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Issue Number - Name
0107-Custom Fabricated Knee Orthoses:Medical Necessity
Review Type
Claim Type
DME by Supplier, DME by Physician
Region and State
All States
Date Approved


Claims for Custom Fabricated Knee Orthoses that do not meet indications of coverage and/or medical necessity outlined in the references listed above will be denied.

Affected Code(s)

L1844, L1846

Applicable Policy References

Social Security Act, Section 1833 (e); Section 1834 (a) 
42 Code of Federal Regulations (CFR) Section 405.980 (b) and (c)
42 CFR 405.986
42 CFR 424.57
CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 4, Sections 4.26 and 4.26.1                                                                 CMS Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.2, 5.7, and 5.8     
Nationwide LCD L33318, Effective Date 10/01/2015; Revision Effective Date 10/16/2017
Nationwide A52465, Effective Date 10/01/2015, Revision Effective Date 01/01/2017
CMS Policy Article-A55426, Effective Date 01/01/2017, Revised 12/21/2017