Medical policy: Knee Braces

Número de política: MP 6.012

Beneficio clínico

  • Minimizar el riesgo o la preocupación de seguridad.
  • Minimizar las intervenciones dañinas o ineficaces.
  • Garantizar el nivel de atención adecuado.
  • Asegurar la duración adecuada del servicio para las intervenciones.
  • Asegurar que se hayan cumplido los requisitos médicos recomendados.
  • Asegurar el lugar apropiado para el tratamiento o servicio.

Fecha de entrada en vigor: 3/1/2026

Política

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 investigational as there is insufficient evidence to support a general conclusion regarding the health outcomes or benefits associated with this item.

Prophylactic knee braces are considered investigational as there is insufficient evidence to support a general conclusion regarding the health outcomes or benefits associated with this item.

Note: The provider requesting/ordering the DME should be a provider with whom the member has established a relationship and is involved in the ongoing care of the member and the condition for which the DME/orthotic is prescribed.

Cross-references:

  • MP 6.062 Ankle-foot and knee-ankle-foot orthoses

Variaciones del producto

Esta política solo se aplica a ciertos programas y productos administrados por Capital Blue Cross y está sujeta a variaciones en los beneficios. Consulte la información adicional a continuación.

FEP PPO - Consulte el Manual de Políticas Médicas de FEP.

Descripción/antecedentes

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 4 categories 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 high-performance sports activities. Functional knee braces have also been 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.

Fundamento

Summary of evidence

Evidence of efficacy is limited for off-the-shelf bracing for osteoarthritis, ligamentous instability, or patellofemoral pain.

Definiciones

Custom-made brace describes a brace that is made according to precise measurements or molds/casts of an individual patient. Thus, this type of 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.

Exención de responsabilidad

Las políticas médicas de Capital Blue Cross se utilizan para determinar la cobertura de tecnologías, procedimientos, equipos y servicios médicos específicos. Estas políticas médicas no constituyen asesoramiento médico y están sujetas a cambios según lo exija la ley o las pruebas clínicas aplicables de las directrices de tratamiento independientes. Los proveedores que brindan tratamiento son individualmente responsables de los consejos médicos y el tratamiento de los miembros. Estas políticas no son una garantía de cobertura o pago. El pago de las reclamaciones está sujeto a la determinación del programa de beneficios del miembro y la elegibilidad en la fecha del servicio, y a la determinación de que los servicios son médicamente necesarios y apropiados. El procesamiento final de una reclamación se basa en los términos del contrato que se aplican al programa de beneficios de los miembros, incluidas las limitaciones y exclusiones de beneficios. Si un proveedor o miembro tiene alguna pregunta sobre esta política médica, debe comunicarse con Servicios para proveedores o Servicios para miembros de Capital Blue Cross.

Información de codificación

Note: This list of codes may not be all-inclusive, and codes are subject to change at any time. La identificación de un código en esta sección no denota cobertura, ya que la cobertura está determinada por los términos de la información de beneficios del miembro. Además, no todos los servicios cubiertos son elegibles para un reembolso por separado.

Custom-made functional and prophylactic knee braces are considered investigational:

Procedure codes

L1834

L1840

L1846

 

 

Custom-made unloader knee braces are covered when medically necessary for painful osteoarthritis:

Procedure codes

L1844

 

 

 

 
ICD-10-CM diagnosis code*
Descripción

M17.0

Bilateral primary osteoarthritis of knee

M17.11

Unilateral primary osteoarthritis, right knee

M17.12

Unilateral primary osteoarthritis, left knee

M17.2

Bilateral post-traumatic osteoarthritis of 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

Prefabricated/off-the-shelf custom fitted knee braces are covered when medically necessary

Procedure codes

L1810

L1812

L1820

L1821

L1830

L1831

L1832

L1833

L1836

L1843

L1845

L1847

L1848

L1850

L1851

L1852

 

 

 

 
ICD-10-CM diagnosis code*
Descripción

M17.0

Bilateral primary osteoarthritis of knee

M17.11

Unilateral primary osteoarthritis, right knee

M17.12

Unilateral primary osteoarthritis, left knee

M17.2

Bilateral post-traumatic osteoarthritis of 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

