Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-061 - Prosthetics Provider Manual Update Transmittal #72

Universal Citation: AR Admin Rules 016.06.05-061

Current through Register Vol. 49, No. 9, September, 2024

Section II Prosthetics

201.000 Arkansas Medicaid Participation Requirements for Prosthetics Providers

Prosthetics providers must meet the following criteria in order to be eligible for participation in the Arkansas Medicaid Program:

A. The provider must complete a provider application (form DMS-652), a Medicaid contract (form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9). View or print the provider application (form DMS-652), the Medicaid contract (form DMS-653) and the Request for Taxpayer Identification Number and Certification (Form W-9).

B. Enrollment as a Medicaid provider is conditioned upon approval of a completed provider application and the execution of a Medicaid provider contract. Persons and entities that are excluded or debarred under any state or federal law, regulation or rule are not eligible to enroll, or to remain enrolled, as Medicaid providers.

C. The provider must be enrolled in the Title XVIII (Medicare) Program as a durable medical equipment/oxygen, orthotic appliances or prosthetic devices provider.

D. A copy of the verification letter that reflects the provider's Medicare supplier number must be submitted with the provider application and Medicaid contract.

E. A separate letter and Medicare supplier number must be submitted for each Medicaid service location.

NOTE: The orthotics/prosthetics provider should maintain accreditation by the American Board for Certification in Orthotics and Prosthetics. The provider should ensure that staff providing patient care (including but not limited to direct care, evaluations, diagnoses, fabrication fittings and follow up care) are accredited by the American Board for Certification in Orthotics and Prosthetics and meet all national licensing and certification requirements and all licensing and certifications required by the State of Arkansas.

242.154 Nasogastric Tubing for Individuals Under Age 21

The procedure code found in this section must be billed with modifier EP for beneficiaries under 21 years of age. Additionally, when billed on paper, the procedure code must be billed with a type of service (TOS) code "6" for individuals under age 21. The code is payable only for beneficiaries under age 21.

Procedure Code	M1	M2	PA	Description	Payment Method
B4082	EP	N	Nasogastric tubing without stylet	Purchase

242.180 Orthotic Appliances, All Ages

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for beneficiaries age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a "Y" in the column; if not, an "N" is shown. When prior authorization is not applicable (for U21) that information is shown with an "N/A" in the column.

When codes are payable for all ages, "All" is indicated in the column, "U21" is shown when the code is payable only for individuals under age 21 and "21+" is shown when the code is payable only for those individuals age 21 and older.

** This item is not a covered service for the diagnosis of Carpal Tunnel Syndrome prior to surgery.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Orthotic Appliances, All Ages (section 242.180)

Procedure Code	M1	M2	TOS	Description	All U21 21+	PA 21+	Payment Method
A5500	NU	H	For diabetics only, fitting (including follow-up) custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe	21+	Y	Purchase
A5501	NU	H	For diabetics only, fitting (including follow-up) custom preparation and supply of molded from cast(s) of patient's foot (custom molded shoe), per shoe	21+	Y	Purchase
A5503	NU	H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe	21+	Y	Purchase
A5504	NU	H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe	21+	Y	Purchase
A5505	NU	H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe	21+	Y	Purchase

A5506	NU	H	For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe	21+	Y	Purchase
A5507	NU	H	For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe	21+	Y	Purchase
A5509	NU	H	For diabetics only, direct formed, molded to foot with external heat source (i.e., heat gun) multiple density inserts(s), prefabricated, per shoe	21+	Y	Purchase
A5510	NU	H	For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe	21+	Y	Purchase
A5511	NU	H	For diabetics only, custom-molded from model of patient's foot multiple-density insert(s) custom-fabricated, per shoe	21+	Y	Purchase
K0630	NU EP	H 6	SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
K0631	NU EP	H 6	SO, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	All	N	Purchase
K0632	NU EP	H 6	SO, flexible, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase

K0633	NU	H	SO, provides pelvic-sacral support,	All	N	Manually
EP	6	with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated	Priced
K0634	NU EP	H 6	LO, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment	All	N	Purchase
K0635	NU EP	H 6	LO, sagittal control, with rigid posterior panel(s), includes straps, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
K0636	NU EP	H 6	LO, sagittal control, with rigid anterior and posterior panel(s), includes straps, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
K0637	NU EP	H 6	LSO, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase

