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Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs) (CPB 0565, reviewed 2026-01-20)
Act
by Jan 20, 2026 (effective immediately)
Effective date
Jan 20, 2026
Identified
Aug 17, 2026
Summary
Aetna updated its medical policy (CPB 0565) for ankle orthoses, AFOs, and KAFOs, effective immediately as of January 20, 2026. This policy establishes specific medical necessity criteria for various ankle and foot orthotic devices, with distinct coverage rules for ambulatory vs. non-ambulatory patients, and excludes coverage for certain indications (e.g., chronic ankle instability prevention, heel pressure ulcer treatment in HMO plans). Billing teams must ensure claims align with the detailed device-specific indications outlined in the policy to avoid denials.
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What to do
by Jan 20, 2026 (effective immediately) · 5 steps
01Billing team must update claim submission rules in billing software to enforce Aetna's specific medical necessity criteria for each orthotic device type (air-stirrups, elastic sleeves, lace-up braces, cast-braces, rigid/semi-rigid casts, Unna boots, AFOs, and KAFOs).
02Clinical documentation team must ensure that provider orders include required justifications: specific diagnosis (acute injury vs. chronic instability), ambulatory status, and relevant clinical findings (e.g., goniometer measurements for contractures, passive range of motion documentation).
03Prior to claim submission: Verify that static/dynamic positioning AFOs for contractures include documentation of stretching programs and baseline goniometer measurements with minimum 10-degree dorsiflexion.
04Flag and deny claims for non-covered indications: air-stirrups for chronic ankle instability, elastic sleeves for prevention, rigid casts for sprains, AFOs for edema-only treatment, and foot drop splints in HMO plans.
05Providers must document that post-operative rehabilitation braces are applied within 6 weeks of surgery.
If missed: Failure to align claims with these specific criteria will result in denials from Aetna.
Original notice
Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs) (CPB 0565, reviewed 2026-01-20)
aetna.com · Always check the source before changing claims.