knee braces 6 - aapc
TRANSCRIPT
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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Original Issue Date (Created): July 1, 2002
Most Recent Review Date (Revised): November 26, 2013
Effective Date: February 1, 2014
I. POLICY
Custom-made unloader knee braces may be considered medically necessary in the
treatment of patients with painful osteoarthritis involving the medial compartment of the
knee.
Off-the-shelf (custom-fitted) functional knee braces may be considered medically
necessary in patients with knee instability due to injury (including patients who have had
surgery for the injury) or in patients with painful osteoarthritis of the medial compartment
of the knee.
Custom-made functional knee braces are considered not medically necessary. However,
the medical necessity of a custom-made knee brace may be given individual consideration
in any of the following situations:
Patients with abnormal limb contour;
Knee deformity; or
Large knee size.
Prophylactic knee braces are considered not medically necessary.
II. PRODUCT VARIATIONS
[N] = No product variation, policy applies as stated
[Y] = Standard product coverage varies from application of this policy, see below
[N] Capital Cares 4 Kids [N] Indemnity
[N] PPO [N] SpecialCare
[N] HMO [N] POS
[Y] SeniorBlue HMO* [N] FEP PPO
[Y] SeniorBlue PPO*
*For components, which describe features that can be physically incorporated in the specified
prefabricated base orthoses or additional indications for custom fabricated knee orthoses, refer to
Durable Medical Equipment Medicare Administrative Contractor (DME MAC A) Local Coverage
Determination (LCD L27263) Knee Orthoses.
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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III. DESCRIPTION/BACKGROUND
Knee braces may be custom made or available off-the-shelf in a variety of sizes. Knee
braces may be intended for rehabilitation, to reduce pain, or to prevent injury in either
stable or unstable knees.
Knee braces typically consist of 3 components: a superstructure (usually a rigid shell), a
hinge, and a strap system. The superstructure extends proximally and distally to a hinge
centered around the knee axis of motion. The strapping system secures the brace to the
limb. Knee braces can be subdivided into 4categories that are based on their intended use:
Prophylactic braces are those that attempt to prevent or reduce the severity of knee
ligament injuries. These braces are primarily designed to prevent injuries to the
medial collateral ligament, which is the area of the most common athletic knee
injuries.
Rehabilitation braces are designed to allow protected motion of injured knees that
have been treated operatively or non-operatively. These braces allow for controlled
joint motion and typically consist of hinges that can be locked into place to limit
range of motion. Rehabilitation braces are commonly used for 6 to 12 weeks after
an injury. Rehabilitation braces are usually purchased off-the-shelf and not custom-
made. Functional braces are designed to assist or provide stability for unstable
knees during activities of daily living (ADL) or sports and may be either off-the-
shelf or custom made. Derotation braces are typically used after injuries to
ligaments and have medial and lateral bars with varying hinge and strap designs.
These derotation braces are designed to permit significant motion and speed; in
many instances, the braces are worn only during elective activities, such as sports.
Braces made of graphite, titanium, or other lightweight materials are specifically
designed for high-performance sports allowing them to be worn during elective
high performance sports activities. Functional knee braces have also be used in
patients with osteoarthritis to help decrease the weight on painful joints.
Unloader knee braces are specifically designed to reduce the pain and disability
associated with osteoarthritis of the medial compartment of the knee by bracing the
knee in the valgus position to unload the compressive forces on the medial
compartment.
IV. RATIONALE
Osteoarthritis
In 1999, Kirkley and colleagues reported on a controlled trial that randomly assigned 119
patients with medial compartment osteoarthritis to receive standard medical management,
medical management plus a polychloroprene (Neoprene) sleeve, or medical management
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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plus an unloader knee brace. (4) Compared to the control group, the unloader knee brace
group was associated with a significant improvement in quality of life and function. In
comparing the unloader knee brace with the Neoprene sleeve, there was a significant
difference in functional outcomes favoring the unloader knee but no significant difference
in terms of quality-of-life measures.
In a 2005 Cochrane review of braces and orthoses for treating osteoarthritis of the knee,
Brouwer et al. concluded that there was limited evidence in favor of an unloader knee
brace. (5) In 2006, Brouwer and colleagues reported a randomized multicenter trial of 117
patients that compared off-the-shelf unloading braces and conservative therapy with
conservative therapy alone for unicompartmental (valgus or varus) osteoarthritis of the
knee. (6) The addition of a brace resulted in a slight increase in reported walking distances
at 3, 6, and 12 months (effect size of 0.4), with trends for improvement in subjective pain (-
0.63 on a 10-point visual analogue scale [VAS]) and knee function (3 points on a 100-point
Hospital for Special Surgery score). Quality of life did not differ between the two groups.
The authors noted that adherence to the brace was low, with 16 of 60 patients (27%)
discontinuing by 3 months and another 9 (15%) stopping treatment by 12 months. Patient-
reported reasons for discontinuing use of the unloading brace were lack of benefit and
adverse effects (i.e., skin irritation, bad fit).
Another study from 2006 compared custom-made and off-the-shelf bracing for varus
gonarthrosis. (7) Ten patients wore each type of brace for 4-5 weeks (approximately 9
hours per day) in a randomized order. Pain scores were reduced from 197 mm (500 mm
maximum) to 71 mm with the custom brace and 120 mm with the off-the-shelf brace.
Stiffness was reduced from 91 mm (200 mm maximum) to 36 mm with the custom brace
and 63 mm with the off-the-shelf brace. Function was improved from 664 mm (1,700 mm
maximum) to 248 mm with the custom brace, whereas the off-the-shelf brace did not
significantly affect function. Kinematic analysis showed a reduction in peak knee
adduction moments during gait and stair-stepping and reduced varus angulation by 1.5
degrees, compared with baseline with the custom brace. The off-the-shelf brace did not
reduce the varus angle.