K0638	NU EP	H 6	LSO, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced
K0639	NU EP	H 6	LSO, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
K0640	NU EP	H 6	LSO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
K0641	NU EP	H 6	LSO, sagittal control, with rigid anterior and posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced

K0642	NU EP	H 6	LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
K0643	NU EP	H 6	LSO, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Manually Priced
K0644	NU EP	H 6	LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
K0645	NU EP	H 6	LSO, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated	All	N	Purchase

K0646	NU EP	H 6	LSO, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
K0647	NU EP	H 6	LSO, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated	All	N	Purchase
K0648	NU EP	H 6	LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid plastic and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment	All	N	Purchase
K0649	NU EP	H 6	LSO, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid plastic and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated	All	N	Purchase

L0100	NU EP	H 6	Cranial orthosis (helmet), with or without soft interface, molded to patient model	All	N	Purchase
L0110	NU EP	H 6	Cranial orthosis (helmet), with or without soft interface, non-molded	All	N	Purchase
L0120	NU EP	H 6	Cervical, flexible, nonadjustable (foam collar)	All	N	Purchase
L0130	NU EP	H 6	Cervical, flexible, thermoplastic collar, molded to patient	All	N	Purchase
L0140	NU EP	H 6	Cervical, semi-rigid, adjustable (plastic collar)	All	N	Purchase
L0150	NU EP	H 6	Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)	All	N	Purchase
L0160	NU EP	H 6	Cervical, semi-rigid wire frame occipital/mandibular support	All	N	Purchase
L0170	NU EP	H 6	Cervical, collar, molded to patient model	All	N	Purchase
L0172	NU EP	H 6	Cervical, collar, semi-rigid thermoplastic foam, two piece	All	N	Purchase
L0174	NU EP	H 6	Cervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extension	All	N	Purchase
L0180	NU EP	H 6	Cervical, multiple post collar, occipital/mandibular supports, adjustable	All	N	Purchase
L0190	NU EP	H 6	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types)	All	N	Purchase
L0200	NU EP	H 6	Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension	All	N	Purchase
L0210	NU EP	H 6	Thoracic, rib belt	All	N	Purchase
L0220	NU EP	H 6	Thoracic, rib belt, custom fabricated	All	N	Purchase

L0450	NU EP	H 6	TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0452	NU EP	H 6	TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated	All	N	Purchase
L0454	NU EP	H 6	TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment	All	N	Purchase
L0456	NU EP	H 6	TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase

L0458	NU EP	H 6	TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0460	NU EP	H 6	TLSO, triplanar control modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0462	NU EP	H 6	TLSO, triplanar control modular segmented spinal system, three rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase

L0464	NU EP	H 6	TLSO, triplanar control modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0466	NU EP	H 6	TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0468	NU EP	H 6	TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	Y	Purchase

L0470	NU EP	H 6	TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0472	NU EP	H 6	TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal) posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0474	NU EP	H 6	TLSO, triplanar control, rigid posterior frame with multiple straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment	All	Y	Purchase

L0480	NU EP	H 6	TLSO, triplanar control, one-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	Y	Purchase
L0482	NU EP	H 6	TLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	Y	Purchase
L0484	NU EP	H 6	TLSO, triplanar control, two-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	Y	Purchase

L0486	NU EP	H 6	TLSO, triplanar control, two-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated	All	Y	Purchase
L0488	NU EP	H 6	TLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0490	NU EP	H 6	TLSO, sagittal-coronal control, one-piece rigid plastic shell with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment	All	Y	Purchase
L0700	NU EP	H 6	Cervical-thoracic-lumbar-sacral orthoses (CTLSO), anterior-posterior-lateral control, molded to patient model (Minerva type)	All	Y	Purchase
L0710	NU EP	H 6	CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)	All	Y	Purchase
L0810	NU EP	H 6	Halo procedure, cervical halo incorporated into jacket vest	All	Y	Purchase

