PINs and Reimbursement Schedule for Orthoses

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PharmaCare approval is based on the provider’s usual and customary price up to the PharmaCare maximum reimbursement specified below. For additional information about reimbursement for orthoses refer to the PharmaCare Prosthetic and Orthotic Policy Manual, Section 3.

Use the applicable PIN on all applications and invoices.

Jump to: Supramalleolar orthosis  |  Ankle foot orthosis  |  Knee ankle foot orthosis  |  Hip abduction orthosis  |  Spinal orthosis


Supramalleolar orthosis

  • Must be made from high temperature plastic
  • Must be custom fabricated from client model
  • Extends to just above malleoli (ankle) and to the toes
PIN Type of Orthosis (Abbreviation)  Description  Maximum Reimbursement 
77123507 Supramalleolar orthosis (SMO)  Note that PharmaCare does not cover:
  • Foot orthoses
  • UCBL (University of California Biomechanics Laboratory)
$1,445

Ankle foot orthosis

  • Must be made from high-temperature plastic
  • Must be custom fabricated from client model
  • Extends from below the knee, down to and including the foot
PIN Type of Orthosis (Abbreviation)  Description  Maximum Reimbursement 
77123508 Ankle foot orthosis (AFO) – rigid
  • May be made from flexible plastic which will allow some movement
  • Ankle joint is not included
$1,890
77123509 Ankle foot orthosis (AFO) – articulated
  • Includes an ankle joint
$2,160
77123510 Ankle foot orthosis with supramalleolar orthosis (AFO w/ SMO) – rigid
  • The SMO is molded and then a different type of AFO is molded over the top of the SMO; they can then be worn separately or together (i.e., SMO for circle time or floor play and AFO with SMO for walking)
  • Ankle joint is not included
$2,160
77123537 Ankle foot orthosis with supramalleolar orthosis (AFO w/ SMO) – articulated
  • The SMO is molded and then a different type of AFO is molded over top of the SMO; they can then be worn separately or together (i.e., SMO for circle time or floor play and AFO with SMO for walking)
  • Includes an ankle joint
$2,325
77123511 Ankle foot orthosis (AFO), patella tendon bearing (PTB) – rigid
  • Must include both a posterior and an anterior shell – double mold
  • Must be used to offload weight from below the knee (i.e. tibia, fibula or ankle joint)
  • Ankle joint is not included
$3,400
77123536 Ankle foot orthosis (AFO), patella tendon bearing (PTB) – articulated
  • Must include both a posterior and an anterior shell – double mold
  • Must be used to offload weight from below the knee (i.e. tibia, fibula or ankle joint)
  • Includes an ankle joint
$4,200
77123538 Ankle foot orthosis (AFO), anti-crouch (ground reaction) – rigid
  • Must include both a posterior and an anterior shell – double mold
  • Must be used to limit or assist in controlling dorsi-flexion and assist in controlling knee extension
  • Ankle joint is not included
$2,200
77123539 Ankle foot orthosis (AFO), anti-crouch (ground reaction) – articulated
  • Must include both a posterior and an anterior shell – double mold
  • Must be used to limit or assist in controlling dorsi-flexion and assist in controlling knee extension
  • Includes an ankle joint
$2,525
77123540 Ankle foot orthosis (AFO), "Chevron"/double wrap
  • A posterior leaf spring (PLS) style AFO, consists of a calf cuff that tapers to a narrow band behind the ankle (the “leaf”) and widens back out to capture the heel and extend to the tip of the toes
  • “Chevron” describes the shape of the posterior reinforcement of the dual layer AFO
  • Chevron style can also be a ridged brace, similar to anti-crouch, which allows movement and brings the foot to a neutral position
  • The principle of the AFO is energy, storage and return (ESR)
  • Ankle joint is not included
$2,300

Knee ankle foot orthosis

  • Shells must be made from high-temperature plastic or similar
  • Should include metal sidebars
  • Must be custom fabricated from client model
  • Extends from above the knee to below knee, where it attaches to an AFO
PIN Type of Orthosis (Abbreviation)  Description  Maximum Reimbursement 
77123543 Knee ankle foot orthosis, knee extension only
  • Additional knee extension orthosis to be used with an AFO during non-ambulatory or night use to provide stretching
  • Full AFO cost is not included
$1,900
77123513 Knee ankle foot orthosis, rigid ankle (KAFO) 
  • Includes a knee joint
  • Ankle joint is not included
$4,760
77123514 Knee ankle foot orthosis, articulated ankle (KAFO)
  • Includes the cost for ankle joint plus a knee joint
$5,030
77123515 Hip knee ankle foot orthosis 
  • Includes the cost for ankle joint, a knee joint, and a hip joint
by approval
77123516 Reciprocating gait orthosis 
  • Must result from a Team Assessment with appropriate Team support
by approval

Hip abduction orthosis

Note that the following are NOT PharmaCare benefits:

  • Dennis Browne boots and/or bars
  • Torsion cables
  • Illfield design (metal spreader bar and thigh cuffs)
  • Bremer type unilateral tibial torsion control
  • Trilateral orthosis
PIN Type of Orthosis (Abbreviation)  Description  Maximum Reimbursement 
77123512 Congenital dislocation of hip (CDH)/hip dysplasia
  • Must be custom fit to client or to client model
  • Generally used only for very young children (i.e., infants)
  • Includes the following types of orthoses:
    • Wheaton brace
    • Pavlik harness
    • Rhino/Rhino cruiser (cruiser – up to 3 years)
    • Von Rosen
by approval
77123541 Standing, walking and sitting hip orthosis (SWASH)
  • Used generally for cerebral palsy patients
  • Must be custom fit to client or to client model
  • Must be determined by a Team Assessment
by approval
77123542 Legg-Calve-Perthes disease
  • Must be custom fit to client or client model
  • Include the following types of orthoses:
    • Scottish-Rite
by approval

Spinal orthosis

  • Must be custom fabricated to client or client model
  • Needed to provide spinal stability for clients with spina bifida, scoliosis, cerebral palsy (or other neuromuscular conditions) and similar medical conditions
  • All requests for Cheneau-style braces must include appropriate documentation showing that the team responsible for the client has taken the Cheneau training. At a minimum, the team must include an orthotist and a physiotherapist.
  • Note that the following orthoses are not PharmaCare benefits:
  • cervical collars (alone)
  • cervicothoracic orthosis (i.e., SOMI – sternal occipital-mandibular immobilizer)
  • Minerva brace
  • Aspen brace
  • Halo devices
  • spinal orthosis required post-surgery
  • spinal orthosis to treat spinal fractures
  • SpineCor brace
PIN Type of Orthosis (Abbreviation)  Description  Maximum Reimbursement 
77123544 Lumbar sacral orthosis (LSO)
  • Two-piece clamshell design but may also be a single piece with an opening on the front
  • Extends from just below the sternum down to and including the pelvis
  • Custom made from rigid plastic
$1,835
77123517 Thoracic lumbar sacral orthosis (TLSO)
  • Two-piece clamshell design but may also be a single piece with anterior or posterior opening
  • Extends from just below the clavicles down to and including the pelvis
  • Custom made from rigid plastic
$2,620
77123545 Cervical thoracic lumbar sacral orthosis (CTLSO)
  • Full-torso brace that extends from the base of the skull down to and including the pelvis
  • Custom made (from rigid plastic) pelvic girdle and a metal structure that extends to the neck
$3,225
77123499 Plagiocephaly orthosis $3,145
77123535 Plagiocephaly orthosis $3,145