A French clinical practice guideline committee evaluated evidence on the use of braces in
knee osteoarthritis in 2009. (8) The review found mainly low-quality evidence in support of
valgus knee braces for symptomatic medial femoro-tibial osteoarthritis with short- and
mid-term reduction of pain and disability. Adverse effects included venous
thromboembolic events. No additional controlled trials were identified in a 2010 review of
bracing in the management of knee osteoarthritis. (9)
A 2010 study compared use of insoles or off-the-shelf braces for medial knee osteoarthritis
in a randomized trial of 91 patients with medial compartmental knee osteoarthritis. (10)
Pain severity, measured by a 10-point VAS, improved by 0.9 in the insole group and 1.0
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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for the brace group in intent-to-treat analysis. Function on the Western Ontario and
McMaster Universities Osteoarthritis Index (WOMAC) improved by 4.2 and 4.0 points,
respectively, out of 100. There was no significant effect on the hip-knee-ankle angle for
either device. Compliance was 45% for the brace group, with a mean wearing time of 39
hours (standard deviation [SD] 32 hours). After 6 months of use, neither insoles nor off-
the-shelf braces resulted in clinically significant changes in varus angle, pain, or function.
In 2011, Hunter et al. reported a randomized trial of patellofemoral bracing for the
treatment of patellofemoral osteoarthritis. (11) Eighty subjects completed 6 weeks with a
BioSkin Q Brace with the patellar realigning strap applied and 6 weeks with the realigning
strap removed. There was a 6-week interval between the 2 conditions, and the order of
treatment was randomized. They found no effect of treatment on VAS knee pain and no
significant difference between the groups for WOMAC pain, function, or stiffness
outcomes.
Ligamentous Instability of the Knee
Soma and colleagues compared the performance of custom-made and off-the-shelf
functional knee braces from 4 manufacturers in 2004. (12) As a group, the custom-made
knee braces restrained anterior displacement better than the off-the-shelf models by a mean
difference of 0.84 mm. The clinical significance of this minimal but statistically significant
difference is questionable.
A 2007 systematic review of 12 randomized controlled trials (RCTs) of bracing for
rehabilitation following anterior cruciate ligament (ACL) reconstruction “found no
evidence supporting the routine use of functional or rehabilitative bracing in a patient with
a reconstructed ACL. In particular, no study demonstrated a clinically important finding of
improved range of motion, decreased pain, improved graft stability, or decreased
complications and reinjuries.” (13)
In 2008, Birmingham and colleagues reported an RCT that compared the use of an off-the-
shelf functional knee brace or Neoprene sleeve beginning 6 weeks after ACL
reconstruction. (14) Of 150 patients randomly assigned to a brace or sleeve after surgery,
127 (85%) completed 24-month follow-up. Compliance was similar for the 2 groups, and 3
patients from each group had graft failures and revision surgeries. Confidence in the knee
was rated higher for the brace (70 vs. 55, respectively out of 100), as was the rating of help
in returning to sport (66 vs. 53, respectively). No other outcome measures differed between
the groups, including the ACL-quality-of-life questionnaire, highest activity level,
satisfaction with the brace/sleeve, side-to-side laxity, or functional tests. As this report
described evaluators as blinded to the patient’s group allocation, it does not appear that the
patients were wearing the brace or sleeve at the time of functional testing.
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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Patellofemoral Pain Syndrome
In 2008, Warden et al. reported a meta-analysis of 16 randomized or quasi-randomized
studies assessing patellar taping or bracing effects on chronic knee pain. (15) Thirteen trials
investigated taping or bracing for anterior knee pain, and 3 investigated taping for
osteoarthritis. The authors concluded there was limited evidence to demonstrate the
efficacy of patellar bracing. They reported high heterogeneity between study outcomes and
significant publication bias in the studies.
Summary
Evidence of efficacy is limited for off-the-shelf bracing for osteoarthritis, ligamentous
instability, or patellofemoral pain.
Practice Guidelines and Position Statements
The American Academy of Orthopaedic Surgeons (AAOS) provided a 2009 clinical
practice guideline on the nonarthroplasty treatment of osteoarthritis of the knee. (16) The
AAOS was unable to make a recommendation for or against the use of a brace with a
varus- or valgus-directing force for patients with medial or lateral unicompartmental
osteoarthritis of the knee, based on limited evidence for the effectiveness of knee braces.
(4,6)
V. DEFINITIONS
BASIC ACTIVITIES OF DAILY LIVING include and are limited to walking in the home,
eating, bathing, dressing, and homemaking.
CUSTOM-MADE BRACE describes a brace that is made according to precise measurements
or molds/casts of an individual patient. Thus, this type of a brace can only be worn by the
individual patient for whom it was customized. A custom-fabricated or molded-to-patient-
model is often referred to as a customized brace.
OFF-THE-SHELF BRACE refers to a brace that is obtained from a selection of readily
available braces. Most often, simple adjustments are made to ensure proper fit.
VI. BENEFIT VARIATIONS
The existence of this medical policy does not mean that this service is a covered benefit
under the member's contract. Benefit determinations should be based in all cases on the
applicable contract language. Medical policies do not constitute a description of benefits.
A member’s individual or group customer benefits govern which services are covered,
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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which are excluded, and which are subject to benefit limits and which require
preauthorization. Members and providers should consult the member’s benefit information
or contact Capital for benefit information.
VII. DISCLAIMER
Capital’s medical policies are developed to assist in administering a member’s benefits, do not
constitute medical advice and are subject to change. Treating providers are solely responsible for
medical advice and treatment of members. Members should discuss any medical policy related to
their coverage or condition with their provider and consult their benefit information to determine if
the service is covered. If there is a discrepancy between this medical policy and a member’s benefit
information, the benefit information will govern. Capital considers the information contained in
this medical policy to be proprietary and it may only be disseminated as permitted by law.
VIII. REFERENCES
1. Liu SH, Mirzayan R. Current review. Functional knee bracing. Clin Orthop Relat Res
1995; (317):273-81.
2. Beynnon BD, Pope MH, Wertheimer CM et al. The effect of functional knee-braces on
strain on the anterior cruciate ligament in vivo. J Bone Joint Surg Am 1992; 74(9):1298-
312.
3. Matsuno H, Kadowaki KM, Tsuji H. Generation II knee bracing for severe medial
compartment osteoarthritis of the knee. Arch Phys Med Rehabil 1997; 78(7):745-9.
4. Kirkley A, Webster-Bogaert S, Litchfield R et al. The effect of bracing on varus
gonarthrosis. J Bone Joint Surg Am 1999; 81(4):539-48.
5. Brouwer RW, Jakma TS, Verhagen AP et al. Braces and orthoses for treating
osteoarthritis of the knee. Cochrane Database Syst Rev 2005; (1):CD004020.
6. Brouwer RW, van Raaij TM, Verhaar JA et al. Brace treatment for osteoarthritis of the
knee: a prospective randomized multi-centre trial. Osteoarthritis Cartilage 2006;
14(8):777-83.