L0820	NU EP	H 6	Halo procedure, cervical halo incorporated into plaster body jacket	All	Y	Purchase
L0830	NU EP	H 6	Halo procedure, cervical halo incorporated into Milwaukee type orthosis	All	Y	Purchase
L0860	NU EP	H 6	Addition to halo procedure, magnetic resonance image compatible system	All	Y	Purchase
L0960	NU EP	H 6	Torso support, post surgical support, pads for post surgical support	All	N	Purchase
L0970	NU EP	H 6	TLSO, corset front	All	N	Purchase
L0972	NU EP	H 6	LSO, corset front	All	N	Purchase
L0974	NU EP	H 6	TLSO, full corset	All	N	Purchase
L0976	NU EP	H 6	LSO, full corset	All	N	Purchase
L0978	NU EP	H 6	Axillary crutch extension	All	N	Purchase
L0980	NU EP	H 6	Peroneal straps, pair	All	N	Purchase
L0982	NU EP	H 6	Stocking supporter grips, set of four (4)	All	N	Purchase
L0984	NU	H	Protective body sock, each	21+	N	Purchase
L1000	NU EP	H 6	CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model	All	Y	Purchase
L1010	NU EP	H 6	TLSO or scoliosis orthosis, axilla sling	All	N	Purchase
L1020	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, kyphosis pad	All	N	Purchase
L1025	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating	All	N	Purchase
L1030	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, lumbar bolster pad	All	N	Purchase
L1040	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad	All	N	Purchase
L1050	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, sternal pad	All	N	Purchase
L1060	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, thoracic pad	All	N	Purchase

L1070	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, trapezius sling	All	N	Purchase
L1080	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, outrigger	All	N	Purchase
L1085	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions	All	N	Purchase
L1090	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, lumbar sling	All	N	Purchase
L1100	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather	All	N	Purchase
L1110	NU EP	H 6	Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model	All	N	Purchase
L1120	NU EP	H 6	Addition to CTLSO, scoliosis orthosis, cover for upright, each	All	N	Purchase
L1200	NU EP	H 6	Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis only	All	Y	Purchase
L1210	NU EP	H 6	Addition to TLSO (low profile), lateral thoracic extension	All	N	Purchase
L1220	NU EP	H 6	Addition to TLSO (low profile), anterior thoracic extension	All	N	Purchase
L1230	NU EP	H 6	Addition to TLSO (low profile), Milwaukee type superstructure	All	N	Purchase
L1240	NU EP	H 6	Addition to TLSO (low profile), lumbar derotation pad	All	N	Purchase
L1250	NU EP	H 6	Addition to TLSO (low profile), anterior ASIS pad	All	N	Purchase
L1260	NU EP	H 6	Addition to TLSO (low profile), anterior thoracic derotation pad	All	N	Purchase
L1270	NU EP	H 6	Addition to TLSO (low profile), abdominal pad	All	N	Purchase
L1280	NU EP	H 6	Addition to TLSO (low profile), rib gusset (elastic), each	All	N	Purchase
L1290	NU EP	H 6	Addition to TLSO (low profile), lateral trochanteric pad	All	N	Purchase
L1300	NU EP	H 6	Other scoliosis procedure, body jacket molded to patient model	All	Y	Purchase
L1310	NU EP	H 6	Other scoliosis procedure, postoperative body jacket	All	Y	Purchase

L1499	NU EP	H 6	Spinal orthosis, not otherwise specified. ***(The manufacturer's invoice must be attached to all claims.)	All	Y	Manually Priced
L1500	NU EP	H 6	THKAO, mobility frame (Newington, Parapodium types)	All	Y	Purchase
L1510	NU EP	H 6	THKAO, standing frame, with or without tray and accessories	All	Y	Purchase
L1520	NU EP	H 6	THKAO, swivel walker	All	Y	Purchase
L1600	NU EP	H 6	HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment	All	N	Purchase
L1610	NU EP	H 6	HO, abduction control of hip joints, flexible (Frejka cover only), prefabricated, includes fitting and adjustment	All	N	Purchase
L1620	NU EP	H 6	HO, abduction control of hip joints, flexible (Pavlik harness), prefabricated, includes fitting and adjustment	All	N	Purchase
L1630	NU EP	H 6	HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated	All	N	Purchase
L1640	NU EP	H 6	HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated	All	N	Purchase
L1650	NU EP	H 6	HO, abduction control of hip joints, static, adjustable, custom fitted (Ilfled type), prefabricated, includes fitting and adjustment	All	N	Purchase
L1660	NU EP	H 6	HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment	All	N	Purchase
L1680	NU EP	H 6	HO; abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated	All	Y	Purchase
L1685	NU EP	H 6	HO, abduction control of hip joint, post operative hip abduction type, custom fabricated	All	Y	Purchase

