteria is consistent with national and/or regional CMS guidelines for Ankle-Foot Orthosis) I. Ankle and Foot Orthotics: (AFO) are considered medical necessary when One or more of the following are met: a. Ankle orthotics are considered medically necessary when One or more of the following are met: i. Off-the-shelf (OTS) fixed orthotics (L4396,L4397) with One or more of the following: 1. Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a non-fixed contracture) and ALL of the following: 2. Reasonable expectation of the ability to correct the contracture

2 3. Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities 4. Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons 5. Treatment for a plantar flexion contracture must meet ALL of the following: a. The pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record b. There must be documentation of an appropriate stretching program carried out be a professional in a facility or caregiver at home c. The contracture is Not fixed 6. The patient has plantar fasciitis ii. Off-the shelf non-fixed orthotics with ALL of the following: 1. Patient is ambulatory 2. Patient has weakness or deformity of the foot and ankle 3. Stabilization is required for medical reasons 4. Patient has the potential to benefit functionally b. Foot Orthotics are considered medically necessary when ALL of the following criteria are met: i. Arch, heel or other foot pain ii. Foot condition, as indicated by One or more of the following: 1. Juvenile idiopathic arthritis 2. Pes cavus (high arch) 3. Rheumatoid arthritis 4. Plantar fasciitis with ALL of the following; a. Adjustment of activities failed to improve symptoms. b. Anti-inflammatory medications failed to improve symptoms. c. Stretching of calf muscles and plantar surface failed to improve symptoms. d. Symptoms are present for 3 months or more. c. Custom Fabricated AFO are considered medically necessary when ALL of the following criteria are met: i. Custom fabricated orthotics (L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386, L4387 and L4631) are covered when One or more of the following are met: 1. The member could not be fitted with a prefabricated AFO 2. The condition necessitating the orthosis is expected to be permanent or longstanding duration (more than 6 months) 3. Symptoms are present for 3 months or more 4. Documentation indicates neurological, circulatory or orthopedic status requires custom fabricated orthosis to prevent tissue injury d. AFO orthotics Not covered by Medicare for ALL of the following: i. The request for L4396, L4397 and L4392 are not for the sole prevention or treatment of a heel pressure ulcer.

3 ii. The request for L4398 and L4394 is not for the sole prevention or treatment of a pressure ulcer iii. The request is Not for socks (L2840, L2850) for use with the orthotic as they are not covered by Medicare iv. The request is Not for a foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394) as this is not covered by Medicare II. Replacement or Repairs of AFO are considered medically necessary when One or more of the following is met: a. Replacement of a complete orthosis or component of an orthosis due to loss, significant change in the beneficiary s condition, or irreparable accidental damage is covered for ALL of the following: i. The device is still reasonable and necessary ii. The reason for the replacement is documented in the supplier s record iii. The request is NOT for replacement components (e.g., soft interfaces) that are provided on a routine basis without regard to whether the original item is worn out. (L4002, L4392) b. Repairs to a covered orthosis due to wear or to accidental damage are covered when All of the following are met: i. They are necessary to make the orthosis functional ii. The reason for the repair MUST be documented in the supplier's record Medicare Reference: LCD: L142 Ankle-Foot/Knee-Ankle-Foot Orthosis Information to be Submitted with Pre-Authorization Request: 1. Medical records documenting medical necessity 2. Applicable HCPC codes related to orthotic and accessories 3. Documentation of reason for repair or replacement if applicable Applicable CPT/HCPC Codes: HCPC Code L1900 L1902 L1904 L1906 L1907 L1910 Description ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND, CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, ANKLE GAUNTLET, PREFABRICATED, OFF-THE-SHELF ANKLE ORTHOSIS, ANKLE GAUNTLET, CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, OFF-THE-SHELF ANKLE ORTHOSIS, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICATED ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

4 L1920 L1930 L1932 L1940 L1945 L1950 L1951 L1960 L1971 L1980 L1990 L2106 L2108 L2112 L2114 L2116 L2200 L2210 L2220 L2230 L2232 L4350 L4360 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE), CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION), CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOMFABRICATED L1970 ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATED FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (DOUBLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI -RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENT ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), PREFABRICATED, OFF-THE-SHELF WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN

5 L4361 L4386 L4387 L4631 L4392 L4394 L4396 L4397 L4398 L4631 TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM, ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHER MATERIAL, INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATED REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, OFF-THE-SHELF FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, OFF-THE -SHELF ANKLE FOOT ORTHOSIS, WALKING BOOT TYPE, VARUS/VALGUS CORRECTION, ROCKER BOTTOM, ANTERIOR TIBIAL SHELL, SOFT INTERFACE, CUSTOM ARCH SUPPORT, PLASTIC OR OTHER MATERIAL, INCLUDES STRAPS AND CLOSURES, CUSTOM FABRICATED Applicable ICD-9 Codes ICD-9 Code Diagnosis ARTHROPATHY ASSOCIATED WITH NEUROLOGICAL DISORDERS CONTRACTURE OF ANKLE AND FOOT JOINT PLANTAR FASCIAL FIBROMATOSIS Contracture of joint, ankle and foot Other joint derangement, not elsewhere classified, ankle and foot Contracture of tendon (sheath) Plantar fascial fibromatosis Spasm of muscle Other disorder of muscle, ligament, and fascia Pathologic of tibia or fibula Other acquired deformity of ankle and foot

6 824.0 Closed of medial malleolus Open of medial malleolus Closed of lateral malleolus Open of lateral malleolus Closed bimalleolar Open bimalleolar Closed trimalleolar Open trimalleolar Unspecified closed of ankle Closed dislocation of ankle Open dislocation of ankle Unspecified site of ankle sprain and strain Sprain and strain of deltoid (ligament) of ankle Sprain and strain of calcaneofibular (ligament) Sprain and strain of tibiofibular (ligament) Other ankle sprain and strain V15.5 Personal history of injury V54.16 Aftercare for healing traumatic of lower leg V54.26 Aftercare for healing pathologic of lower leg V54.89 Other orthopedic aftercare V58.43 Aftercare following surgery for injury and trauma V58.78 Aftercare following surgery of the musculoskeletal system, NEC Applicable ICD-10 Codes ICD-10 Code Diagnosis A52.16 Charcà t's arthropathy (tabetic) E Diabetes mellitus due to underlying condition with diabetic neuropathic arthropathy E Type 2 diabetes mellitus with diabetic neuropathic arthropathy E Other specified diabetes mellitus with diabetic neuropathic arthropathy M14.60 Charcà t's joint, unspecified site M Charcà t's joint, right ankle and foot M Charcà t's joint, left ankle and foot M Charcà t's joint, unspecified ankle and foot M Contracture, right ankle M Contracture, left ankle M Contracture, unspecified ankle M Contracture, right foot M Contracture, left foot M Contracture, unspecified foot M Disorder of ligament, right ankle M Disorder of ligament, left ankle M Disorder of ligament, unspecified ankle

7 M Disorder of ligament, right foot M Disorder of ligament, left foot M Disorder of ligament, unspecified foot M Contracture of muscle, right ankle and foot M Contracture of muscle, left ankle and foot M Contracture of muscle, unspecified ankle and foot M62.81 Muscle weakness (generalized) M Other specific joint derangements of right ankle, not elsewhere classified M Other specific joint derangements of left ankle, not elsewhere classified M Other specific joint derangements of unspecified ankle, not elsewhere classified M Other specific joint derangements of right foot, not elsewhere classified M Other specific joint derangements left foot, not elsewhere classified M Other specific joint derangements of unspecified foot, not elsewhere classified M Flail joint, right ankle and foot M Flail joint, left ankle and foot M Flail joint, unspecified ankle and foot M Other instability, right ankle M Other instability, left ankle M Other instability, unspecified ankle M Other instability, right foot M Other instability, left foot M Other instability, unspecified foot M67.00 Short Achilles tendon (acquired), unspecified ankle M67.01 Short Achilles tendon (acquired), right ankle M67.02 Short Achilles tendon (acquired), left ankle M72.2 Plantar fascial fibromatosis M80.871A Other osteoporosis with current pathological, right ankle and foot, initial encounter for M80.879A Other osteoporosis with current pathological, unspecified ankle and foot, initial encounter for M80.062A Age-related osteoporosis with current pathological, left lower leg, initial encounter for M80.069A Age-related osteoporosis with current pathological, unspecified lower leg, initial encounter for M80.071A Age-related osteoporosis with current pathological, right ankle and foot, initial encounter for M80.072A Age-related osteoporosis with current pathological, left ankle and foot, initial encounter for M80.079A Age-related osteoporosis with current pathological, unspecified ankle and foot, initial encounter for M84.471A Pathological, right ankle, initial encounter for M84.472A Pathological, left ankle, initial encounter for M84.473A Pathological, unspecified ankle, initial encounter for M84.569A Pathological in neoplastic disease, unspecified tibia and fibula, initial encounter for

