An Ankle-Foot Orthosis (AFO) is a brace designed to support the ankle and foot, helping to control position and motion, correct deformities, or compensate for weakness. These devices are frequently custom-fabricated or custom-fitted to provide precise support for individuals with conditions like foot drop, stroke, or multiple sclerosis. Medicare covers AFOs, but the process is governed by specific rules and documentation requirements that beneficiaries must understand.
Defining AFO Coverage Under Medicare Part B
Medicare covers Ankle-Foot Orthoses because they are classified as Durable Medical Equipment (DME) under Medicare Part B. For the initial acquisition of an AFO to be covered, it must be determined to be medically necessary for the diagnosis or treatment of an illness or injury, or to improve the function of a malformed body member. The orthosis must be a rigid or semi-rigid device that supports a weak or deformed body member or restricts motion.
The process begins with a physician’s prescription detailing the specific condition being treated, which serves as proof of medical necessity. This prescription must be supported by medical record documentation from the treating physician confirming the patient is an ambulatory individual who requires stabilization. For a custom-fabricated AFO, additional documentation is required to justify why a prefabricated device would not meet the patient’s needs.
Medicare also requires that the AFO be supplied by a supplier who is enrolled with Medicare and accepts assignment. If the supplier is not enrolled in Medicare, or if the documentation does not meet all the Local Coverage Determination (LCD) criteria, the claim will be denied.
Understanding Patient Out-of-Pocket Costs
Once an AFO is determined to be medically necessary and all coverage criteria are met, the cost-sharing structure of Medicare Part B applies. The beneficiary is first responsible for meeting the annual Part B deductible. This deductible must be paid out-of-pocket before Medicare begins to pay its share for any Part B services, including the AFO.
After the deductible has been satisfied, Medicare Part B typically pays 80% of the Medicare-approved amount for the device. The remaining 20% is the patient’s coinsurance responsibility. The financial burden is manageable when the supplier agrees to “accept assignment,” meaning they accept the Medicare-approved amount as payment in full.
If a supplier does not accept assignment, they may charge the beneficiary more than the Medicare-approved amount, which is known as a balance bill. Beneficiaries who have supplemental insurance, such as Medigap or a Medicare Advantage plan, may find their 20% coinsurance is covered by that secondary policy.
When Medicare Allows AFO Replacement
The frequency of Medicare coverage for a new AFO is governed by the “Reasonable Useful Lifetime” (RUL) rule applied to durable medical equipment and orthoses. For an AFO, the RUL is generally set at five years, meaning Medicare will typically not pay for a replacement device within this five-year period.
A new AFO can be covered before the five-year RUL expires under specific, limited exceptions, which must be clearly documented. One exception is if the device is lost, stolen, or has sustained irreparable damage from a specific accident or natural disaster. Irreparable damage refers to catastrophic failure, not simple wear and tear from daily use, which Medicare expects to be managed through repairs.
The other primary exception for replacement is a significant change in the patient’s medical condition that renders the existing orthosis medically inappropriate. This could include an anatomical change, such as substantial weight fluctuation or a worsening of the underlying condition, requiring a different type of brace to meet the patient’s needs. When a replacement is medically necessary due to a change in condition, the new AFO must often be a different type of device than the original to avoid denial under the “same or similar” policy. Repairs to an existing AFO, such as replacing straps or pads, are covered as often as necessary, provided the total cost of repairs does not exceed the cost of replacing the entire device.