L1686	NU EP	H 6	HO, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustments	All	Y	Purchase
L1690	NU	H	Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment	21+	Y	Purchase
L1700	NU EP	H 6	Legg Perthes orthosis (Toronto type), custom fabricated	All	Y	Purchase
L1710	NU EP	H 6	Legg Perthes orthosis (Newington type), custom fabricated	All	Y	Purchase
L1720	NU EP	H 6	Legg Perthes orthosis, trilateral (Tachdijan type), custom fabricated	All	Y	Purchase
L1730	NU EP	H 6	Legg Perthes orthosis (Scottish Rite type) custom fabricated	All	Y	Purchase
L1750	NU EP	H 6	Legg Perthes orthosis, Legg Perthes sling (Sam Brown type), prefabricated, includes fitting and adjustment	All	Y	Purchase
L1755	NU EP	H 6	Legg Perthes orthosis (Patten bottom type), custom fabricated	All	Y	Purchase
L1800	NU EP	H 6	KO, elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L1810	NU EP	H 6	KO, elastic with joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1815	NU EP	H 6	KO, elastic or other elsastic type material with condylar pad(s), prefabricated, includes fitting and adjustment	All	N	Purchase
L1820	NU EP	H 6	KO, elastic with condyle pads and joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L1825	NU EP	H 6	KO, elastic knee cap. prefabricated, includes fitting and adjustment	All	N	Purchase
L1830	NU EP	H 6	KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment	All	N	Purchase
L1832	NU EP	H 6	KO, adjustable knee joints, positional orthosis, rigid support, prefabricated, includes fitting and adjustment rigid support	All	N	Purchase

L1834	NU EP	H 6	KO, without knee joint, rigid, custom fabricated	All	N	Purchase
L1840	NU EP	H 6	KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated	All	Y	Purchase
L1843	NU	H	Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment	21+	Y	Purchase
L1844	NU	H	KO, single upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated	21+	Y	Purchase
L1845	NU EP	H 6	KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, prefabricated, includes fitting and adjustment	All	Y	Purchase
L1846	NU EP	H 6	KO, double upright, thigh and calf, with adjustable flexion and extension joint, medial-lateral and rotation control, custom fabricated	All	Y	Purchase
L1847	NU	H	Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment	21+	N	Purchase
L1850	NU EP	H 6	KO, Swedish type, prefabricated, includes fitting and adjustment	All	N	Purchase
L1855	NU EP	H 6	KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated	All	Y	Purchase
L1858	NU EP	H 6	KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated	All	Y	Purchase
L1860	NU EP	H 6	KO, modification of supracondylar prosthetic socket, custom fabricated (SK)	All	Y	Purchase
L1870	NU EP	H 6	KO, double upright, thigh and calf lacers, with knee joints, custom fabricated	All	Y	Purchase