7. Draganich L, Reider B, Rimington T et al. The effectiveness of self-adjustable custom and
off-the-shelf bracing in the treatment of varus gonarthrosis. J Bone Joint Surg Am 2006;
88(12):2645-52.
8. Beaudreuil J, Bendaya S, Faucher M et al. Clinical practice guidelines for rest orthosis,
knee sleeves, and unloading knee braces in knee osteoarthritis. Joint Bone Spine 2009;
76(6):629-36.
9. Rannou F, Poiraudeau S, Beaudreuil J. Role of bracing in the management of knee
osteoarthritis. Curr Opin Rheumatol 2010; 22(2):218-22.
10. van Raaij TM, Reijman M, Brouwer RW et al. Medial Knee Osteoarthritis Treated by
Insoles or Braces: A Randomized Trial. Clin Orthop Relat Res 2010; 468(7):1926-32.
11. Hunter DJ, Harvey W, Gross KD et al. A randomized trial of patellofemoral bracing for
treatment of patellofemoral osteoarthritis. Osteoarthritis Cartilage 2011 (in press).
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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12. Soma CA, Cawley PW, Liu S et al. Custom-fit versus premanufactured braces.
Orthopedics 2004; 27(3):307-10.
13. Wright RW, Fetzer GB. Bracing after ACL reconstruction: a systematic review. Clin
Orthop Relat Res 2007; 455:162-8.
14. Birmingham TB, Bryant DM, Giffin JR et al. A randomized controlled trial comparing
the effectiveness of functional knee brace and neoprene sleeve use after anterior cruciate
ligament reconstruction. Am J Sports Med 2008; 36(4):648-55.
15. Warden SJ, Hinman RS, Watson MA, Jr. et al. Patellar taping and bracing for the
treatment of chronic knee pain: a systematic review and meta-analysis. Arthritis Rheum
2008; 59(1):73-83.
16. Richmond J, Hunter D, Irrgang J et al. Treatment of osteoarthritis of the knee
(nonarthroplasty). J Am Acad Orthop Surg 2009; 17(9):591-600.
Other:
Durable Medical Equipment Medicare Administrative Contractor (DME MAC A) Local
Coverage Determination (LCD) L27263. Knee Orthoses. Effective
02/04/11.[Website]:
http://www.medicarenhic.com/dme/medical_review/mr_lcds/mr_lcd_current/L27263_
2012-07-01_PA_2012-07.pdf Accessed September 16, 2013.
IX. CODING INFORMATION
Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. The
identification of a code in this section does not denote coverage as coverage is determined
by the terms of member benefit information. In addition, not all covered services are
eligible for separate reimbursement.
Covered when medically necessary:
HCPCS
Code Description
K0672 ADDITION TO LOWER EXTREMITY ORTHOSIS, REMOVABLE SOFT INTERFACE, ALL
COMPONENTS, REPLACEMENT ONLY, EACH
L1810 KO, ELASTIC WITH JOINTS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L1820 KO ELAST W/CONDYLR PADS&JNT PRFAB INCL FIT&ADJ
L1830 KO, IMMOBILIZER, CANVAS LONGITUDINAL, PREFABRICATED, INCLUDES FITTING AND
ADJUSTMENT
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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HCPCS
Code Description
L1831 KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED,
INCLUDES FITTING AND ADJUSTMENT
L1832 KO ADJ KNEE JNT UNICENT/POLYCNT RIGD PREFAB
L1834 KO, WITHOUT KNEE JOINT, RIGID, CUSTOM FABRICATED
L1836 KNEE ORTHOS RIGD NO JNT W/INTRFCE
L1840 KO, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOM
FABRICATED
L1843 KO 1 UPRT THI&CALF ADJ UNICNT/POLYCNT PREFAB
L1844 KO 1 UPRT THI&CALF ADJ UNICNT/POLYCNT CSTM FAB
L1845 KO DBL UPRT THI&CALF ADJ UNICNT/POLYCNT PREFAB
L1846 KO DBL UPRT THI&CALF ADJ UNICNT/POLYCNT CSTM FAB
L1847 KO DBL UPRT W/ADJ JNT-INFLAT AIR SUPP CHMB PRFAB
L1850 KO, SWEDISH TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT
L1860 KO, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM FABRICATED
(SK)
L2275 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC
MODIFICATION, PADDED/LINED
L2385 ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT
L2390 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT
L2395 ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT
L2397 ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE
L2405 ADDITION TO KNEE JOINT DROP LOCK EACH
L2415 ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM (BAIL, CABLE, OR
EQUAL), ANY MATERIAL, EACH JOINT
L2425 ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION,
EACH JOINT
L2430 ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE
EXTENSION, EACH JOINT
L2492 ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING
L2750 ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BAR
L2780 ADDITION TO LOWER EXTREMITY ORTHOSIS, NONCORROSIVE FINISH, PER BAR
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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HCPCS
Code Description
L2785 ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACH
L2795 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAP
L2810 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD
L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC,
BELOW KNEE SECTION
L2830 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC,
ABOVE KNEE SECTION
L4002 REPACLEMENT STRAP, ANY ORTHOTIC, INCLUDES ALL COMPONENTS, ANY LENGTH,
ANY TYPE
ICD-9-CM
Diagnosis
Code*
Description
715.16 PRIMARY LOCALIZED OSTEOARTHROSIS, LOWER LEG
715.26 SECONDARY LOCALIZED OSTEOARTHROSIS, LOWER LEG
715.36 LOCALIZED OSTEOARTHROSIS NOT SPECIFIED WHETHER PRIMARY OR SECONDARY,
LOWER LEG
717.0 -
717.9 INTERNAL DERANGEMENT OF KNEE
718.86 OTHER JOINT DERANGEMENT, NOT ELSEWHERE CLASSIFIED, LOWER LEG
727.66 NONTRAUMATIC RUPTURE OF PATELLAR TENDON
736.41-
736.42 GENU VALGUM OR VARUM (ACQUIRED)
736.5 GENU RECURVATUM (ACQUIRED)
736.6 OTHER ACQUIRED DEFORMITIES OF KNEE
822.0 CLOSED FRACTURE OF PATELLA
822.1 OPEN FRACTURE OF PATELLA
836.0-
836.69 DISLOCATION OF KNEE
844.0 -
844.9 SPRAINS AND STRAINS OF KNEE AND LEG
V58.78 AFTERCARE FOLLOWING SURGERY OF THE MUSCULOSKELETAL SYSTEM, NEC
*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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The following ICD-10 diagnosis codes will be effective October 1, 2014
ICD-10-CM
Diagnosis
Code*
Description
M17.0 Bilateral primary osteoarthritis of knee
M17.10 Unilateral primary osteoarthritis, unspecified knee
M17.11 Unilateral primary osteoarthritis, right knee
M17.12 Unilateral primary osteoarthritis, left knee
M17.2 Bilateral post-traumatic osteoarthritis of knee
M17.30 Unilateral post-traumatic osteoarthritis, unspecified knee
M17.31 Unilateral post-traumatic osteoarthritis, right knee
M17.32 Unilateral post-traumatic osteoarthritis, left knee
M17.4 Other bilateral secondary osteoarthritis of knee
M17.5 Other unilateral secondary osteoarthritis of knee
M17.9 Osteoarthritis of knee, unspecified
M21.061 Valgus deformity, not elsewhere classified, right knee
M21.062 Valgus deformity, not elsewhere classified, left knee
M21.069 Valgus deformity, not elsewhere classified, unspecified knee
M21.161 Varus deformity, not elsewhere classified, right knee
M21.162 Varus deformity, not elsewhere classified, left knee
M21.169 Varus deformity, not elsewhere classified, unspecified knee
