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HealthPartners

Coverage criteria policies

Orthotics / braces / shoes

These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Prior authorization is not required for orthotics or braces.

Prior authorization is not applicable for a microprocessor/ electronic/ electromagnetic stance controlled orthotic.

Prior authorization is not required for custom molded or stock orthopedic shoes.

Coverage

Orthotics, braces, and custom molded or stock orthopedic shoes are generally covered subject to the indications listed below and per your plan documents.

A microprocessor/ electronic/ electromagnetic stance controlled orthotic is considered investigational/ experimental and is therefore not covered.

Indications that are covered

Orthotics
  1. Foot Orthotics (sometimes referred to as inserts) are covered only when custom-molded (formed or molded to patient model). Covered for treatment of affected area only. Limited to one or one pair per 12 month period, unless replacement is needed either to accommodate growth requirements, or when needed due to changes in medical condition which affect the fit and/or function of the orthotic.
  2. Foot orthotics ordered for individuals diagnosed with diabetes and who have a history of foot amputation, ulceration, pre-ulcerative calluses, peripheral neuropathy with evidence of callus formation, deformity or poor circulation will have coverage for three pair of custom-molded per 12 month period.
Braces
  1. Braces that are off-the-shelf prefabricated, pre-molded or custom-molded will be covered as long as they are rigid or semi-rigid. Elastic supports with stays or condylar pads are considered semi-rigid. Supports, braces or sleeves made entirely of elastic are not covered.
  2. Brace adjustments, repairs or replacements are covered:
    1. To accommodate growth requirements;
    2. Due to changes in medical condition which affect the fit and/or function of the device.
    3. For individuals who are dependent on their device for constant/continuous support in order to carry out all activities of daily living.
  3. Finger/ ring splints meet the definition of a brace and are covered.
Shoes
  1. Custom molded shoes, one or one pair of shoes, are covered every 12 months only when an orthotist determines that the individual’s medical condition cannot be met with stock orthopedic shoes.
  2. Stock orthopedic shoes (such as depth shoes), one or one pair of shoes, are covered every 12 months only for the following:
    1. When attached to a leg brace; or
    2. Member has a diagnosis of diabetes with a history of foot amputation, ulcers, pre-ulcerative calluses, peripheral neuropathy with evidence of callus formation, deformity or poor circulation.
  3. Corrective shoes are only covered for children up to their second birth date and are limited to 2 pair every 12 months.
  4. Shoe adaptations / modifications are custom-made items and are covered when attached to a shoe. They are limited to one pair of shoes every 12 months. These include items such as rocker bottoms, metatarsal bars, wedges, and lift elevation or heels.

Indications that are not covered

  1. Foot orthotics / arch supports which are off-the-shelf, adjusted, modified, pre molded or prefabricated.
  2. Supports, braces, or sleeves made entirely of elastic are not considered rigid or semi-rigid and therefore are not covered.
  3. Replacements of foot orthotics and/or braces when lost or stolen.
  4. Duplicate and similar items.
  5. Orthotics ordered or provided by a chiropractor are not covered.
  6. A microprocessor/ electronic/ electromagnetic stance controlled orthotic (i.e. Ottobock Sensor Walk™, Ottobock E-MAG Active™, Becker 9001 E-knee™, Ottobock C-Brace™) is not covered as it is considered investigational/experimental. There is insufficient reliable evidence to establish the safety and efficacy of these devices or their effect on health outcomes.

Definitions

An orthotic is a brace or an external device made for a specific joint on the body. An orthotic can increase or decrease motion, or support a diseased or injured body segment. The following are examples of orthotics: KAFO (Knee Ankle Foot Orthotic), TLSO (Thoracic Lumbar Sacral Orthotic), AFO (Ankle Foot Orthotic), HKAFO (Hip Knee Ankle Foot Orthotic), WHO (Wrist Hand Orthotic), KO (Knee Orthotic), FO (Foot Orthotic).

Microprocessor/ electronic/ electromagnetic stance controlled orthotics –

The Becker E-Knee™ (Becker Orthopedic) is a foot force activated, computer controlled, electromechanical orthotic knee joint. An adjustable pressure sensitive footplate signals the microprocessor to lock the knee joint when pressure is applied and to unlock the knee joint in the absence of pressure. The E-Knee™ comes equipped with a free motion joint for the medial side.

