LCD L33686 Ankle-Foot/Knee-Ankle-Foot Orthosis:…

Where this LCD applies

Each contract number is a jurisdiction on the remittance; the policy binds claims processed under these contracts and no others.

Contracts that apply LCD L33686
Contract	Contractor	Type	States
19003	Noridian Healthcare Solutions, LLC	DME MAC	AK AS AZ CA CNMI GU HI IA ID KS MO MT ND NE NV OR SD UT WA WY
18003	CGS Administrators, LLC	DME MAC	AL AR CO FL GA LA MS NC NM OK PR SC TN TX VA VI WV
17013	CGS Administrators, LLC	DME MAC	IL IN KY MI MN OH WI
16013	Noridian Healthcare Solutions, LLC	DME MAC	CT DC DE MA MD ME NH NJ NY PA RI VT

Billing and coding: diagnoses and procedure codes

Since 2019 the codes live in the companion article rather than the LCD. Article A52457 (Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article) carries the diagnosis and procedure lists the contractor loads as the claims edit. CPT codes are shown as bare numbers because the descriptors are licensed by the AMA; HCPCS Level II descriptors are public and shown.

A52457: Ankle-Foot/Knee-Ankle-Foot Orthoses - Policy Article (Article, effective 2026-04-01)

Covered ICD-10-CM codes: 12; 2 groups
Non-covered ICD-10-CM codes: 0
Procedure codes listed: 0
Full article: cms.gov record

First 12 covered ICD-10-CM codes in A52457
ICD-10-CM	Description (FY2027)
A52.16	—
E08.610	—
E09.610	—
E10.610	—
E11.610	—
M14.671	—
M14.672	—
M24.571	—
M24.572	—
M24.574	—
M24.575	—
M72.2	—