M21.861 Other specified acquired deformities of right lower leg
M21.862 Other specified acquired deformities of left lower leg
M21.869 Other specified acquired deformities of unspecified lower leg
M22.2x1 Patellofemoral disorders, right knee
M22.2x2 Patellofemoral disorders, left knee
M22.2x9 Patellofemoral disorders, unspecified knee
M22.3x1 Other derangements of patella, right knee
M22.3x2 Other derangements of patella, left knee
M22.3x9 Other derangements of patella, unspecified knee
M22.40 Chondromalacia patellae, unspecified knee
M22.41 Chondromalacia patellae, right knee
M22.42 Chondromalacia patellae, left knee
M22.8x1 Other disorders of patella, right knee
M22.8x2 Other disorders of patella, left knee
M22.8x9 Other disorders of patella, unspecified knee
M22.90 Unspecified disorder of patella, unspecified knee
M22.91 Unspecified disorder of patella, right knee
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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ICD-10-CM
Diagnosis
Code*
Description
M22.92 Unspecified disorder of patella, left knee
M23.000 Cystic meniscus, unspecified lateral meniscus, right knee
M23.001 Cystic meniscus, unspecified lateral meniscus, left knee
M23.002 Cystic meniscus, unspecified lateral meniscus, unspecified knee
M23.003 Cystic meniscus, unspecified medial meniscus, right knee
M23.004 Cystic meniscus, unspecified medial meniscus, left knee
M23.005 Cystic meniscus, unspecified medial meniscus, unspecified knee
M23.006 Cystic meniscus, unspecified meniscus, right knee
M23.007 Cystic meniscus, unspecified meniscus, left knee
M23.009 Cystic meniscus, unspecified meniscus, unspecified knee
M23.011 Cystic meniscus, anterior horn of medial meniscus, right knee
M23.012 Cystic meniscus, anterior horn of medial meniscus, left knee
M23.019 Cystic meniscus, anterior horn of medial meniscus, unspecified knee
M23.021 Cystic meniscus, posterior horn of medial meniscus, right knee
M23.022 Cystic meniscus, posterior horn of medial meniscus, left knee
M23.029 Cystic meniscus, posterior horn of medial meniscus, unspecified knee
M23.031 Cystic meniscus, other medial meniscus, right knee
M23.032 Cystic meniscus, other medial meniscus, left knee
M23.039 Cystic meniscus, other medial meniscus, unspecified knee
M23.041 Cystic meniscus, anterior horn of lateral meniscus, right knee
M23.042 Cystic meniscus, anterior horn of lateral meniscus, left knee
M23.049 Cystic meniscus, anterior horn of lateral meniscus, unspecified knee
M23.051 Cystic meniscus, posterior horn of lateral meniscus, right knee
M23.052 Cystic meniscus, posterior horn of lateral meniscus, left knee
M23.059 Cystic meniscus, posterior horn of lateral meniscus, unspecified knee
M23.061 Cystic meniscus, other lateral meniscus, right knee
M23.062 Cystic meniscus, other lateral meniscus, left knee
M23.069 Cystic meniscus, other lateral meniscus, unspecified knee
M23.200 Derangement of unspecified lateral meniscus due to old tear or injury, right knee
M23.201 Derangement of unspecified lateral meniscus due to old tear or injury, left knee
M23.202 Derangement of unspecified lateral meniscus due to old tear or injury, unspecified knee
M23.203 Derangement of unspecified medial meniscus due to old tear or injury, right knee
M23.204 Derangement of unspecified medial meniscus due to old tear or injury, left knee
M23.205 Derangement of unspecified medial meniscus due to old tear or injury, unspecified knee
M23.206 Derangement of unspecified meniscus due to old tear or injury, right knee
M23.207 Derangement of unspecified meniscus due to old tear or injury, left knee
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
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ICD-10-CM
Diagnosis
Code*
Description
M23.209 Derangement of unspecified meniscus due to old tear or injury, unspecified knee
M23.211 Derangement of anterior horn of medial meniscus due to old tear or injury, right knee
M23.212 Derangement of anterior horn of medial meniscus due to old tear or injury, left knee
M23.219 Derangement of anterior horn of medial meniscus due to old tear or injury, unspecified knee
M23.221 Derangement of posterior horn of medial meniscus due to old tear or injury, right knee
M23.222 Derangement of posterior horn of medial meniscus due to old tear or injury, left knee
M23.229 Derangement of posterior horn of medial meniscus due to old tear or injury, unspecified knee
M23.231 Derangement of other medial meniscus due to old tear or injury, right knee
M23.232 Derangement of other medial meniscus due to old tear or injury, left knee
M23.239 Derangement of other medial meniscus due to old tear or injury, unspecified knee
M23.241 Derangement of anterior horn of lateral meniscus due to old tear or injury, right knee
M23.242 Derangement of anterior horn of lateral meniscus due to old tear or injury, left knee
M23.249 Derangement of anterior horn of lateral meniscus due to old tear or injury, unspecified knee
M23.251 Derangement of posterior horn of lateral meniscus due to old tear or injury, right knee
M23.252 Derangement of posterior horn of lateral meniscus due to old tear or injury, left knee
M23.259 Derangement of posterior horn of lateral meniscus due to old tear or injury, unspecified knee
M23.261 Derangement of other lateral meniscus due to old tear or injury, right knee
M23.262 Derangement of other lateral meniscus due to old tear or injury, left knee
M23.269 Derangement of other lateral meniscus due to old tear or injury, unspecified knee
M23.300 Other meniscus derangements, unspecified lateral meniscus, right knee
M23.301 Other meniscus derangements, unspecified lateral meniscus, left knee
M23.302 Other meniscus derangements, unspecified lateral meniscus, unspecified knee
M23.303 Other meniscus derangements, unspecified medial meniscus, right knee
M23.304 Other meniscus derangements, unspecified medial meniscus, left knee
M23.305 Other meniscus derangements, unspecified medial meniscus, unspecified knee
M23.306 Other meniscus derangements, unspecified meniscus, right knee
M23.307 Other meniscus derangements, unspecified meniscus, left knee
M23.309 Other meniscus derangements, unspecified meniscus, unspecified knee
M23.311 Other meniscus derangements, anterior horn of medial meniscus, right knee
M23.312 Other meniscus derangements, anterior horn of medial meniscus, left knee
M23.319 Other meniscus derangements, anterior horn of medial meniscus, unspecified knee
M23.321 Other meniscus derangements, posterior horn of medial meniscus, right knee
M23.322 Other meniscus derangements, posterior horn of medial meniscus, left knee
M23.329 Other meniscus derangements, posterior horn of medial meniscus, unspecified knee
M23.331 Other meniscus derangements, other medial meniscus, right knee
M23.332 Other meniscus derangements, other medial meniscus, left knee
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
Page 13 [Note: Final page is signature page and is kept on file, but not issued with Policy.]
