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IMS Experts Partnership with HCA
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Indications for Medical Necessity

Pt requires brace:
⃝     To provide stabilization to weak or injured wrists
⃝     To prevent wrist flexion, extension, rotation, and deviation
⃝     To provide treatment of carpal tunnel syndrome, tendinitis or Rheumatoid arthritis
⃝     Post-surgical treatment of wrist and thumb
⃝     Post cast healing or soft tissue injury


Clinical Note Requirements: Dictation must be exactly as shown above for the indication chosen.

Wrist Brace Indications for Prescribed PT:

(Must select one of the following):

Wrist Brace



Most common ICD-10 codes:

G56.00 - Carpal tunnel syndrome
M06.9 - Rheumatoid arthritis 
M84.339K - Radius with ulna
S62.109A - Closed, carpal bone, unspecified Wrist NOS
S62.90XK - Malunion and nonunion of fracture 
S62.90XP - Malunion of fracture


Wrist Document Requirements: Signed/Dated RX, Clinicals with Indications. Up to date patient demographics with insurance information.

Foot/Ankle Brace Indications for Prescribed PT:
⃝     Require stabilization for medical reasons,

and, ⃝     Have the potential to benefit functionally.


An L4397 (Static or dynamic positioning ankle-foot orthosis) is covered if either all of criteria 1 - 4 OR criterion 5 is met:
1) Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing of at least 10 degrees (i.e., a nonfixed contracture); and,
2) Reasonable expectation of the ability to correct the contracture; and,
3) Contracture is interfering or expected to interfere significantly with the beneficiary's functional abilities; and,
4) Used as a component of a therapy program which includes active stretching of the involved muscles and/or tendons. OR
5) The beneficiary has plantar fasciitis


Clinical Requirements: Must be Multi-Level Fusion. No single level fusion approvals. 

Foot/Ankle Brace

L1902, L1906, L1930, L1971, L4387

Most common ICD-10 codes:

M24.576 - Contracture, unspecified foot
M72.2 - Plantar fascial fibromatosis

S92.0 - Fracture of calcaneus
S92.1 - Fracture of talus
S92.2 - Fracture of other & unspecified tarsal 
S92.3 - Fracture of metatarsal bone(s)
S92.4- Fracture of great toe

S93.X - Dislocation and sprain of joints and ligaments at ankle, foot and toe

S93.40 - Sprain of unspecified ligament

S94.X - Injury of nerves at ankle and foot level

S96.X - Injury of muscle and tendon at ankle and foot level

S97.0 - Crushing injury of ankle

Foot/Ankle Document Requirements: Signed/Dated RX, Clinicals with Indications. Signed/Dated CMN. Up to date patient demographics with insurance information.

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