Procedure codes named in the LCD

A4467 (Belt, Strap, Sleeve, Garment, Or Covering, Any Type), A9283 (Foot Pressure Off Loading/Supportive Device, Any Type, Each), A9285 (Inversion/Eversion Correction Device), L1900 (Ankle Foot Orthosis, Spring Wire, Dorsiflexion Assist Calf Band, Custom Fabricated), L1902 (Ankle Orthosis, Ankle Gauntlet Or Similar, With Or Without Joints, Prefabricated, Off-The-Shelf), L1904 (Ankle Orthosis, Ankle Gauntlet Or Similar, With Or Without Joints, Custom Fabricated), L1906 (Ankle Foot Orthosis, Multiligamentous Ankle Support, Prefabricated, Off-The-Shelf), L1907 (Ankle Orthosis, Supramalleolar With Straps, With Or Without Interface/Pads, Custom Fabricated), L1910 (Ankle Foot Orthosis, Posterior, Single Bar, Clasp Attachment To Shoe Counter, Prefabricated, Includes Fitting And Adjustment), L1920 (Ankle Foot Orthosis, Single Upright With Static Or Adjustable Stop (Phelps Or Perlstein Type), Custom Fabricated), L1930 (Ankle Foot Orthosis, Plastic Or Other Material, Prefabricated, Includes Fitting And Adjustment), L1932 (Ankle Foot Orthosis, Rigid Anterior Tibial Section, Total Carbon Fiber Or Equal Material, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise), L1933 (Ankle Foot Orthosis, Rigid Anterior Tibial Section, Total Carbon Fiber Or Equal Material, Prefabricated, Off-The-Shelf), L1940 (Ankle Foot Orthosis, Plastic Or Other Material, Custom Fabricated), L1945 (Ankle Foot Orthosis, Plastic, Rigid Anterior Tibial Section (Floor Reaction), Custom Fabricated), L1950 (Ankle Foot Orthosis, Spiral, (Institute Of Rehabilitative Medicine Type), Plastic, Custom Fabricated), L1951 (Ankle Foot Orthosis, Spiral, (Institute Of Rehabilitative Medicine Type), Plastic Or Other Material, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise), L1952 (Ankle Foot Orthosis, Spiral, (Institute Of Rehabilitative Medicine Type), Plastic Or Other Material, Prefabricated, Off-The-Shelf), L1960 (Ankle Foot Orthosis, Posterior Solid Ankle, Plastic, Custom Fabricated), L1970 (Ankle Foot Orthosis, Plastic With Ankle Joint, Custom Fabricated), L1971 (Ankle Foot Orthosis, Plastic Or Other Material With Ankle Joint, With Or Without Dorsiflexion Assist, Prefabricated, Includes Fitting And Adjustment), L1980 (Ankle Foot Orthosis, Single Upright Free Plantar Dorsiflexion, Solid Stirrup, Calf Band/Cuff (Single Bar 'Bk' Orthosis), Custom Fabricated), L1990 (Ankle Foot Orthosis, Double Upright Free Plantar Dorsiflexion, Solid Stirrup, Calf Band/Cuff (Double Bar 'Bk' Orthosis), Custom Fabricated), L2000 (Knee Ankle Foot Orthosis, Single Upright, Free Knee, Free Ankle, Solid Stirrup, Thigh And Calf Bands/Cuffs (Single Bar 'Ak' Orthosis), Custom Fabricated), L2005 (Knee Ankle Foot Orthosis, Any Material, Single Or Double Upright, Stance Control, Automatic Lock And Swing Phase Release, Any Type Activation, Includes Ankle Joint, Any Type, Custom Fabricated), L2006 (Knee Ankle Foot Device, Any Material, Single Or Double Upright, Swing And Stance Phase Microprocessor Control With Adjustability, Includes All Components (E.G., Sensors, Batteries, Charger), Any Type Activation, With Or Without Ankle Joint(S), Custom Fabricated), L2010 (Knee Ankle Foot Orthosis, Single Upright, Free Ankle, Solid Stirrup, Thigh And Calf Bands/Cuffs (Single Bar 'Ak' Orthosis), Without Knee Joint, Custom Fabricated), L2020 (Knee Ankle Foot Orthosis, Double Upright, Free Ankle, Solid Stirrup, Thigh And Calf Bands/Cuffs (Double Bar 'Ak' Orthosis), Custom Fabricated), L2030 (Knee Ankle Foot Orthosis, Double Upright, Free Ankle, Solid Stirrup, Thigh And Calf Bands/Cuffs, (Double Bar 'Ak' Orthosis), Without Knee Joint, Custom Fabricated), L2034 (Knee Ankle Foot Orthosis, Full Plastic, Single Upright, With Or Without Free Motion Knee, Medial Lateral Rotation Control, With Or Without Free Motion Ankle, Custom Fabricated), L2035 (Knee Ankle Foot Orthosis, Full Plastic, Static (Pediatric Size), Without Free Motion Ankle, Prefabricated, Includes Fitting And Adjustment), L2036 (Knee Ankle Foot Orthosis, Full Plastic, Double Upright, With Or Without Free Motion Knee, With Or Without Free Motion Ankle, Custom Fabricated), L2037 (Knee Ankle Foot Orthosis, Full Plastic, Single Upright, With Or Without Free Motion Knee, With Or Without Free Motion Ankle, Custom Fabricated), L2038 (Knee Ankle Foot Orthosis, Full Plastic, With Or Without Free Motion Knee, Multi-Axis