Ankle-Foot (AFO)/Knee-Ankle-Foot (KAFO)/Hip-Knee-Ankle-Foot (HKAFO) Orthoses (Custom fabricated)
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Defines medical necessity, prior authorization requirements, covered and non-covered indications, and coding for custom-fabricated ankle-foot, knee-ankle-foot, and hip-knee-ankle-foot orthoses for Moda Health members.
Coverage Criteria for Custom-Fabricated Orthoses
Custom-fabricated AFO/KAFO medical necessity
Covered when ALL of the following are met:
Primary coverage conditions
- Knee functional deficit: Functional deficit of the knee, as indicated by one or more of: (1) knee joint contracture in the patient receiving physical therapy to promote ambulation; (2) knee joint instability not corrected by ankle-orthotic alone, and assistance with functional or therapeutic ambulation needed.
- Safety and capacity: No balance, trunk control, or upper body strength deficits that prevent safe ambulation with or without assistive devices; no cardiopulmonary disease limiting energy expenditure; no cognitive impairment preventing gait training or problem-solving during orthosis use.
- Ankle functional deficit: Functional deficit of the ankle, as indicated by one or more of: (1) need to prevent or reduce ankle joint contracture; (2) ankle joint mediolateral instability requiring assistance with ambulation; (3) dorsiflexors or plantar flexors paralyzed or weak with need for ambulation assistance; (4) plantar flexor muscles hypertonic or spastic with need for ambulation assistance.
Additional qualifying conditions (one required)
- Prefab fit failure: The member could not be fitted with a prefabricated AFO.
- Duration expectation: The condition necessitating the orthosis is expected to be permanent or lasting greater than 6 months.
- Multiplanar control need: There is a need (not prophylactic) to control the knee, ankle, or foot in more than one plane.
- Tissue injury prevention: Documented neurological, circulatory, or orthopedic status necessitates custom fabrication to prevent tissue injury.
- Anatomic/healing fracture: Patient has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.
The policy excludes certain uses of custom AFOs and KAFOs. Specifically, orthoses that are prescribed solely for use during participation in sports are considered not covered because sports participation is an elective activity; this exclusion is subject to the modifications described in Senate Bill 699 (SB 699) as noted in the addendum. Also excluded are orthoses used on uninjured body parts or prescribed solely to prevent injury, orthoses intended to treat pressure ulcers or edema, and "deluxe" equipment when a basic (standard) device meets the member's functional needs.
Custom-fabricated AFOs and KAFOs that do not meet the specified medical necessity criteria in this policy are considered not medically necessary. Requests for custom devices that lack documentation demonstrating fulfillment of the coverage criteria will be denied.
Coding — HCPCS / L-codes
| L1900 | Ankle-foot orthotic (AFO), custom fabricated |
| L1904 | Ankle-foot orthotic (AFO), spring wire, dorsiflexion assist calf band, custom fabricated |
| L1907 | Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated |
| L1920 | Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated |
| L1940 | Ankle-foot orthotic (AFO), single upright with static or adjustable stop, custom fabricated |
| L1945 | Ankle-foot orthotic (AFO), plastic or other material, custom fabricated |
| L1960 | Ankle-foot orthotic (AFO), posterior solid ankle, plastic, custom fabricated |
| L1970 | Ankle-foot orthotic (AFO), plastic with ankle joint, custom fabricated |
| L1980 | Ankle-foot orthotic (AFO), single upright free plantar dorsiflexion, solid stirrup, calf band/cuff, custom fabricated |
| L2000 | KAFO custom-fabricated |
| No codes listed |
Provider Actions and Prior Authorization Requirements
Submit all required information with PA request
Submit a complete prior authorization request including all items listed under “Information Submitted with the Prior Authorization Request”: a physician order/prescription stating the purpose of the orthosis; documentation of the member’s physical functional impairment as it affects ADLs and the medical condition requiring long‑term orthotic use; records of other devices trialed and found inadequate, unsafe, or contraindicated; and clear documentation that justifies the need for a CUSTOM orthotic.
- Include a physician order/prescription that states the purpose of the orthosis.
- Provide documentation of functional impairment in ADLs and the condition requiring long‑term orthotic use.
- Supply records of prior device trials and why they were inadequate, unsafe, or contraindicated.
- Ensure documentation clearly justifies the need for a CUSTOM orthotic or the request will be denied.
Document prior trial or failed fitting of prefabricated orthosis
Document that a prefabricated orthosis was tried and found inadequate or that the member could not be fitted with a prefabricated AFO when using that fact as the basis for requesting a custom device.
- If custom fabrication is requested because a prefab device failed, include evidence the member could not be fitted with a prefabricated AFO (see medical necessity criteria: “The member could not be fitted with a prefabricated AFO”).
- If no trial was possible, document why fitting was not feasible for this member.
- Attach fitting notes, measurements, or clinician observations supporting the fit failure.
Specific documentation to submit with PA
Include the physician order that states the purpose of the orthosis, plus objective documentation of functional impairment and records of other devices trialed and found inadequate, unsafe, or contraindicated.
- Physician order/prescription must state the purpose of the orthosis.
- Document how the member’s physical functional impairment affects activities of daily living without the device.
- Provide records describing other devices trialed and the reasons they were inadequate, unsafe, or contraindicated.
- Ensure documentation explicitly addresses the need for a CUSTOM orthotic.
Insufficient documentation or unmet medical‑necessity criteria will result in denial
Requests that lack documentation clearly addressing the need for a CUSTOM orthotic will be denied; custom AFOs and KAFOs that do not meet the stated medical necessity criteria (all required coverage criteria) are considered not medically necessary and will be denied.
- If documentation does not clearly justify custom fabrication, the prior authorization will be denied.
- Custom AFOs/KAFOs that fail to meet the policy’s medical necessity criteria (all required elements in Section II.A) are not medically necessary and will be denied.
Definitions
Background
Orthoses are external devices designed to modify neuromuscular and skeletal function to support mobility and prevent fixed deformities. Ankle-foot orthoses (AFOs) address foot and ankle weakness or deformity to improve gait and stability; knee-ankle-foot orthoses (KAFOs) add knee support to manage quadriceps weakness, knee instability, or hyperextension; and hip-knee-ankle-foot orthoses (HKAFOs) provide additional hip and pelvic control for conditions such as paralysis or spinal cord injury. These devices are intended to restore or improve safe ambulation, protect tissue, and maintain alignment when conservative measures are insufficient.
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