ICD-10-CM
Diagnosis
Code*
Description
M23.339 Other meniscus derangements, other medial meniscus, unspecified knee
M23.341 Other meniscus derangements, anterior horn of lateral meniscus, right knee
M23.342 Other meniscus derangements, anterior horn of lateral meniscus, left knee
M23.349 Other meniscus derangements, anterior horn of lateral meniscus, unspecified knee
M23.351 Other meniscus derangements, posterior horn of lateral meniscus, right knee
M23.352 Other meniscus derangements, posterior horn of lateral meniscus, left knee
M23.359 Other meniscus derangements, posterior horn of lateral meniscus, unspecified knee
M23.361 Other meniscus derangements, other lateral meniscus, right knee
M23.362 Other meniscus derangements, other lateral meniscus, left knee
M23.369 Other meniscus derangements, other lateral meniscus, unspecified knee
M23.40 Loose body in knee, unspecified knee
M23.41 Loose body in knee, right knee
M23.42 Loose body in knee, left knee
M23.50 Chronic instability of knee, unspecified knee
M23.51 Chronic instability of knee, right knee
M23.52 Chronic instability of knee, left knee
M23.601 Other spontaneous disruption of unspecified ligament of right knee
M23.602 Other spontaneous disruption of unspecified ligament of left knee
M23.609 Other spontaneous disruption of unspecified ligament of unspecified knee
M23.611 Other spontaneous disruption of anterior cruciate ligament of right knee
M23.612 Other spontaneous disruption of anterior cruciate ligament of left knee
M23.619 Other spontaneous disruption of anterior cruciate ligament of unspecified knee
M23.621 Other spontaneous disruption of posterior cruciate ligament of right knee
M23.622 Other spontaneous disruption of posterior cruciate ligament of left knee
M23.629 Other spontaneous disruption of posterior cruciate ligament of unspecified knee
M23.631 Other spontaneous disruption of medial collateral ligament of right knee
M23.632 Other spontaneous disruption of medial collateral ligament of left knee
M23.639 Other spontaneous disruption of medial collateral ligament of unspecified knee
M23.641 Other spontaneous disruption of lateral collateral ligament of right knee
M23.642 Other spontaneous disruption of lateral collateral ligament of left knee
M23.649 Other spontaneous disruption of lateral collateral ligament of unspecified knee
M23.671 Other spontaneous disruption of capsular ligament of right knee
M23.672 Other spontaneous disruption of capsular ligament of left knee
M23.679 Other spontaneous disruption of capsular ligament of unspecified knee
M23.8x1 Other internal derangements of right knee
M23.8x2 Other internal derangements of left knee
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
Page 14 [Note: Final page is signature page and is kept on file, but not issued with Policy.]
ICD-10-CM
Diagnosis
Code*
Description
M23.8x9 Other internal derangements of unspecified knee
M23.90 Unspecified internal derangement of unspecified knee
M23.91 Unspecified internal derangement of right knee
M23.92 Unspecified internal derangement of left knee
M25.261 Flail joint, right knee
M25.262 Flail joint, left knee
M25.269 Flail joint, unspecified knee
M25.361 Other instability, right knee
M25.362 Other instability, left knee
M25.369 Other instability, unspecified knee
M66.261 Spontaneous rupture of extensor tendons, right lower leg
M66.262 Spontaneous rupture of extensor tendons, left lower leg
M66.269 Spontaneous rupture of extensor tendons, unspecified lower leg
Q68.6 Discoid meniscus
S81.009a Unspecified open wound, unspecified knee, initial encounter
S82.001a Unspecified fracture of right patella, initial encounter for closed fracture
S82.001b Unspecified fracture of right patella, initial encounter for open fracture type I or II
S82.001c Unspecified fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or IIIC
S82.002a Unspecified fracture of left patella, initial encounter for closed fracture
S82.002b Unspecified fracture of left patella, initial encounter for open fracture type I or II
S82.002c Unspecified fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or IIIC
S82.009a Unspecified fracture of unspecified patella, initial encounter for closed fracture
S82.009b Unspecified fracture of unspecified patella, initial encounter for open fracture type I or II
S82.009c Unspecified fracture of unspecified patella, initial encounter for open fracture type IIIA, IIIB, or IIIC
S82.011a Displaced osteochondral fracture of right patella, initial encounter for closed fracture
S82.011b Displaced osteochondral fracture of right patella, initial encounter for open fracture type I or II
S82.011c Displaced osteochondral fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.012a Displaced osteochondral fracture of left patella, initial encounter for closed fracture
S82.012b Displaced osteochondral fracture of left patella, initial encounter for open fracture type I or II
S82.012c Displaced osteochondral fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.013a Displaced osteochondral fracture of unspecified patella, initial encounter for closed fracture
S82.013b Displaced osteochondral fracture of unspecified patella, initial encounter for open fracture type I or II
S82.013c Displaced osteochondral fracture of unspecified patella, initial encounter for open fracture type IIIA,
IIIB, or IIIC
S82.014a Nondisplaced osteochondral fracture of right patella, initial encounter for closed fracture
S82.014b Nondisplaced osteochondral fracture of right patella, initial encounter for open fracture type I or II
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
Page 15 [Note: Final page is signature page and is kept on file, but not issued with Policy.]