M22.01

Recurrent dislocation of patella, right knee

M22.02

Recurrent dislocation of patella, left knee

M22.11

Recurrent subluxation of patella, right knee

M22.12

Recurrent subluxation of patella, left knee

M22.2X1

Patellofemoral disorders, right knee

M22.2X2

Patellofemoral disorders, left knee

M22.41

Chondromalacia patellae, right knee

M22.42

Chondromalacia patellae, left 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

M23.203

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

M23.206

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

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

M23.231

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

M23.241

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

M23.251

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

M23.261

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

M23.300

Other meniscus derangements, unspecified lateral meniscus, right knee

M23.301

Other meniscus derangements, unspecified lateral meniscus, left knee

M23.303

Other meniscus derangements, unspecified medial meniscus, right knee

M23.304

Other meniscus derangements, unspecified medial meniscus, left knee

M23.306

Other meniscus derangements, unspecified meniscus, right knee

M23.307

Other meniscus derangements, unspecified meniscus, left 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

M23.331

Other meniscus derangements, other medial meniscus, right knee

M23.332

Other meniscus derangements, other medial meniscus, left 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

M23.351

Other meniscus derangements, posterior horn of lateral meniscus, right knee

M23.352

Other meniscus derangements, posterior horn of lateral meniscus, left knee

M23.361

Other meniscus derangements, other lateral meniscus, right knee

M23.362

Other meniscus derangements, other lateral meniscus, left knee

M23.41

Loose body in knee, right knee

M23.42

Loose body in knee, left knee

M23.51

Chronic instability of knee, right knee

M23.52

Chronic instability of knee, left 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

M23.621

Other spontaneous disruption of posterior cruciate ligament of right knee

M23.622

Other spontaneous disruption of posterior cruciate ligament of left 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

M23.641

Other spontaneous disruption of lateral collateral ligament of right knee

M23.642

Other spontaneous disruption of lateral collateral ligament of left knee

M23.671

Other spontaneous disruption of capsular ligament of right knee

M23.672

Other spontaneous disruption of capsular ligament of left knee

M23.8X1

Other internal derangements of right knee

M23.8X2

Other internal derangements of left knee

M25.261

Flail joint, right knee

M25.262

Flail joint, left knee

M25.361

Other instability, right knee

M25.362

Other instability, left knee

S82.011A

Displaced osteochondral fracture of right patella, initial encounter for closed fracture

S82.012A

Displaced osteochondral fracture of left patella, initial encounter for closed fracture

S82.014A

Nondisplaced osteochondral fracture of right patella, initial encounter for closed fracture

S82.015A

Nondisplaced osteochondral fracture of left patella, initial encounter for closed fracture

S82.016A

Nondisplaced osteochondral fracture of unspecified patella, initial encounter for closed fracture

S82.021A

Displaced longitudinal fracture of right patella, initial encounter for closed fracture

S82.022A

Displaced longitudinal fracture of left patella, initial encounter for closed fracture

S82.024A

Nondisplaced longitudinal fracture of right patella, initial encounter for closed fracture

S82.025A

Nondisplaced longitudinal fracture of left patella, initial encounter for closed fracture

S82.031A

Displaced transverse fracture of right patella, initial encounter for closed fracture

S82.032A

Displaced transverse fracture of left patella, initial encounter for closed fracture

S82.034A

Nondisplaced transverse fracture of right patella, initial encounter for closed fracture

S82.035A

Nondisplaced transverse fracture of left patella, initial encounter for closed fracture

S82.041A

Displaced comminuted fracture of right patella, initial encounter for closed fracture

S82.042A

Displaced comminuted fracture of left patella, initial encounter for closed fracture

S82.044A

Nondisplaced comminuted fracture of right patella, initial encounter for closed fracture

S82.045A

Nondisplaced comminuted fracture of left patella, initial encounter for closed fracture

S82.091A

Other fracture of right patella, initial encounter for closed fracture

S82.092A

Other fracture of left patella, initial encounter for closed fracture

S83.011A

Lateral subluxation of right patella, initial encounter

S83.012A

Lateral subluxation of left patella, initial encounter

S83.014A

Lateral dislocation of right patella, initial encounter

S83.015A

Lateral dislocation of left patella, initial encounter

S83.091A

Other subluxation of right patella, initial encounter

S83.092A

Other subluxation of left patella, initial encounter

S83.094A

Other dislocation of right patella, initial encounter

S83.095A

Other dislocation of left patella, 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