The C-Brace™ (Ottobock) is a microprocessor stance and swing control knee ankle foot orthosis (MP-SSCO). It is microprocessor designed with a carbon fiber strut with integrated ankle controlled moment sensor and a monocentric microprocessor-controlled knee joint. A knee angle sensor provides feedback on knee angle and knee angle velocity. Extension and flexion damping are adjusted at a frequency of 50 Hz by a microprocessor with the ankle moment, the knee angle, the knee angle velocity, and the temperature of the hydraulic as input signals. Each C-Brace is custom made and designed for specific indications. The C-Brace is the next generation of the Sensor Walk™.

The E-MAG Active™ (Ottobock) is a stance control KAFO that is calibrated to the patient’s step length. It can also be recalibrated if the patient’s step length changes over time. The stance control function will remain locked during weight bearing, then unlock for swing phase. It simplifies gait training and allows for varied cadence. A gyroscope built into the KAFO monitors the patient’s step length. During the fitting process, the E-MAG Active’s calibrating feature allows it to recognize the patient’s gait pattern.

Shoes –

Custom molded orthopedic shoes are custom molded (fabricated) according to an individual’s specifications.

Stock orthopedic shoe(s) and corrective shoes are off the shelf items and are not custom molded according to a person's individual specifications. Depth shoes (shoes that are deeper to accommodate inserts) are an example.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy contact Member Services at 952-883-7979 or 1-800-233-9645.

Vendor

  • Item is received from an orthotic vendor.
    • Orthotic vendors provide devices such as braces, foot orthotics, splints and orthopedic shoes.
    • A contracted clinic or specialist may also provide some orthotic devices.

References

  1. Bernhardt, K., Oh, T., & Kaufman, K. (2011). Stance control orthosis trial in patients with inclusion body myositis. Prosthetics and Orthotics International, 35(1), 39–44.
  2. Busch, K., & Chantelau, E. (2003). Effectiveness of a new brand of stock `diabetic' shoes to protect against diabetic foot ulcer relapse. A prospective cohort study. Diabetic Medicine, 20, 665-669.
  3. Davis, P. C., Bach, T. M., & Pereira, D .M. (2010). The effect of stance control orthoses on gait characteristics and energy expenditure in knee-ankle-foot orthosis users. Prosthetics and Orthotics International, 34(2), 206-215.
  4. ECRI Institute. (2013). Wearable powered exoskeleton use after spinal cord injury. Plymouth Meeting, PA: ECRI Institute.
  5. Hebert, J. S., & Liggins, A. B. (2005). Gait evaluation of an automatic stance-control knee orthosis in a patient with
  6. Archives of Physical Medicine and Rehabilitation, 86(8), 676-80.
  7. Irby, S. E., Bernhardt, K. A., & Kaufman, K. R. (2005). Gait of stance control orthosis users: the dynamic knee brace system. Prosthetics and Orthotics International, 29(3), 269-82.
  8. Irby, S. E., Bernhardt, K. A., & Kaufman, K. R. (2007). Gait changes over time in stance control orthosis users. Prosthetics and Orthotics International, 31(4), 353-61.
  9. Minnesota Health Care Programs (MHCP) Provider Manual: Orthotics. Revised 9-13-2012.
  10. Yakamovich, T., Lemaire, E. D., & Kofman, J. (2006). Preliminary kinematic evaluation of a new stance-control knee–ankle–foot orthosis. Clinical Biomechanics, 21(10), 1081-9.
  11. Zijlstra, T. R., Heijnsdijk-Rouwenhorst, L., & Rasker, J. J. (2004). Silver ring splints improve dexterity in patients with rheumatoid arthritis. Arthritis & Rheumatism (Arthritis Care & Research), 51(6), 947–951.
  12. Zissimopoulos, A., Fatone, S., & Gard, S. A. (2007). Biomechanical and energetic effects of a stance-control orthotic knee joint. Journal of Rehabilitation Research & Development, 44(4), 503-51.

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Policy activity

  • 01/01/1999 - Date of origin
  • 07/01/2017 - Effective date
Review date
  • 06/2017
Revision date
  • 06/23/2017

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