8 M84.571A Pathological in neoplastic disease, right ankle, initial encounter for M84.572A Pathological in neoplastic disease, left ankle, initial encounter for M84.573A Pathological in neoplastic disease, unspecified ankle, initial encounter for M84.671A Pathological in other disease, right ankle, initial encounter for M84.672A Pathological in other disease, left ankle, initial encounter for M84.673A Pathological in other disease, unspecified ankle, initial encounter for M Varus deformity, not elsewhere classified, right ankle M Varus deformity, not elsewhere classified, left ankle M Varus deformity, not elsewhere classified, unspecified ankle M Acquired clubfoot, right foot M Acquired clubfoot, left foot M Acquired clubfoot, unspecified foot M21.6X9 Other acquired deformities of unspecified foot M Acquired clubfoot, right foot M Acquired clawfoot, left foot M Acquired clawfoot, unspecified foot S82.51XA Displaced of medial malleolus of right tibia, initial encounter for closed S82.52XA Displaced of medial malleolus of left tibia, initial encounter for closed S82.53XA Displaced of medial malleolus of unspecified tibia, initial encounter for closed S82.54XA Nondisplaced of medial malleolus of right tibia, initial encounter for closed S82.55XA Nondisplaced of medial malleolus of left tibia, initial encounter for closed S82.56XA Nondisplaced of medial malleolus of unspecified tibia, initial encounter for closed S82.871A Displaced pilon of right tibia, initial encounter for closed S82.872A Displaced pilon of left tibia, initial encounter for closed S82.873A Displaced pilon of unspecified tibia, initial encounter for closed S82.874A Nondisplaced pilon of right tibia, initial encounter for closed S82.875A Nondisplaced pilon of left tibia, initial encounter for closed S82.876A Nondisplaced pilon of unspecified tibia, initial encounter for closed S82.51XB Displaced of medial malleolus of right tibia, initial encounter for open S82.51XC Displaced of medial malleolus of right tibia, initial encounter for open S82.52XB Displaced of medial malleolus of left tibia, initial encounter for open type I or II S82.52XC Displaced of medial malleolus of left tibia, initial encounter for open type S82.53XB Displaced of medial malleolus of unspecified tibia, initial encounter for open S82.53XC Displaced of medial malleolus of unspecified tibia, initial encounter for open

