Key facts for NCD 280.12
- Benefit category
- Leg, Arm, Back, and Neck Braces (orthotics)
- Effective date
- This is a longstanding national coverage determination. The effective date of this version has not been posted.
- Transmittal
- n/a
- Versions published
- 1
- Manual chapter
- 280
- NCD Manual (Pub. 100-03)
TL;DR
NCD 280.12 sets Medicare's national policy for sykes hernia control under the benefit category "Leg, Arm, Back, and Neck Braces (orthotics)", effective This is a longstanding national coverage determination. The effective date of this version has not been posted.. Based on professional advice, it has been determined that the sykes hernia control (a spring-type, U-shaped, strapless truss) is not functionally more beneficial than a conventional truss. Make program reimbursement for this device only when an ordinary… It has been revised once since publication and binds every Medicare Administrative Contractor nationally.
Indications and limitations of coverage
Based on professional advice, it has been determined that the sykes hernia control (a spring-type, U-shaped, strapless truss) is not functionally more beneficial than a conventional truss. Make program reimbursement for this device only when an ordinary truss would be covered. (Like all trusses, it is only of benefit when dealing with a reducible hernia). Thus, when a charge for this item is substantially in excess of that which would be reasonable for a conventional truss used for the same condition, base reimbursement on the reasonable charges for the conventional truss.
Text reproduced from the CMS Medicare Coverage Database record for NCD 280.12 version 1. View the original on cms.gov.
How this NCD shows up on remittances
A service denied under a National Coverage Determination returns CARC 50 (not deemed medically necessary) with remark N386 (decision based on an NCD); a denial citing a local policy instead carries N115. Because NCDs bind nationally, the appeal path is documentation that the patient meets the indications above, not a contractor-policy argument.
How QuickIntell applies NCD 280.12
QuickAuth checks the ordered service and diagnosis against NCD and LCD criteria before the encounter, QuickCode validates the diagnosis pairing on the claim, and QuickRCM routes CARC 50 denials with the policy text and the covered-code list attached so the appeal starts with evidence.
Frequently asked questions — NCD 280.12
What does NCD 280.12 cover?
Based on professional advice, it has been determined that the sykes hernia control (a spring-type, U-shaped, strapless truss) is not functionally more beneficial than a conventional truss. Make program reimbursement for this device only when an ordinary truss would be covered. (Like all trusses, it is only of benefit when dealing with a reducible hernia). Thus, when a charge for this item is substantially in excess… The full indications and limitations are reproduced on this page from the CMS Medicare Coverage Database.
When did NCD 280.12 take effect?
The current version (1) is effective This is a longstanding national coverage determination. The effective date of this version has not been posted.. This is the only published version.
Does a Local Coverage Determination override NCD 280.12?
No. A National Coverage Determination binds all Medicare Administrative Contractors; an LCD can only address services or circumstances the NCD leaves open. Claims denied under this NCD typically return CARC 50 with remark N386 (NCD) rather than N115 (LCD).
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 NCDs via the CMS Coverage APIVersion API snapshot 2026-09-27 · effective 2026-09-20 · file national-coverage-ncd.jsonSHA-256 a90fadfd264b9ef4…
Disclaimer
This page reproduces the CMS National Coverage Determination text and, for laboratory NCDs, the CMS ICD-10 edit lists, as an operational reference. Coverage decisions depend on the full policy, the claim and the contractor; nothing here is legal, clinical or billing advice. CPT codes are shown as numbers only; CPT descriptors are copyright AMA.