ICD-10-CM
Diagnosis
Code*
Description
S82.014c Nondisplaced osteochondral fracture of right patella, initial encounter for open fracture type IIIA,
IIIB, or IIIC
S82.015a Nondisplaced osteochondral fracture of left patella, initial encounter for closed fracture
S82.015b Nondisplaced osteochondral fracture of left patella, initial encounter for open fracture type I or II
S82.015c Nondisplaced osteochondral fracture of left patella, initial encounter for open fracture type IIIA, IIIB,
or IIIC
S82.016a Nondisplaced osteochondral fracture of unspecified patella, initial encounter for closed fracture
S82.016b Nondisplaced osteochondral fracture of unspecified patella, initial encounter for open fracture type I
or II
S82.016c Nondisplaced osteochondral fracture of unspecified patella, initial encounter for open fracture type
IIIA, IIIB, or IIIC
S82.021a Displaced longitudinal fracture of right patella, initial encounter for closed fracture
S82.021b Displaced longitudinal fracture of right patella, initial encounter for open fracture type I or II
S82.021c Displaced longitudinal fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.022a Displaced longitudinal fracture of left patella, initial encounter for closed fracture
S82.022b Displaced longitudinal fracture of left patella, initial encounter for open fracture type I or II
S82.022c Displaced longitudinal fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.023a Displaced longitudinal fracture of unspecified patella, initial encounter for closed fracture
S82.023b Displaced longitudinal fracture of unspecified patella, initial encounter for open fracture type I or II
S82.023c Displaced longitudinal fracture of unspecified patella, initial encounter for open fracture type IIIA,
IIIB, or IIIC
S82.024a Nondisplaced longitudinal fracture of right patella, initial encounter for closed fracture
S82.024b Nondisplaced longitudinal fracture of right patella, initial encounter for open fracture type I or II
S82.024c Nondisplaced longitudinal fracture of right patella, initial encounter for open fracture type IIIA, IIIB,
or IIIC
S82.025a Nondisplaced longitudinal fracture of left patella, initial encounter for closed fracture
S82.025b Nondisplaced longitudinal fracture of left patella, initial encounter for open fracture type I or II
S82.025c Nondisplaced longitudinal fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.026a Nondisplaced longitudinal fracture of unspecified patella, initial encounter for closed fracture
S82.026b Nondisplaced longitudinal fracture of unspecified patella, initial encounter for open fracture type I or
II
S82.026c Nondisplaced longitudinal fracture of unspecified patella, initial encounter for open fracture type IIIA,
IIIB, or IIIC
S82.031a Displaced transverse fracture of right patella, initial encounter for closed fracture
S82.031b Displaced transverse fracture of right patella, initial encounter for open fracture type I or II
S82.031c Displaced transverse fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.032a Displaced transverse fracture of left patella, initial encounter for closed fracture
S82.032b Displaced transverse fracture of left patella, initial encounter for open fracture type I or II
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
Page 16 [Note: Final page is signature page and is kept on file, but not issued with Policy.]
ICD-10-CM
Diagnosis
Code*
Description
S82.032c Displaced transverse fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or IIIC
S82.033a Displaced transverse fracture of unspecified patella, initial encounter for closed fracture
S82.033b Displaced transverse fracture of unspecified patella, initial encounter for open fracture type I or II
S82.033c Displaced transverse fracture of unspecified patella, initial encounter for open fracture type IIIA, IIIB,
or IIIC
S82.034a Nondisplaced transverse fracture of right patella, initial encounter for closed fracture
S82.034b Nondisplaced transverse fracture of right patella, initial encounter for open fracture type I or II
S82.034c Nondisplaced transverse fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.035a Nondisplaced transverse fracture of left patella, initial encounter for closed fracture
S82.035b Nondisplaced transverse fracture of left patella, initial encounter for open fracture type I or II
S82.035c Nondisplaced transverse fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.036a Nondisplaced transverse fracture of unspecified patella, initial encounter for closed fracture
S82.036b Nondisplaced transverse fracture of unspecified patella, initial encounter for open fracture type I or II
S82.036c Nondisplaced transverse fracture of unspecified patella, initial encounter for open fracture type IIIA,
IIIB, or IIIC
S82.041a Displaced comminuted fracture of right patella, initial encounter for closed fracture
S82.041b Displaced comminuted fracture of right patella, initial encounter for open fracture type I or II
S82.041c Displaced comminuted fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.042a Displaced comminuted fracture of left patella, initial encounter for closed fracture
S82.042b Displaced comminuted fracture of left patella, initial encounter for open fracture type I or II
S82.042c Displaced comminuted fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or
IIIC
S82.043a Displaced comminuted fracture of unspecified patella, initial encounter for closed fracture
S82.043b Displaced comminuted fracture of unspecified patella, initial encounter for open fracture type I or II
S82.043c Displaced comminuted fracture of unspecified patella, initial encounter for open fracture type IIIA,
IIIB, or IIIC
S82.044a Nondisplaced comminuted fracture of right patella, initial encounter for closed fracture
S82.044b Nondisplaced comminuted fracture of right patella, initial encounter for open fracture type I or II
S82.044c Nondisplaced comminuted fracture of right patella, initial encounter for open fracture type IIIA, IIIB,
or IIIC
S82.045a Nondisplaced comminuted fracture of left patella, initial encounter for closed fracture
S82.045b Nondisplaced comminuted fracture of left patella, initial encounter for open fracture type I or II
S82.045c Nondisplaced comminuted fracture of left patella, initial encounter for open fracture type IIIA, IIIB,
or IIIC
S82.046a Nondisplaced comminuted fracture of unspecified patella, initial encounter for closed fracture
S82.046b Nondisplaced comminuted fracture of unspecified patella, initial encounter for open fracture type I or
II
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
Page 17 [Note: Final page is signature page and is kept on file, but not issued with Policy.]
