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Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs) (CPB 0565, reviewed 2026-08-26)
Act
immediately
Effective date
Not stated in the notice
Identified
Oct 4, 2026
Summary
Aetna has updated its medical policy (CPB 0565) on ankle orthoses, AFOs, and KAFOs with specific coverage criteria. The policy clarifies medical necessity requirements, distinguishes coverage for acute vs. chronic conditions, and explicitly excludes coverage for certain indications (e.g., HMO plans do not cover foot drop splints, air-stirrups for chronic instability). Billing teams must ensure claims align with these specific clinical criteria and plan type restrictions to avoid denials.
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What to do
immediately · 33 steps
01Billing team must review and implement the following Aetna coverage restrictions in the claims submission system:
1. RESTRICTIONS BY PLAN TYPE:
- For HMO plans: Do NOT bill foot drop splints/recumbent positioning devices or related interfaces.
02Do NOT bill static/dynamic positioning AFOs when used solely for heel pressure ulcer prevention/treatment.
03- Ensure billing system flags HMO claims with these codes for denial/rejection before submission.
042. SPECIFIC COVERAGE DENIALS (All plan types):
- Air-stirrups (e.g., Air Cast): Deny when billed for chronic ankle instability or re-injury prevention.
05Approve only after acute ankle injury (fractures/sprains).
06- Elastic ankle sleeves: Deny for chronic ankle instability or re-injury prevention.
07Approve only for acute injury (acute and rehabilitative stages).
08- Orthoplast ankle stirrups: Deny for chronic instability or re-injury prevention.
09Approve only after acute injury.
10- Rigid ankle casts: Deny for ankle sprains, chronic instability, or re-injury prevention.
11Approve only for ankle fractures.
12- Semi-rigid ankle casts: Deny for ankle fractures, chronic instability, or re-injury prevention.
13Approve only for ankle sprains.
14- Unna boots: Deny for ankle fractures, chronic instability, or re-injury prevention.
15Approve only for ankle sprains and soft tissue injuries.
16- Static/dynamic positioning AFOs with knee/hip components: Deny (experimental/unproven).
17- AFO additions: Deny if base orthosis is not medically necessary.
18- AFOs in ambulatory members for edema or heel pressure ulcer prevention/treatment: Deny.
193. APPROVAL REQUIREMENTS:
- All orders must be prescribed by eligible providers (physician, NP, podiatrist, or qualified health professional per state law).
20- Verify prescriber is licensed/certified as required by state.
21- Confirm orthotic provider is certified by ABC or BOC, or licensed by state.
22- For custom molded AFOs in ambulatory patients: Verify medical necessity documentation in chart.
23- For static/dynamic positioning AFOs (contracture splints): Verify goniometer measurement documenting at least 10-degree dorsiflexion on passive ROM testing, documented stretching program, and contracture impact on function.
24- For post-operative ankle braces: Confirm application within 6 weeks of surgery.
25- For all orders: Verify provision within 6 months of prescription date.
264. DOCUMENTATION REQUIREMENTS:
- Instruct providers to document clinical indication (acute vs. chronic) on prescription/order.
27- For contracture splints: Require pre-treatment ROM measurements and stretching program details in medical record before billing.
28- Ensure medical records show physical examination supporting functional improvement/restoration of ADLs.
295. SYSTEM UPDATES:
- Update billing software edit rules to flag claims for non-approved indications.
30- Create denial reason codes mapping to each excluded indication.
31- Add billing alerts for HMO plan type restrictions.
32Consequences of inaction: Claims will be denied for lack of medical necessity, requiring rework and appeals.
33Systematic billing of non-covered indications may trigger audits.
Original notice
Ankle Orthoses, Ankle-Foot Orthoses (AFOs), and Knee-Ankle-Foot Orthoses (KAFOs) (CPB 0565, reviewed 2026-08-26)
aetna.com · Always check the source before changing claims.