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:
|
$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 |
|
$1,890 |
77123509 | Ankle foot orthosis (AFO) – articulated |
|
$2,160 |
77123510 | Ankle foot orthosis with supramalleolar orthosis (AFO w/ SMO) – rigid |
|
$2,160 |
77123537 | Ankle foot orthosis with supramalleolar orthosis (AFO w/ SMO) – articulated |
|
$2,325 |
77123511 | Ankle foot orthosis (AFO), patella tendon bearing (PTB) – rigid |
|
$3,400 |
77123536 | Ankle foot orthosis (AFO), patella tendon bearing (PTB) – articulated |
|
$4,200 |
77123538 | Ankle foot orthosis (AFO), anti-crouch (ground reaction) – rigid |
|
$2,200 |
77123539 | Ankle foot orthosis (AFO), anti-crouch (ground reaction) – articulated |
|
$2,525 |
77123540 | Ankle foot orthosis (AFO), "Chevron"/double wrap |
|
$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 |
|
$1,900 |
77123513 | Knee ankle foot orthosis, rigid ankle (KAFO) |
|
$4,760 |
77123514 | Knee ankle foot orthosis, articulated ankle (KAFO) |
|
$5,030 |
77123515 | Hip knee ankle foot orthosis |
|
by approval |
77123516 | Reciprocating gait orthosis |
|
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 |
|
by approval |
77123541 | Standing, walking and sitting hip orthosis (SWASH) |
|
by approval |
77123542 | Legg-Calve-Perthes disease |
|
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) |
|
$1,835 |
77123517 | Thoracic lumbar sacral orthosis (TLSO) |
|
$2,620 |
77123545 | Cervical thoracic lumbar sacral orthosis (CTLSO) |
|
$3,225 |
77123499 | Plagiocephaly orthosis |
|
$3,145 |
77123535 | Plagiocephaly orthosis |
|
$3,145 |