ICD-10-CM
Diagnosis
Code*
Description
S82.046c Nondisplaced comminuted fracture of unspecified patella, initial encounter for open fracture type
IIIA, IIIB, or IIIC
S82.091a Other fracture of right patella, initial encounter for closed fracture
S82.091b Other fracture of right patella, initial encounter for open fracture type I or II
S82.091c Other fracture of right patella, initial encounter for open fracture type IIIA, IIIB, or IIIC
S82.092a Other fracture of left patella, initial encounter for closed fracture
S82.092b Other fracture of left patella, initial encounter for open fracture type I or II
S82.092c Other fracture of left patella, initial encounter for open fracture type IIIA, IIIB, or IIIC
S82.099a Other fracture of unspecified patella, initial encounter for closed fracture
S82.099b Other fracture of unspecified patella, initial encounter for open fracture type I or II
S82.099c Other fracture of unspecified patella, initial encounter for open fracture type IIIA, IIIB, or IIIC
S83.001a Unspecified subluxation of right patella, initial encounter
S83.002a Unspecified subluxation of left patella, initial encounter
S83.003a Unspecified subluxation of unspecified patella, initial encounter
S83.004a Unspecified dislocation of right patella, initial encounter
S83.005a Unspecified dislocation of left patella, initial encounter
S83.006a Unspecified dislocation of unspecified patella, initial encounter
S83.011a Lateral subluxation of right patella, initial encounter
S83.012a Lateral subluxation of left patella, initial encounter
S83.013a Lateral subluxation of unspecified patella, initial encounter
S83.014a Lateral dislocation of right patella, initial encounter
S83.015a Lateral dislocation of left patella, initial encounter
S83.016a Lateral dislocation of unspecified patella, initial encounter
S83.091a Other subluxation of right patella, initial encounter
S83.092a Other subluxation of left patella, initial encounter
S83.093a Other subluxation of unspecified patella, initial encounter
S83.094a Other dislocation of right patella, initial encounter
S83.095a Other dislocation of left patella, initial encounter
S83.096a Other dislocation of unspecified patella, initial encounter
S83.101a Unspecified subluxation of right knee, initial encounter
S83.102a Unspecified subluxation of left knee, initial encounter
S83.103a Unspecified subluxation of unspecified knee, initial encounter
S83.104a Unspecified dislocation of right knee, initial encounter
S83.105a Unspecified dislocation of left knee, initial encounter
S83.106a Unspecified dislocation of unspecified knee, initial encounter
S83.111a Anterior subluxation of proximal end of tibia, right knee, initial encounter
S83.112a Anterior subluxation of proximal end of tibia, left knee, initial encounter
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
Page 18 [Note: Final page is signature page and is kept on file, but not issued with Policy.]
ICD-10-CM
Diagnosis
Code*
Description
S83.113a Anterior subluxation of proximal end of tibia, unspecified knee, initial encounter
S83.114a Anterior dislocation of proximal end of tibia, right knee, initial encounter
S83.115a Anterior dislocation of proximal end of tibia, left knee, initial encounter
S83.116a Anterior dislocation of proximal end of tibia, unspecified knee, initial encounter
S83.121a Posterior subluxation of proximal end of tibia, right knee, initial encounter
S83.122a Posterior subluxation of proximal end of tibia, left knee, initial encounter
S83.123a Posterior subluxation of proximal end of tibia, unspecified knee, initial encounter
S83.124a Posterior dislocation of proximal end of tibia, right knee, initial encounter
S83.125a Posterior dislocation of proximal end of tibia, left knee, initial encounter
S83.126a Posterior dislocation of proximal end of tibia, unspecified knee, initial encounter
S83.131a Medial subluxation of proximal end of tibia, right knee, initial encounter
S83.132a Medial subluxation of proximal end of tibia, left knee, initial encounter
S83.133a Medial subluxation of proximal end of tibia, unspecified knee, initial encounter
S83.134a Medial dislocation of proximal end of tibia, right knee, initial encounter
S83.135a Medial dislocation of proximal end of tibia, left knee, initial encounter
S83.136a Medial dislocation of proximal end of tibia, unspecified knee, initial encounter
S83.146a Lateral dislocation of proximal end of tibia, unspecified knee, initial encounter
S83.191a Other subluxation of right knee, initial encounter
S83.192a Other subluxation of left knee, initial encounter
S83.193a Other subluxation of unspecified knee, initial encounter
S83.194a Other dislocation of right knee, initial encounter
S83.195a Other dislocation of left knee, initial encounter
S83.196a Other dislocation of unspecified knee, initial encounter
S83.200a Bucket-handle tear of unspecified meniscus, current injury, right knee, initial encounter
S83.201a Bucket-handle tear of unspecified meniscus, current injury, left knee, initial encounter
S83.202a Bucket-handle tear of unspecified meniscus, current injury, unspecified knee, initial encounter
S83.203a Other tear of unspecified meniscus, current injury, right knee, initial encounter
S83.204a Other tear of unspecified meniscus, current injury, left knee, initial encounter
S83.205a Other tear of unspecified meniscus, current injury, unspecified knee, initial encounter
S83.206a Unspecified tear of unspecified meniscus, current injury, right knee, initial encounter
S83.207a Unspecified tear of unspecified meniscus, current injury, left knee, initial encounter
S83.209a Unspecified tear of unspecified meniscus, current injury, unspecified knee, initial encounter
S83.211a Bucket-handle tear of medial meniscus, current injury, right knee, initial encounter
S83.212a Bucket-handle tear of medial meniscus, current injury, left knee, initial encounter
S83.219a Bucket-handle tear of medial meniscus, current injury, unspecified knee, initial encounter
S83.221a Peripheral tear of medial meniscus, current injury, right knee, initial encounter
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
Page 19 [Note: Final page is signature page and is kept on file, but not issued with Policy.]
