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

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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

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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

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Knee ankle foot orthosis

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

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Hip abduction orthosis

Note that the following are NOT PharmaCare benefits:

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

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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:

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	Use when pre-approval is required (see PharmaCare Prosthetic and Orthotic Policy Manual, section 5.7.4)	$3,145
77123535	Plagiocephaly orthosis	Use when no pre-approval is required (see PharmaCare Prosthetic and Orthotic Policy Manual, section 5.7.2) Must meet all criteria and complete form HLTH 5450	$3,145