A lot of times insurance requirements begin with Medicare/Medicare Replacement plan rules. Typically when Medicare comes up with a way to limit usage by requiring a lot of documentation, the private insurers pick up these rules for their own policies as well.
When it comes to proper documentation for AFO and KAFO devices a patient must first have a face to face visit with their doctor. This visit must be documented in the medical progress notes and all of the following criteria are met:
For a prefabricated AFO only:
The beneficiary is ambulatory
The beneficiary has a weakness or deformity of the foot and ankle
The beneficiary requires stabilization of the foot and ankle for medical reasons
The beneficiary has the potential to benefit functionally from the use of an AFO
For a custom made AFO, all of the above plus one of the following to support medical necessity:
The beneficiary could not be fit with a prefabricated orthosis
The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months)
There is a need to control the knee, ankle or foot in more than one plane
The beneficiary has documented neurological, circulatory or orthopedic status that requires custom fabricating to prevent tissue injury
The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions
For a custom made KAFO, all of the above coverage criteria are met and
Additional knee stability is required and documented in the medical pross notes
Hopefully this post is helpful, the information is very specific to dictate to the insurance company the medical necessity of these devices.
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