Ankle, Custom Fabricated), L2106 (Ankle Foot Orthosis, Fracture Orthosis, Tibial Fracture Cast Orthosis, Thermoplastic Type Casting Material, Custom Fabricated), L2108 (Ankle Foot Orthosis, Fracture Orthosis, Tibial Fracture Cast Orthosis, Custom Fabricated), L2112 (Ankle Foot Orthosis, Fracture Orthosis, Tibial Fracture Orthosis, Soft, Prefabricated, Includes Fitting And Adjustment), L2114 (Ankle Foot Orthosis, Fracture Orthosis, Tibial Fracture Orthosis, Semi-Rigid, Prefabricated, Includes Fitting And Adjustment), L2116 (Ankle Foot Orthosis, Fracture Orthosis, Tibial Fracture Orthosis, Rigid, Prefabricated, Includes Fitting And Adjustment), L2126 (Knee Ankle Foot Orthosis, Fracture Orthosis, Femoral Fracture Cast Orthosis, Thermoplastic Type Casting Material, Custom Fabricated), L2128 (Knee Ankle Foot Orthosis, Fracture Orthosis, Femoral Fracture Cast Orthosis, Custom Fabricated), L2132 (Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis, Soft, Prefabricated, Includes Fitting And Adjustment), L2134 (Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis, Semi-Rigid, Prefabricated, Includes Fitting And Adjustment), L2136 (Kafo, Fracture Orthosis, Femoral Fracture Cast Orthosis, Rigid, Prefabricated, Includes Fitting And Adjustment), L2180 (Addition To Lower Extremity Fracture Orthosis, Plastic Shoe Insert With Ankle Joints), L2182 (Addition To Lower Extremity Fracture Orthosis, Drop Lock Knee Joint), L2184 (Addition To Lower Extremity Fracture Orthosis, Limited Motion Knee Joint), L2186 (Addition To Lower Extremity Fracture Orthosis, Adjustable Motion Knee Joint, Lerman Type), L2188 (Addition To Lower Extremity Fracture Orthosis, Quadrilateral Brim), L2190 (Addition To Lower Extremity Fracture Orthosis, Waist Belt), L2192 (Addition To Lower Extremity Fracture Orthosis, Hip Joint, Pelvic Band, Thigh Flange, And Pelvic Belt), L2200 (Addition To Lower Extremity, Limited Ankle Motion, Each Joint), L2210 (Addition To Lower Extremity, Dorsiflexion Assist (Plantar Flexion Resist), Each Joint), L2220 (Addition To Lower Extremity, Dorsiflexion And Plantar Flexion Assist/Resist, Each Joint), L2221 (Addition To Lower Extremity Orthosis, Ankle System, Microprocessor-Controlled Feature Plantarflexion And/Or Dorsiflexion, Includes Power Source), L2230 (Addition To Lower Extremity, Split Flat Caliper Stirrups And Plate Attachment), L2232 (Addition To Lower Extremity Orthosis, Rocker Bottom For Total Contact Ankle Foot Orthosis, For Custom Fabricated Orthosis Only), L2240 (Addition To Lower Extremity, Round Caliper And Plate Attachment), L2250 (Addition To Lower Extremity, Foot Plate, Molded To Patient Model, Stirrup Attachment), L2260 (Addition To Lower Extremity, Reinforced Solid Stirrup (Scott-Craig Type)), L2265 (Addition To Lower Extremity, Long Tongue Stirrup), L2270 (Addition To Lower Extremity, Varus/Valgus Correction ('T') Strap, Padded/Lined Or Malleolus Pad), L2275 (Addition To Lower Extremity, Varus/Valgus Correction, Plastic Modification, Padded/Lined), L2280 (Addition To Lower Extremity, Molded Inner Boot), L2300 (Addition To Lower Extremity, Abduction Bar (Bilateral Hip Involvement), Jointed, Adjustable), L2310 (Addition To Lower Extremity, Abduction Bar-Straight), L2320 (Addition To Lower Extremity, Non-Molded Lacer, For Custom Fabricated Orthosis Only), L2330 (Addition To Lower Extremity, Lacer Molded To Patient Model, For Custom Fabricated Orthosis Only), L2335 (Addition To Lower Extremity, Anterior Swing Band), L2340 (Addition To Lower Extremity, Pre-Tibial Shell, Molded To Patient Model), L2350 (Addition To Lower Extremity, Prosthetic Type, (Bk) Socket, Molded To Patient Model, (Used For 'Ptb' 'Afo' Orthoses)), L2360 (Addition To Lower Extremity, Extended Steel Shank), L2370 (Addition To Lower Extremity, Patten Bottom), L2375 (Addition To Lower Extremity, Torsion Control, Ankle Joint And Half Solid Stirrup), L2380 (Addition To Lower Extremity, Torsion Control, Straight Knee Joint, Each Joint), L2385 (Addition To Lower Extremity, Straight Knee Joint, Heavy Duty, Each Joint), L2387 (Addition To Lower Extremity, Polycentric Knee Joint, For Custom Fabricated Knee Ankle Foot Orthosis, 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), L2500 (Addition To Lower Extremity, Thigh/Weight Bearing, Gluteal/ Ischial Weight Bearing, Ring), L2510 (Addition To Lower Extremity, Thigh/Weight Bearing, Quadri- Lateral Brim, Molded