9 S82.54XB S82.54XC S82.55XB S82.55XC S82.56XB S82.56XC S82.871B S82.871C S82.872B S82.872C S82.873B S82.873C S82.874B S82.874C S82.875B S82.876B S82.876C S82.61XA S82.62XA S82.63XA S82.64XA S82.65XA S82.66XA S82.61XB S82.61XC S82.62XB S82.62XC Nondisplaced of medial malleolus of right tibia, initial encounter for open Nondisplaced of medial malleolus of right tibia, initial encounter for open Nondisplaced of medial malleolus of left tibia, initial encounter for open Nondisplaced of medial malleolus of left tibia, initial encounter for open Nondisplaced of medial malleolus of unspecified tibia, initial encounter for open Nondisplaced of medial malleolus of unspecified tibia, initial encounter for open Displaced pilon of right tibia, initial encounter for open Displaced pilon of right tibia, initial encounter for open type IIIA, IIIB, or IIIC Displaced pilon of left tibia, initial encounter for open Displaced pilon of left tibia, initial encounter for open Displaced pilon of unspecified tibia, initial encounter for open Displaced pilon of unspecified tibia, initial encounter for open type IIIA, IIIB, or IIIC Nondisplaced pilon of right tibia, initial encounter for open Nondisplaced pilon of right tibia, initial encounter for open type IIIA, IIIB, or IIIC Nondisplaced pilon of left tibia, initial encounter for open Nondisplaced pilon of unspecified tibia, initial encounter for open type I or II Nondisplaced pilon of unspecified tibia, initial encounter for open type Displaced of lateral malleolus of right fibula, initial encounter for closed Displaced of lateral malleolus of left fibula, initial encounter for closed Displaced of lateral malleolus of unspecified fibula, initial encounter for closed Nondisplaced of lateral malleolus of right fibula, initial encounter for closed Nondisplaced of lateral malleolus of left fibula, initial encounter for closed Nondisplaced of lateral malleolus of unspecified fibula, initial encounter for closed Displaced of lateral malleolus of right fibula, initial encounter for open Displaced of lateral malleolus of right fibula, initial encounter for open Displaced of lateral malleolus of left fibula, initial encounter for open type I or II Displaced of lateral malleolus of left fibula, initial encounter for open type

10 S82.63XB S82.63XC S82.64XB S82.64XC S82.65XB S82.65XC S82.66XB S82.66XC S82.841A S82.842A S82.843A S82.844A S82.845A S82.846A S82.841B S82.841C S82.842B S82.842C S82.843B S82.843C S82.844B S82.844C S82.845B S82.845C S82.846B Displaced of lateral malleolus of unspecified fibula, initial encounter for open Displaced of lateral malleolus of unspecified fibula, initial encounter for open Nondisplaced of lateral malleolus of right fibula, initial encounter for open Nondisplaced of lateral malleolus of right fibula, initial encounter for open Nondisplaced of lateral malleolus of left fibula, initial encounter for open Nondisplaced of lateral malleolus of left fibula, initial encounter for open Nondisplaced of lateral malleolus of unspecified fibula, initial encounter for open Nondisplaced of lateral malleolus of unspecified fibula, initial encounter for open Displaced bimalleolar of right lower leg, initial encounter for closed Displaced bimalleolar of left lower leg, initial encounter for closed Displaced bimalleolar of unspecified lower leg, initial encounter for closed Nondisplaced bimalleolar of right lower leg, initial encounter for closed Nondisplaced bimalleolar of left lower leg, initial encounter for closed Nondisplaced bimalleolar of unspecified lower leg, initial encounter for closed Displaced bimalleolar of right lower leg, initial encounter for open type I or II Displaced bimalleolar of right lower leg, initial encounter for open type Displaced bimalleolar of left lower leg, initial encounter for open type I or II Displaced bimalleolar of left lower leg, initial encounter for open type IIIA, IIIB, or IIIC Displaced bimalleolar of unspecified lower leg, initial encounter for open Displaced bimalleolar of unspecified lower leg, initial encounter for open Nondisplaced bimalleolar of right lower leg, initial encounter for open Nondisplaced bimalleolar of right lower leg, initial encounter for open Nondisplaced bimalleolar of left lower leg, initial encounter for open type I or II Nondisplaced bimalleolar of left lower leg, initial encounter for open type Nondisplaced bimalleolar of unspecified lower leg, initial encounter for open

