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Dorsal Night Splint

Suggested HCPCS Code:Β L4396/L4397

  • Soft, flexible brace
  • Easily fasten and adjust with Velcro closures
  • Gentle stretch provided through simple dorsiflexion strap
  • Fits either left or right foot


Underlying Conditions:

  • Plantar Fascial Fibromatosis
  • Contracture of Ankle
  • Contracture of Foot
  • Cervical Disc Disorder with Radiculopathy/Myelopathy


Coverage Criteria:Β (Patient must meet one of the following criteria)

  • Plantar Fasciitis


Or all of the following:

  • Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees.
  • Reasonable expectation of the ability to correct the contracture
  • Contracture is interfering/expected to interfere significantly with functional abilities
  • Splint is used as part of therapy program including active stretching of the involved muscles/tendons

Β 

Posterior Night Splint

Suggested HCPCS Code:Β L4396/L4397

  • Essential treatment for alleviation of night time plantar fasciitis pain
  • Three padded straps with buckles to ensure immobilization
  • Dual tension straps allow for increased flexion and foot angle for the optimum pain-relieving stretch
  • Lightweight night splint, low profile shell is sturdy
  • and breathable for proper plantar fasciitis treatment


Underlying Conditions:

  • Plantar Fascial Fibromatosis
  • Contracture of Ankle
  • Contracture of Foot


Coverage Criteria:Β (Patient must meet one of the following criteria)

  • Plantar Fasciitis


Or all of the following:

  • Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees.
  • Reasonable expectation of the ability to correct the contracture
  • Contracture is interfering/expected to interfere significantly with functional abilities
  • Splint is used as part of therapy program including active stretching of the involved muscles/tendons

Β 

Multi PODUS Boot

Suggested HCPCS Code:Β L4396/L4397

  • Flex Technology splint moves with the patient’s abnormal muscle tone and spasticity for comfort and helps to relax the abnormal muscle tone
  • Anti-rotation bar prevents rolling of the patient’s leg
  • Non-slip sole allows brief standing and walking
  • Dorsiflexion assist (flex) straps (aid in proper alignment of the foot and adjustable tension helps to control plantar flexion
  • Toe support has β€œtoe off” angle to assist in gait training and short ambulation
  • Available in fleece lining
  • Available with Flo Form


Underlying Conditions:

  • Plantar Fascial Fibromatosis
  • Contracture of Ankle
  • Contracture of Foot


Coverage Criteria:Β (Patient must meet one of the following criteria)

  • Plantar Fasciitis


Or all of the following:

  • Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees.
  • Reasonable expectation of the ability to correct the contracture
  • Contracture is interfering/expected to interfere significantly with functional abilities
  • Splint is used as part of therapy program including active stretching of the involved muscles/tendons

Equinus Brace

Suggested HCPCS Code:Β L4396 & L2210x2

  • Only dorsiflexion brace that fully extends the leg
  • Ensures gastric-soleus stretch
  • Controls ankle joint placement
  • Engages windlass mechanism


Underlying Conditions:

  • Plantar Fascial Fibromatosis
  • Contracture of Ankle
  • Contracture of Foot


Coverage Criteria:Β (Patient must meet one of the following criteria)

  • Plantar Fasciitis


Or all of the following:

  • Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees.
  • Reasonable expectation of the ability to correct the contracture
  • Contracture is interfering/expected to interfere significantly with functional abilities
  • Splint is used as part of therapy program including active stretching of the involved muscles/tendons

Β 

Air Cam Walker (High or Low)

Suggested HCPCS Code:Β L4360/L4361

  • Air bladders for customized compression
  • Hook and fastening straps for quick, easy fitting and adjustments
  • Velcro straps and padded insole for comfort and fit
  • Fits either left or right foot


Underlying Conditions:

  • Ankle Sprain
  • Ankle Fracture
  • Foot Fracture
  • Tendinitis
  • Flexion Deformity
  • Plantar Fascitis
  • Ankle Instability


Coverage Criteria:Β 

  • Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally from the boot