To Patient Model), L2520 (Addition To Lower Extremity, Thigh/Weight Bearing, Quadri- Lateral Brim, Custom Fitted), L2525 (Addition To Lower Extremity, Thigh/Weight Bearing, Ischial Containment/Narrow M-L Brim Molded To Patient Model), L2526 (Addition To Lower Extremity, Thigh/Weight Bearing, Ischial Containment/Narrow M-L Brim, Custom Fitted), L2530 (Addition To Lower Extremity, Thigh-Weight Bearing, Lacer, Non-Molded), L2540 (Addition To Lower Extremity, Thigh/Weight Bearing, Lacer, Molded To Patient Model), L2550 (Addition To Lower Extremity, Thigh/Weight Bearing, High Roll Cuff), L2750 (Addition To Lower Extremity Orthosis, Plating Chrome Or Nickel, Per Bar), L2755 (Addition To Lower Extremity Orthosis, High Strength, Lightweight Material, All Hybrid Lamination/Prepreg Composite, Per Segment, For Custom Fabricated Orthosis Only), L2760 (Addition To Lower Extremity Orthosis, Extension, Per Extension, Per Bar (For Lineal Adjustment For Growth)), L2768 (Orthotic Side Bar Disconnect Device, Per Bar), L2780 (Addition To Lower Extremity Orthosis, Non-Corrosive Finish, Per Bar), L2785 (Addition To Lower Extremity Orthosis, Drop Lock Retainer, Each), L2795 (Addition To Lower Extremity Orthosis, Knee Control, Full Kneecap), L2800 (Addition To Lower Extremity Orthosis, Knee Control, Knee Cap, Medial Or Lateral Pull, For Use With Custom Fabricated Orthosis Only), 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), L2840 (Addition To Lower Extremity Orthosis, Tibial Length Sock, Fracture Or Equal, Each), L2850 (Addition To Lower Extremity Orthosis, Femoral Length Sock, Fracture Or Equal, Each), L2999 (Lower Extremity Orthoses, Not Otherwise Specified), L4002 (Replacement Strap, Any Orthosis, Includes All Components, Any Length, Any Type), L4010 (Replace Trilateral Socket Brim), L4020 (Replace Quadrilateral Socket Brim, Molded To Patient Model), L4030 (Replace Quadrilateral Socket Brim, Custom Fitted), L4040 (Replace Molded Thigh Lacer, For Custom Fabricated Orthosis Only), L4045 (Replace Non-Molded Thigh Lacer, For Custom Fabricated Orthosis Only), L4050 (Replace Molded Calf Lacer, For Custom Fabricated Orthosis Only), L4055 (Replace Non-Molded Calf Lacer, For Custom Fabricated Orthosis Only), L4060 (Replace High Roll Cuff), L4070 (Replace Proximal And Distal Upright For Kafo), L4080 (Replace Metal Bands Kafo, Proximal Thigh), L4090 (Replace Metal Bands Kafo-Afo, Calf Or Distal Thigh), L4100 (Replace Leather Cuff Kafo, Proximal Thigh), L4110 (Replace Leather Cuff Kafo-Afo, Calf Or Distal Thigh), L4130 (Replace Pretibial Shell), L4205 (Repair Of Orthotic Device, Labor Component, Per 15 Minutes), L4210 (Repair Of Orthotic Device, Repair Or Replace Minor Parts), L4350 (Ankle Control Orthosis, Stirrup Style, Rigid, Includes Any Type Interface (E.G., Pneumatic, Gel), Prefabricated, Off-The-Shelf), L4360 (Walking Boot, Pneumatic And/Or Vacuum, With Or Without Joints, With Or Without Interface Material, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise), L4361 (Walking Boot, Pneumatic And/Or Vacuum, With Or Without Joints, With Or Without Interface Material, Prefabricated, Off-The-Shelf), L4370 (Pneumatic Full Leg Splint, Prefabricated, Off-The-Shelf), L4386 (Walking Boot, Non-Pneumatic, With Or Without Joints, With Or Without Interface Material, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise), L4387 (Walking Boot, Non-Pneumatic, With Or Without Joints, With Or Without Interface Material, Prefabricated, Off-The-Shelf), L4392 (Replacement, Soft Interface Material, Static Afo), L4394 (Replace Soft Interface Material, Foot Drop Splint), L4396 (Static Or Dynamic Ankle Foot Orthosis, Including Soft Interface Material, Adjustable For Fit, For Positioning, May Be Used For Minimal Ambulation, Prefabricated Item That Has Been Trimmed, Bent, Molded, Assembled, Or Otherwise Customized To Fit A Specific Patient By An Individual With Expertise), L4397 (Static Or Dynamic Ankle Foot Orthosis, Including Soft Interface Material, Adjustable For Fit, For Positioning, May Be Used For Minimal Ambulation, Prefabricated, Off-The-Shelf), L4398 (Foot Drop Splint, Recumbent Positioning Device, Prefabricated, Off-The-Shelf), L4631 (Ankle Foot Orthosis, Walking Boot Type, Varus/Valgus Correction, Rocker Bottom, Anterior Tibial Shell, Soft Interface, Custom Arch Support, Plastic Or Other Material, Includes Straps And Closures, Custom Fabricated).