ICD-10-CM
Diagnosis
Code*
Description
S83.222a Peripheral tear of medial meniscus, current injury, left knee, initial encounter
S83.229a Peripheral tear of medial meniscus, current injury, unspecified knee, initial encounter
S83.231a Complex tear of medial meniscus, current injury, right knee, initial encounter
S83.232a Complex tear of medial meniscus, current injury, left knee, initial encounter
S83.239a Complex tear of medial meniscus, current injury, unspecified knee, initial encounter
S83.241a Other tear of medial meniscus, current injury, right knee, initial encounter
S83.242a Other tear of medial meniscus, current injury, left knee, initial encounter
S83.249a Other tear of medial meniscus, current injury, unspecified knee, initial encounter
S83.251a Bucket-handle tear of lateral meniscus, current injury, right knee, initial encounter
S83.252a Bucket-handle tear of lateral meniscus, current injury, left knee, initial encounter
S83.259a Bucket-handle tear of lateral meniscus, current injury, unspecified knee, initial encounter
S83.261a Peripheral tear of lateral meniscus, current injury, right knee, initial encounter
S83.262a Peripheral tear of lateral meniscus, current injury, left knee, initial encounter
S83.269a Peripheral tear of lateral meniscus, current injury, unspecified knee, initial encounter
S83.271a Complex tear of lateral meniscus, current injury, right knee, initial encounter
S83.272a Complex tear of lateral meniscus, current injury, left knee, initial encounter
S83.279a Complex tear of lateral meniscus, current injury, unspecified knee, initial encounter
S83.281a Other tear of lateral meniscus, current injury, right knee, initial encounter
S83.282a Other tear of lateral meniscus, current injury, left knee, initial encounter
S83.289a Other tear of lateral meniscus, current injury, unspecified knee, initial encounter
S83.30xa Tear of articular cartilage of unspecified knee, current, initial encounter
S83.31xa Tear of articular cartilage of right knee, current, initial encounter
S83.32xa Tear of articular cartilage of left knee, current, initial encounter
S83.401a Sprain of unspecified collateral ligament of right knee, initial encounter
S83.402a Sprain of unspecified collateral ligament of left knee, initial encounter
S83.409a Sprain of unspecified collateral ligament of unspecified knee, initial encounter
S83.411a Sprain of medial collateral ligament of right knee, initial encounter
S83.412a Sprain of medial collateral ligament of left knee, initial encounter
S83.419a Sprain of medial collateral ligament of unspecified knee, initial encounter
S83.421a Sprain of lateral collateral ligament of right knee, initial encounter
S83.422a Sprain of lateral collateral ligament of left knee, initial encounter
S83.429a Sprain of lateral collateral ligament of unspecified knee, initial encounter
S83.501a Sprain of unspecified cruciate ligament of right knee, initial encounter
S83.502a Sprain of unspecified cruciate ligament of left knee, initial encounter
S83.509a Sprain of unspecified cruciate ligament of unspecified knee, initial encounter
S83.511a Sprain of anterior cruciate ligament of right knee, initial encounter
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
Page 20 [Note: Final page is signature page and is kept on file, but not issued with Policy.]
ICD-10-CM
Diagnosis
Code*
Description
S83.512a Sprain of anterior cruciate ligament of left knee, initial encounter
S83.519a Sprain of anterior cruciate ligament of unspecified knee, initial encounter
S83.521a Sprain of posterior cruciate ligament of right knee, initial encounter
S83.522a Sprain of posterior cruciate ligament of left knee, initial encounter
S83.529a Sprain of posterior cruciate ligament of unspecified knee, initial encounter
S83.60xa Sprain of the superior tibiofibular joint and ligament, unspecified knee, initial encounter
S83.61xa Sprain of the superior tibiofibular joint and ligament, right knee, initial encounter
S83.62xa Sprain of the superior tibiofibular joint and ligament, left knee, initial encounter
S83.8x1a Sprain of other specified parts of right knee, initial encounter
S83.8x2a Sprain of other specified parts of knee, initial encounter
S83.8x9a Sprain of other specified parts of knee, initial encounter
S83.90xa Sprain of unspecified site of unspecified knee, initial encounter
S86.911a Strain of unspecified muscle(s) and tendon(s) at lower leg level, right leg, initial encounter
S86.912a Strain of unspecified muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
S86.919a Strain of unspecified muscle(s) and tendon(s) at lower leg level, unspecified leg, initial encounter
S83.91xa Sprain of unspecified site of right knee, initial encounter
S83.92xa Sprain of unspecified site of left knee, initial encounter
S86.111a Strain of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, right leg, initial
encounter
S86.112a Strain of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, left leg, initial
encounter
S86.119a Strain of other muscle(s) and tendon(s) of posterior muscle group at lower leg level, unspecified leg,
initial encounter
S86.211a Strain of muscle(s) and tendon(s) of anterior muscle group at lower leg level, right leg, initial
encounter
S86.212a Strain of muscle(s) and tendon(s) of anterior muscle group at lower leg level, left leg, initial encounter
S86.219a Strain of muscle(s) and tendon(s) of anterior muscle group at lower leg level, unspecified leg, initial
encounter
S86.311a Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, right leg, initial
encounter
S86.312a Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, left leg, initial
encounter
S86.319a Strain of muscle(s) and tendon(s) of peroneal muscle group at lower leg level, unspecified leg, initial
encounter
S86.811a Strain of other muscle(s) and tendon(s) at lower leg level, right leg, initial encounter
S86.812a Strain of other muscle(s) and tendon(s) at lower leg level, left leg, initial encounter
S86.819a Strain of other muscle(s) and tendon(s) at lower leg level, unspecified leg, initial encounter
*If applicable, please see Medicare LCD or NCD for additional covered diagnoses.
MEDICAL POLICY
POLICY TITLE KNEE BRACES
POLICY NUMBER MP- 6.012
Page 21 [Note: Final page is signature page and is kept on file, but not issued with Policy.]
X. POLICY HISTORY
MP-6.012 CAC 2/25/03
CAC 9/28/04
CAC 9/27/05
CAC 11/28/06
CAC 2/27/07
CAC 1/29/08 Consensus
CAC 7/29/08
CAC 7/28/09
CAC 7/27/10 Consensus review.
CAC 10/25/11 Adopt BCBSA. Information related to individual consideration for
custom-made functional knee braces was retained in the policy.
CAC 10/30/12 consensus. No change to policy statements. References updated.
Codes reviewed 10/23/12 klr
CAC 11/26/13 Consensus review. No change to policy statements. References
updated. Rationale added.
Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company®,
Capital Advantage Assurance Company® and Keystone Health Plan® Central. Independent licensees of the BlueCross BlueShield Association.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.