11 S82.846C S82.851A S82.852A S82.853A S82.854A S82.855A S82.856A S82.851B S82.851C S82.852B S82.852C S82.853B S82.853C S82.854B S82.854C S82.855B S82.855C S82.856B S82.856C S82.301A S82.302A S82.309A S82.391A S82.392A S82.399A S82.891A S82.892A S82.899A S89.101A S89.102A Nondisplaced bimalleolar of unspecified lower leg, initial encounter for open Displaced trimalleolar of right lower leg, initial encounter for closed Displaced trimalleolar of left lower leg, initial encounter for closed Displaced trimalleolar of unspecified lower leg, initial encounter for closed Nondisplaced trimalleolar of right lower leg, initial encounter for closed Nondisplaced trimalleolar of left lower leg, initial encounter for closed Nondisplaced trimalleolar of unspecified lower leg, initial encounter for closed Displaced trimalleolar of right lower leg, initial encounter for open type I or II Displaced trimalleolar of right lower leg, initial encounter for open type Displaced trimalleolar of left lower leg, initial encounter for open type I or II Displaced trimalleolar of left lower leg, initial encounter for open type Displaced trimalleolar of unspecified lower leg, initial encounter for open Displaced trimalleolar of unspecified lower leg, initial encounter for open Nondisplaced trimalleolar of right lower leg, initial encounter for open Nondisplaced trimalleolar of right lower leg, initial encounter for open Nondisplaced trimalleolar of left lower leg, initial encounter for open type I or II Nondisplaced trimalleolar of left lower leg, initial encounter for open type Nondisplaced trimalleolar of unspecified lower leg, initial encounter for open Nondisplaced trimalleolar of unspecified lower leg, initial encounter for open Unspecified of lower end of right tibia, initial encounter for closed Unspecified of lower end of left tibia, initial encounter for closed Unspecified of lower end of unspecified tibia, initial encounter for closed Other of lower end of right tibia, initial encounter for closed Other of lower end of left tibia, initial encounter for closed Other of lower end of unspecified tibia, initial encounter for closed Other of right lower leg, initial encounter for closed Other of left lower leg, initial encounter for closed Other of unspecified lower leg, initial encounter for closed Unspecified physeal of lower end of right tibia, initial encounter for closed Unspecified physeal of lower end of left tibia, initial encounter for closed

12 S89.109A S89.111A S89.112A S89.119A S89.121A S89.122A S89.129A S89.131A S89.132A S89.139A S89.141A S89.142A S89.149A S89.191A S89.192A S89.199A S89.301A S89.302A S89.309A S89.311A S89.312A S89.319A S89.321A S89.322A Unspecified physeal of lower end of unspecified tibia, initial encounter for closed Salter-Harris Type I physeal of lower end of right tibia, initial encounter for closed Salter-Harris Type I physeal of lower end of left tibia, initial encounter for closed Salter-Harris Type I physeal of lower end of unspecified tibia, initial encounter for closed Salter-Harris Type II physeal of lower end of right tibia, initial encounter for closed Salter-Harris Type II physeal of lower end of left tibia, initial encounter for closed Salter-Harris Type II physeal of lower end of unspecified tibia, initial encounter for closed Salter-Harris Type III physeal of lower end of right tibia, initial encounter for closed Salter-Harris Type III physeal of lower end of left tibia, initial encounter for closed Salter-Harris Type III physeal of lower end of unspecified tibia, initial encounter for closed Salter-Harris Type IV physeal of lower end of right tibia, initial encounter for closed Salter-Harris Type IV physeal of lower end of left tibia, initial encounter for closed Salter-Harris Type IV physeal of lower end of unspecified tibia, initial encounter for closed Other physeal of lower end of right tibia, initial encounter for closed Other physeal of lower end of left tibia, initial encounter for closed Other physeal of lower end of unspecified tibia, initial encounter for closed Unspecified physeal of lower end of right fibula, initial encounter for closed Unspecified physeal of lower end of left fibula, initial encounter for closed Unspecified physeal of lower end of unspecified fibula, initial encounter for closed Salter-Harris Type I physeal of lower end of right fibula, initial encounter for closed Salter-Harris Type I physeal of lower end of left fibula, initial encounter for closed Salter-Harris Type I physeal of lower end of unspecified fibula, initial encounter for closed Salter-Harris Type II physeal of lower end of right fibula, initial encounter for closed Salter-Harris Type II physeal of lower end of left fibula, initial encounter for closed