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

S83.121A

Posterior subluxation of proximal end of tibia, right knee, initial encounter

S83.122A

Posterior subluxation of proximal end of tibia, left knee, initial encounter

S83.124A

Posterior dislocation of proximal end of tibia, right knee, initial encounter

S83.125A

Posterior dislocation of proximal end of tibia, left knee, initial encounter

S83.131A

Medial subluxation of proximal end of tibia, right knee, initial encounter

S83.132A

Medial subluxation of proximal end of tibia, left knee, initial encounter

S83.134A

Medial dislocation of proximal end of tibia, right knee, initial encounter

S83.135A

Medial dislocation of proximal end of tibia, left knee, initial encounter

S83.141A

Lateral subluxation of proximal end of tibia, right knee, initial encounter

S83.142A

Lateral subluxation of proximal end of tibia, left knee, initial encounter

S83.144A

Lateral dislocation of proximal end of tibia, right knee, initial encounter

S83.145A

Lateral dislocation of proximal end of tibia, left knee, initial encounter

S83.191A

Other subluxation of right knee, initial encounter

S83.192A

Other subluxation of left knee, initial encounter

S83.194A

Other dislocation of right knee, initial encounter

S83.195A

Other dislocation of left 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

S83.221A

Peripheral tear of medial meniscus, current injury, right knee, initial encounter

S83.222A

Peripheral tear of medial meniscus, current injury, left 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

S83.241A

Other tear of medial meniscus, current injury, right knee, initial encounter

S83.242A

Other tear of medial meniscus, current injury, left knee, initial encounter

S83.251A

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

S83.261A

Peripheral tear of lateral meniscus, current injury, right knee, initial encounter

S83.262A

Peripheral tear of lateral meniscus, current injury, left knee, initial encounter

S83.271A

Complex tear of lateral meniscus, current injury, right knee, initial encounter

S83.272A

Complex tear of lateral meniscus, current injury, left knee, initial encounter

S83.281A

Other tear of lateral meniscus, current injury, right knee, initial encounter

S83.282A

Other tear of lateral meniscus, current injury, left knee, initial encounter

S83.411A

Sprain of medial collateral ligament of right knee, initial encounter

S83.412A

Sprain of medial collateral ligament of left 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

S83.501A

Sprain of unspecified cruciate ligament of right knee, initial encounter

S83.502A

Sprain of unspecified cruciate ligament of left knee, initial encounter

S83.511A

Sprain of anterior cruciate ligament of right knee, initial encounter

S83.512A

Sprain of anterior cruciate ligament of left 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

S83.61XA

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 left knee, initial encounter

T84.012A

Broken internal right knee prosthesis

T84.013A

Broken internal left knee prosthesis

T84.022A

Instability of internal right knee prosthesis

T84.023A

Instability of internal left knee prosthesis

T84.032A

Mechanical loosening of internal right knee prosthetic joint

T84.033A

Mechanical loosening of internal left knee prosthetic joint

Z47.89

Encounter for other orthopedic aftercare

Referencias

  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, Kawakami K, 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).
  12. Sorna 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, 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 sources:

  1. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty) Evidence-Based Clinical Practice Guideline. Rosemont, IL: American Academy of Orthopaedic Surgeons; August 31, 2021.
  2. Deveza LA, Bennell K. Management of moderate to severe knee osteoarthritis. In: Hunter D, Law K, ed. UpToDate. UpToDate Inc; 2025. updated July 15, 2025.

Antecedentes de la política

MP 6.012

04/22/2020 Consensus review. No change to policy statements. References reviewed. Language revised under product variations, benefit variations, and disclaimer sections.

07/01/2021 Consensus review. No change to policy statement. Revisión y actualización de referencias.

02/11/2022 Consensus review. No change to policy statement. Cross reference added. Product variations updated.

12/08/2023 Consensus review. No change to policy statement. Rationale, definitions, and references updated.

09/18/2024 Administrative update. New code L1821 added effective 10/01/2024.

12/19/2024 Minor review. Removed individual consideration criteria from custom-made functional knee braces. References updated.

06/04/2025 Administrative update. Removed the Benefit Variations Section and updated the Disclaimer.

10/17/2025 Consensus review. No change to policy statement. Updated clinical benefit, definitions, and references. Coding reviewed with no coding changes.