DME Services, Ortho and Rehab Products

Medicare Diagnostic Criteria
Knee 
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Text Box: Text Box: Medicare Knee Orthoses Policy ICD-9 Matrix Revised April 4, 2011

ALL OF THE FOLLOWING CRITERIA FOR THE SPECIFIED PRODUCT
MUST BE MET TO BE COVERED

The patient must ambulatory; AND must have  knee instability that must be documented by examination of the beneficiary and objective description of joint laxity (e.g., varus/valgus instability, anterior/posterior Drawer test) due to a condition specified in the of the diagnoses listed below. NOTE:  Claims will be denied if only pain or a subjective description of joint instability is documented.

Rheumatoid arthritis (714.0-714.4)

Fx of femur-lower end (821.20-821.39)

Osteoarthritis (715.16, 715.26, 715.36, 715.96)

Fx of patella (822.0, 822.1)

Meniscal cartilage derangement (717.0-717.5)

Fx of tibia and/or fibula-upper end (823.00-823.42)

Chondromalacia of patella (717.7)

Dislocation of knee (836.00-836.69)

Knee Ligamentous disruption (717.81-717.9)

Sprain & strains of knee (844.0-844.2, 844.8)

Rupture of tendon nontraumatic quad tendon (727.65)

Failed total knee arthroplasty (996.40-996.49, 996.66, 996.77, V43.65)

Pathologic Fx of femur (733.15)

Multiple sclerosis (340)

Pathologic Fx of tibia or fibula (733.16)

Hemiplegia, unspecified (342.90)

Aseptic necrosis of tibia or fibula (733.49)

Infantile cerebral palsy, unspecified (343.9)

Stress fracture of the tibia or fibula (733.95)

Paraplegia of both lower limbs (344.1)

Congenital deformity of the knee (755.64)

Mononeuritis of lower limb, unspecified (355.0. 355.2)