K0901 – Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

HCPCS Level II code · K codes: Temporary Codes for DME

Discontinued December 31, 2016 Carrier judgment

HCPCS codeK0901
Long description
Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
Short description
Ko single upright pre ots
Pricing indicator
38 Orthotics, prosthetics, prosthetic devices & vision services
Medicare coverage
C Carrier judgment – coverage decided by the Medicare contractor
BETOS category
D1F Prosthetic/Orthotic devices
Cross reference
L1851
Added
October 1, 2014
Last change
January 1, 2017 – No change
Termination date
December 31, 2016

Frequently asked questions

What is HCPCS code K0901?

K0901 is a HCPCS Level II code for knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf. It was discontinued on December 31, 2016.

Does Medicare cover K0901?

The HCPCS file lists coverage code C: Carrier judgment – coverage decided by the Medicare contractor. Coverage and payment also depend on local coverage determinations and the patient’s plan.

Nearby K codes

Source: CMS HCPCS Level II quarterly file, October 2026. Reference only – check payer policy before billing.