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The rules say that plans must pay for a medical service or item if regular Medicare would pay for it in this case.
You can find this rule at 42 Code of Federal Regulations (CFR) Section 422.101.
The rules state that A knee flexion contracture is a condition in which there is shortening of the muscles and/or
tendons with the resulting inability to bring the knee to 0 degrees extension or greater (i.e., hyperextension) by
passive range of motion. (0 degrees knee extension is when the femur and tibia are in alignment in a horizontal
plane). A knee extension contracture is a condition in which there is shortening of the muscles and/or tendons
with the resulting inability to bring the knee to 80 degrees flexion or greater by passive range of motion. A
contracture is distinguished from the temporary loss of range of motion of a joint following injury, surgery,
casting, or other immobilization.
A knee orthosis with joints (L1810, L1812) or knee orthosis with condylar pads and joints with or without
patellar control (L1820) are covered for ambulatory beneficiaries who have weakness or deformity of the knee
and require stabilization.
If an L1810, L1812 or L1820 is provided but the criteria above are not met, the orthosis will be denied as not
reasonable and necessary.
A knee orthosis with a locking knee joint (L1831) or a rigid knee orthosis (L1836) is covered for beneficiaries
with flexion or extension contractures of the knee with movement on passive range of motion testing of at least
10 degrees (i.e., a nonfixed contracture) (refer to the Group 1 ICD-10 Codes in the LCD-related Policy Article).
If an L1831 or L1836 orthosis is provided but the criterion above is not met, the orthosis will be denied as not
reasonable and necessary.
There is no proven clinical benefit to the inflatable air bladder incorporated into the design of code L1847 or
L1848; therefore, claims for code L1847 or L1848 will be denied as not reasonable and necessary.
A knee immobilizer without joints (L1830), or a knee orthosis with adjustable knee joints (L1832, L1833), or a
knee orthosis, with an adjustable flexion and extension joint that provides both medial-lateral and rotation
control (L1843, L1845, L1851, L1852), are covered if the beneficiary has had recent injury to or a surgical
procedure on the knee(s). Refer to the diagnoses listed in the Groups 2 or 4 ICD-10 Codes in the LCD-related
Policy Article.
Knee orthoses L1832, L1833, L1843, L1845, L1851 and L1852 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.
A knee orthosis, Swedish type, prefabricated (L1850) is covered for a beneficiary who is ambulatory and has
knee instability due to genu recurvatum - hyperextended knee, congenital or acquired (refer to the Group 5
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).
Claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and
necessary when the beneficiary does not meet the above criteria for coverage. For example, they will be denied
if only pain or a subjective description of joint instability is documented.
You can find more information at Local Coverage Determination (LCD): Knee Orthoses (L33318).
If you want to read these Medicare rules, you can go to this website www.medicareappeal.com.
The Plan contract says that the Plan covers items and services in accordance with Medicare rules.