Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve a knee orthosis (code L1843). 
 
You asked the Plan to pre-approve a knee orthosis (code L1843). You say that the patient has bilateral knee 
pain due to osteoarthritis, history of knee injections, bilateral knee x-rays show severe tri-compartmental 
osteoarthritis and reports routine falling due to instability in the knee causing minor injuries. The Plan denied 
your request. The Plan says that a corticosteroid steroid injection of the left knee was performed in January 
2023. You have not done physical therapy, previously ordered by your provider. Your provider notes do not 
show objective findings of knee joint deformity, laxity or a knee examination. 
 
The Plan follows Medicare rules. Medicare rules say that a knee orthosis (code L1843) is covered when the 
criteria listed in the Medicare rules section of this decision are met. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve a knee orthosis (code L1843). Our 
reviewer says that the requested knee orthosis (code L1843) is considered medically necessary in this case. Our 
physician reviewer found that per the Medicare LCD, L33318, Knee orthoses L1843 are also covered for a 
beneficiary who is ambulatory and has knee instability due to a condition specified in the Group 4 ICD-10 
codes in the LCD-related Policy Article. For codes L1832, L1833, L1843, L1845, L1850, L1851 and L1852, 
knee instability must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test). The examples of joint laxity given above, 
caused by specific ligament damage, are just that, examples only. They are not an exhaustive list of all possible 
exams that can be considered sufficient to provide coverage for knee braces. Knee arthritis generally, and the 
enrollees ICD-10 code, M17.32, specifically, is listed among the Group 4 codes referred to in the LCD. 
Therefore, it is Medicares intention to permit coverage of knee orthoses to treat the cartilaginous damage 
caused by osteoarthritis (OA) on its own without requiring enrollees to have OA and some other form of 
ligamentous knee injury/instability in addition. As such objective descriptions of joint laxity inherent to knee 
OA necessarily must include tests for internal, cartilaginous knee compartment damage which cause the knee 
to be unstable when walking, and those exam findings are sufficient on their own to justify coverage. This 
enrollee has documented positive OA confirmed by x-ray in the left knee to substantiate the subjective history 
documented.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a knee orthosis (code L1843) have been met. Therefore, we decided that the 
Plan has to pre-approve a knee orthosis (code L1843).  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.