Coverage indications, limitations and medical necessity

For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements.

The purpose of a Local Coverage Determination (LCD) is to provide information regarding “reasonable and necessary” criteria based on Social Security Act § 1862(a)(1)(A) provisions.

In addition to the “reasonable and necessary” criteria contained in this LCD there are other payment rules, which are discussed in the following documents, that must also be met prior to Medicare reimbursement:

• The LCD-related Standard Documentation Requirements Article, located at the bottom of this policy under the Related Local Coverage Documents section.

• The LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

• Refer to the Supplier Manual for additional information on documentation requirements.

• Refer to the DME MAC web sites for additional bulletin articles and other publications related to this LCD.

For the items addressed in this LCD, the “reasonable and necessary” criteria, based on Social Security Act § 1862(a)(1)(A) provisions, are defined by the following coverage indications, limitations and/or medical necessity.

For Ankle-Foot Orthoses (AFO) and Knee-Ankle-Foot Orthoses (KAFO) definitions of off-the-shelf and custom fitted, refer to the CODING GUIDELINES section in the LCD-related Policy Article.

AFOs NOT USED DURING AMBULATION:

An L4396 or L4397 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria 1 - 4 or criterion 5 is met:

• Plantar flexion contracture of the ankle ( refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses ) with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and,

• Reasonable expectation of the ability to correct the contracture; and,

• Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities; and,

• Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons.

• The beneficiary has plantar fasciitis ( refer to the Group 1 Codes in the ICD-10 code list in the LCD-related Policy Article for applicable diagnoses ).

If an L4396 or L4397 is used for the treatment of a plantar flexion contracture, the pre-treatment passive range of motion must be measured with a goniometer and documented in the medical record. There must be documentation of an appropriate stretching program carried out by professional staff (in a nursing facility) or caregiver (at home).

An L4396 or L4397 and replacement interface (L4392) will be denied as not reasonable and necessary if the contracture is fixed. Codes L4396, L4397 and L4392 will be denied as not reasonable and necessary for a beneficiary with a foot drop but without an ankle flexion contracture. A component of a static/dynamic AFO that is used to address positioning of the knee or hip will be denied as not reasonable and necessary because the effectiveness of this type of component is not established.

If code L4396 or L4397 is covered, a replacement interface (L4392) is covered as long as the beneficiary continues to meet indications and other coverage rules for the splint. Coverage of a replacement interface is limited to a maximum of one (1) per 6 months. Additional interfaces will be denied as not reasonable and necessary.

