Orthopedic Casts, Braces and Splints (CPB 0009, reviewed 2026-01-20)

By January 20, 2026: Billing team must implement the following changes: (1) Verify all orthotic device claims include prescriber credentials (physician, NP, podiatrist, or qualified health professional per state law) before processing; (2) Confirm provider certification status with American Board for Certification (ABC), Board of Certification/Accreditation (BOC), or state licensure documentation on file prior to claim submission; (3) Update claim scrubbing rules to reject cast-braces and back braces without evidence of prescription within 6 months of device provision; (4) Flag post-operative back braces (must be applied within 6 weeks post-surgery) separately from DME back braces in billing system; (5) Implement requirement that custom-fitted back braces must show prior failure/contraindication/intolerance to off-the-shelf braces or post-operative use, or claims will be denied; (6) Educate providers that cervical foam neck collars are non-covered (not durable) and should not be billed; (7) For pediatric hip braces and scoliosis braces, ensure documentation demonstrates stabilization/correction of congenital defect or medical necessity. Claims lacking proper documentation of prescriber qualifications, provider certification, or medical necessity criteria will face denial or recoupment.