13 S89.329A S89.391A S89.392A S89.399A S93.01XA S93.02XA S93.03XA S93.04XA S93.05XA S93.06XA S93.401A S93.402A S93.409A S96.919A S93.421A S93.422A S93.429A S93.411A S93.412A S93.419A S93.431A S93.432A S93.439A S86.011A S86.012A S86.019A S93.491A S93.492A S93.499A S96.011A S96.012A S96.019A S96.111A S96.112A S96.119A Salter-Harris Type II physeal of lower end of unspecified fibula, initial encounter for closed Other physeal of lower end of right fibula, initial encounter for closed Other physeal of lower end of left fibula, initial encounter for closed Other physeal of lower end of unspecified fibula, initial encounter for closed Subluxation of right ankle joint, initial encounter Subluxation of left ankle joint, initial encounter Subluxation of unspecified ankle joint, initial encounter Dislocation of right ankle joint, initial encounter Dislocation of left ankle joint, initial encounter Dislocation of unspecified ankle joint, initial encounter Sprain of unspecified ligament of right ankle, initial encounter Sprain of unspecified ligament of left ankle, initial encounter Sprain of unspecified ligament of unspecified ankle, initial encounter Strain of unspecified muscle and tendon at ankle and foot level, unspecified foot, initial encounter Sprain of deltoid ligament of right ankle, initial encounter Sprain of deltoid ligament of left ankle, initial encounter Sprain of deltoid ligament of unspecified ankle, initial encounter Sprain of calcaneofibular ligament of right ankle, initial encounter Sprain of calcaneofibular ligament of left ankle, initial encounter Sprain of calcaneofibular ligament of unspecified ankle, initial encounter Sprain of tibiofibular ligament of right ankle, initial encounter Sprain of tibiofibular ligament of left ankle, initial encounter Sprain of tibiofibular ligament of unspecified ankle, initial encounter Strain of right Achilles tendon, initial encounter Strain of left Achilles tendon, initial encounter Strain of unspecified Achilles tendon, initial encounter Sprain of other ligament of right ankle, initial encounter Sprain of other ligament of left ankle, initial encounter Sprain of other ligament of unspecified ankle, initial encounter Strain of muscle and tendon of long flexor muscle of toe at ankle and foot level, right foot, initial encounter Strain of muscle and tendon of long flexor muscle of toe at ankle and foot level, left foot, initial encounter Strain of muscle and tendon of long flexor muscle of toe at ankle and foot level, unspecified foot, initial encounter Strain of muscle and tendon of long extensor muscle of toe at ankle and foot level, right foot, initial encounter Strain of muscle and tendon of long extensor muscle of toe at ankle and foot level, left foot, initial encounter Strain of muscle and tendon of long extensor muscle of toe at ankle and foot level, unspecified foot, initial encounter

14 S96.211A S96.212A S96.219A S96.811A S96.812A S96.819A S96.911A S96.912A Strain of intrinsic muscle and tendon at ankle and foot level, right foot, initial encounter Strain of intrinsic muscle and tendon at ankle and foot level, left foot, initial encounter Strain of intrinsic muscle and tendon at ankle and foot level, unspecified foot, initial encounter Strain of other specified muscles and tendons at ankle and foot level, right foot, initial encounter Strain of other specified muscles and tendons at ankle and foot level, left foot, initial encounter Strain of other specified muscles and tendons at ankle and foot level, unspecified foot, initial encounter Strain of unspecified muscle and tendon at ankle and foot level, right foot, initial encounter Strain of unspecified muscle and tendon at ankle and foot level, left foot, initial encounter Review Date Revisions Effective Date 05/2015 New criteria includes Medicare and CWQI criteria 07/01/2015 References: CMS Centers for Medicare & Medicaid Services; LCD (L142) Ankle-Foot/Knee-Ankle-Foot Orthosis; Noridian Healthcare Solutions, LLC; Original Effective Date 10/01/1993; Revision Effective Date; 05/01/2015; Centers for Medicare & Medicaid Services, National Coverage Determination (NCD) for Durable Medical Equipment Reference List (280.1); Publication Number 100-3, Manual Section Number 280.1, Version 2; Effective Date 5/5/2005; Implementation Date 7/5/2005 Oandp.com; Your Resource for Orthotics & Prosthetics Information; Crow Boot L-Codes; Jim Marshall June 29, 2011 Physician Advisers