Medicare does not reimburse for a foot drop splint/recumbent positioning device (L4398) or replacement interface (L4394). A foot drop splint/recumbent positioning device and replacement interface will be denied as not reasonable and necessary in a beneficiary with foot drop who is nonambulatory because there are other more appropriate treatment modalities.

AFOs AND KAFOs USED DURING AMBULATION:

Ankle-foot orthoses (AFO) described by codes L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1933, L1940, L1945, L1950, L1951, L1952, L1960, L1970, L1971, L1980, L1990, L2106, L2108, L2112, L2114, L2116, L4350, L4360, L4361, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:

Require stabilization for medical reasons, and,

Have the potential to benefit functionally.

Knee-ankle-foot orthoses (KAFO) described by codes L2000, L2005, L2010, L2020, L2030, L2034, L2035, L2036, L2037, L2038, L2126, L2128, L2132, L2134, L2136, and L4370 are covered for ambulatory beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.

If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable and necessary.

AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage criteria listed above and one of the following criteria are met:

• The beneficiary could not be fit with a prefabricated AFO; or,

• The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,

• There is a need to control the knee, ankle or foot in more than one plane; or,

• The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating to prevent tissue injury; or,

• The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

If a custom fabricated orthosis is provided but basic coverage criteria above and the additional criteria 1-5 for a custom fabricated orthosis are not met, the custom fabricated orthosis will be denied as not reasonable and necessary.

L coded additions to AFOs and KAFOs (L2180, L2182, L2184, L2186, L2188, L2190, L2192, L2200, L2210, L2220, L2230, L2232, L2240, L2250, L2260, L2265, L2270, L2275, L2280, L2300, L2310, L2320, L2330, L2335, L2340, L2350, L2360, L2370, L2375, L2380, L2385, L2387, L2390, L2395, L2397, L2405, L2415, L2425, L2430, L2492, L2500, L2510, L2520, L2525, L2526, L2530, L2540, L2550, L2750, L2755, L2760, L2768, L2780, L2785, L2795, L2800, L2810, L2820, L2830) will be denied as not reasonable and necessary if either the base orthosis is not reasonable and necessary or the specific addition is not reasonable and necessary.

Concentric adjustable torsion style mechanisms used to assist knee joint extension are coded as L2999 and are covered for beneficiaries who require knee extension assist in the absence of any co-existing joint contracture.

Concentric adjustable torsion style mechanisms used to assist ankle joint plantarflexion or dorsiflexion are coded as L2999 and are covered for beneficiaries who require ankle plantar or dorsiflexion assist in the absence of any co-existing joint contracture.

Concentric adjustable torsion style mechanisms used for the treatment of contractures, regardless of any co-existing condition(s), are coded as E1810, E1813, E1814, E1815, E1822, and/or E1823 and are covered under the Durable Medical Equipment benefit (refer to the CODING GUIDELINES section in the LCD-related Policy Article).

Claims for devices incorporating concentric adjustable torsion style mechanisms used for the treatment of any joint contracture and coded as L2999 will be denied as incorrect coding.

Refer to the Orthopedic Footwear policy for information on coverage of shoes and related items which are an integral part of a brace.

Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are covered under the refill requirements.

GENERAL

A Standard Written Order (SWO) must be communicated to the supplier before a claim is submitted. If the supplier bills for an item addressed in this policy without first receiving a completed SWO, the claim shall be denied as not reasonable and necessary.

For Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) base items that require a Written Order Prior to Delivery (WOPD), the supplier must have received a signed SWO before the DMEPOS item is delivered to a beneficiary. If a supplier delivers a DMEPOS item without first receiving a WOPD, the claim shall be denied as not reasonable and necessary. Refer to the LCD-related Policy Article, located at the bottom of this policy under the Related Local Coverage Documents section.

For DMEPOS base items that require a WOPD, and also require separately billed associated options, accessories, and/or supplies, the supplier must have received a WOPD which lists the base item and which may list all the associated options, accessories, and/or supplies that are separately billed prior to the delivery of the items. In this scenario, if the supplier separately bills for associated options, accessories, and/or supplies without first receiving a completed and signed WOPD of the base item prior to delivery, the claim(s) shall be denied as not reasonable and necessary.

