MedicaidCoverageHigh impact
Orthotics - MEDICAID - SOUTH CAROLINA (Revised)
Humana·SC · Orthopedics, PM&R (Physical Medicine & Rehab), Physical Therapy +2 more·Medicaid
Effective date
Sep 23, 2026
We identified it
Sep 24, 2026
Summary
Humana SC Medicaid has issued a revised orthotics coverage policy (HUM-SC-2177-001) effective 09/23/2026 that establishes medical necessity criteria for braces, splints, casts, and orthopedic devices across lower extremity, foot, and spine categories. The policy specifies which HCPCS codes are covered and requires detailed clinical documentation and physician prescriptions for approval. Billing teams must ensure claims include proper medical justification aligned with the specific clinical criteria outlined for each orthotic type.
Action Required
Before 09/23/2026: Billing team must update claims submission and prior authorization processes to align with Humana SC Medicaid orthotics policy HUM-SC-2177-001. For all lower extremity orthotics (AFO L2108, L4631; hip orthotics L1681, L1685, L1686, L1690; KAFO L2126, L2134; Legg Perthes L1720, L1730, L1755), spine orthotics (cervical halo L0810, L0820, L0830, L0859; CTLSO L0700, L1000; TLSO L0970, L0974, L0976, L0980, L1200, L1310), and foot orthotics (L3202, L3203, L3204, L3649): (1) Providers must include detailed clinical documentation justifying medical necessity per policy criteria; (2) Billing team must require physician prescription documentation in claim files; (3) For AFO L2108 claims, require detailed description of tibial fracture with explanation of why support beyond ankle is medically necessary; (4) For static AFO L4631 contracture cases, require goniometer measurements of passive range of motion and documentation of stretching program; (5) Custom KAFO L2126 claims require clinical documentation explaining why prefabricated L2134 cannot be used; (6) For L3649 shoe modifications, require documentation of unique anatomical needs or advanced deformities. Update claim submission forms and provider order templates to include these documentation requirements. Implement internal pre-submission review to catch missing medical necessity documentation before sending to payer. Failure to include required documentation will result in claim denials.