An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. Claims that do not meet coding guidelines shall be denied as not reasonable and necessary/incorrectly coded.

Proof of delivery (POD) is a Supplier Standard and DMEPOS suppliers are required to maintain POD documentation in their files. Proof of delivery documentation must be made available to the Medicare contractor upon request. All services that do not have appropriate proof of delivery from the supplier shall be denied as not reasonable and necessary.

Summary of evidence (opening)

N/A

the full summary and analysis of evidence are in the CMS record.

Dates, lineage and related policies

Original determination effective: 2015-10-01
Current revision effective: 2026-04-01
Last reviewed by the contractor: 2019-01-08
MCD version: 43
Derived from: L11517

Other related documents: A55426 (Article).

Using this policy on a claim

Match the documented indication to the covered indications above before the service is scheduled, carry a diagnosis from the article's covered list on the claim line, and keep the elements the documentation section asks for in the record, because the contractor can request it later through medical review. A denial under this policy arrives as CARC 50 with remark N115; the LCD lookup guide walks through the appeal path and the Advance Beneficiary Notice rules, and the Noridian Healthcare Solutions, LLC hub and CGS Administrators, LLC hub list every other active policy from the same contractor.

Frequently asked questions

What does LCD L33686 cover?

For Ankle-Foot Orthoses (AFO) and Knee-Ankle-Foot Orthoses (KAFO) definitions of off-the-shelf and custom fitted, refer to the CODING GUIDELINES section in the LCD-related Policy Article. The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database export of September 24, 2026.

Which states does LCD L33686 apply to?

Noridian Healthcare Solutions, LLC and CGS Administrators, LLC apply it to Medicare claims in AK, AL, AR, AS, AZ, CA, CNMI, CO, CT, DC, DE, FL, GA, GU, HI, IA, ID, IL, IN, KS, KY, LA, MA, MD, ME, MI, MN, MO, MS, MT, NC, ND, NE, NH, NJ, NM, NV, NY, OH, OK, OR, PA, PR, RI, SC, SD, TN, TX, UT, VA, VI, VT, WA, WI, WV, WY. A Local Coverage Determination binds only the contractor that wrote it; the same service in another jurisdiction is judged under that contractor's own policy or, where none exists, claim by claim.

Which diagnosis codes support medical necessity under LCD L33686?

The companion article article A52457 lists 12 ICD-10-CM codes in 2 groups that support medical necessity; the first 12 appear on this page and the complete list is in the article on cms.gov.

How do I appeal a denial under LCD L33686?

The remittance carries claim adjustment reason code 50 with remark code N115, naming the LCD. Compare the documented indication with the policy's covered indications and the article's diagnosis list, then file a redetermination within 120 days with the record attached; if the service genuinely falls outside the policy, the patient can be billed only when a valid Advance Beneficiary Notice was obtained before the service.

Sources

Every figure on this page is taken from the CMS publications below, as released by the Centers for Medicare & Medicaid Services. Projection built 2026-10-02. Verify against the primary file before billing or contracting decisions.

Medicare Coverage Database, current LCD export
Version MCD release 2026-09-24 · effective 2026-09-20 · file lcd.csvSHA-256 2fcc4251b6ddd1eb…
Medicare Coverage Database, current Billing and Coding Articles export
Version MCD release 2026-09-24 · effective 2026-09-20 · file article.csvSHA-256 f31932f1df3b4035…
ICD-10-CM FY2027 code descriptions
Version FY2027 · effective 2026-10-01 · file icd10cm_codes_2027.txtSHA-256 3c0583a38ee0e848…

Disclaimer

The policy text and code lists are reproduced from the CMS Medicare Coverage Database export as an operational reference. Verify against the current LCD and article on cms.gov before billing; coverage depends on the full record and the contractor. Not legal, clinical or billing advice.

LCD L33686: Ankle-Foot/Knee-Ankle-Foot Orthosis