L1880	NU EP	H 6	KO, double upright, nonmolded thigh and calf cuff/lacers with knee joints, custom fabricated	All	N	Purchase
L1900	NU EP	H 6	AFO, spring wire, dorsiflexion assist calf band, custom fabricated	All	N	Purchase
L1902	NU EP	H 6	AFO, ankle gauntlet, prefabricated, includes fitting and adjustment	All	N	Purchase
L1904	NU EP	H 6	AFO, molded ankle gauntlet, custom fabricated	All	N	Purchase
L1906	NU EP	H 6	AFO, multigamentus ankle support, prefabricated, includes fitting and adjustment	All	N	Purchase
L1907	NU EP	H 6	AFO, supramalleolar with straps, with or without interface/pads, custom fabricated	All	N	Purchase
L1910	NU EP	H 6	AFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustment	All	N	Purchase
L1920	NU EP	H 6	AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated	All	N	Purchase
L1920	EP	6	***(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated	U21	N/A	Purchase
L1930	NU EP	H 6	AFO, plastic or other material, prefabricated, includes fitting and adjustment	All	N	Purchase
L1932	NU EP	H 6	AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment	All	N	Purchase
L1940	NU EP	H 6	AFO, plastic or other material, custom-fabricated	All	N	Purchase
L1945	NU EP	H 6	AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated	All	Y	Purchase
L1950	NU EP	H 6	AFO, spiral (Institute of Rehabilitative Medicine type), plastic, custom fabricated	All	N	Purchase
L1960	NU EP	H 6	AFO, posterior solid ankle, plastic, custom fabricated	All	N	Purchase

L1970	NU EP	H 6	AFO, plastic, with ankle joint, custom fabricated	All	N	Purchase
L1980	NU EP	H 6	AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar "BK" orthosis), custom fabricated	All	N	Purchase
L1990	NU EP	H 6	AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar "BK" orthosis), custom fabricated	All	N	Purchase
L2000	NU EP	H 6	KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), custom fabricated	All	Y	Purchase
L2005	NU EP	H 6	KAFO, any material, single or double upright, stance control, automatic lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricated	All	N	Purchase
L2010	NU EP	H 6	KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), without knee joint, custom fabricated	All	Y	Purchase
L2020	NU EP	H 6	KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar "AK" orthosis), custom fabricated	All	Y	Purchase
L2030	NU EP	H 6	KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis), without knee joint, custom fabricated	All	Y	Purchase
L2035	NU	H	KAFO, full plastic, static prefabricated (pediatric size) prefabricated, includes fitting and adjustment	21+	N	Purchase
L2036	NU EP	H 6	KAFO, full plastic, double upright, free knee, custom fabricated	All	Y	Purchase
L2037	NU EP	H 6	KAFO, full plastic, single upright, free knee, custom fabricated	All	Y	Purchase
L2038	NU EP	H 6	KAFO, full plastic, without knee joint, multi-axis ankle, (Lively orthosis or equal), custom fabricated	All	Y	Purchase

L2039	NU	H	KAFO, full plastic, single upright, poly-axial hinge, medial lateral rotation control, custom fabricated	21+	Y	Purchase
L2040	NU EP	H 6	HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Purchase
L2040	NU EP	U1 U1	***(Night "A" frame-KAFO, torsion control, bilateral night "A" frame) HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Manually Priced Purchase
L2040	NU EP	U1 U1	H 6	***(Night "A" frame-KAFO, torsion control, bilateral night "A" frame) HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Manually Priced Purchase
L2050	NU EP	H 6	HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2060	NU EP	H 6	HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2070	NU EP	H 6	HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated	All	N	Purchase
L2080	NU EP	H 6	HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2090	NU EP	H 6	HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated	All	N	Purchase
L2106	NU EP	H 6	AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	N	Purchase
L2108	NU EP	H 6	AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated	All	Y	Purchase
L2112	NU EP	H 6	AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment	All	N	Purchase
L2114	NU EP	H 6	AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment	All	N	Purchase
L2116	NU EP	H 6	AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment	All	N	Purchase

L2126	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, molded to patient	All	Y	Purchase
L2128	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated	All	Y	Purchase
L2132	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2134	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid custom fitted	All	Y	Purchase
L2136	NU EP	H 6	KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment	All	Y	Purchase
L2180	NU EP	H 6	Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints	All	N	Purchase
L2182	NU EP	H 6	Addition to lower extremity fracture orthosis, drop lock knee joint	All	N	Purchase
L2184	NU EP	H 6	Addition to lower extremity fracture orthosis, limited motion knee joint	All	N	Purchase
L2186	NU EP	H 6	Addition to lower extremity fracture orthosis, adjustable motion knee joint (Lerman type)	All	N	Purchase
L2188	NU EP	H 6	Addition to lower extremity fracture orthosis, quadrilateral brim	All	N	Purchase
L2190	NU EP	H 6	Addition to lower extremity fracture orthosis, waist belt	All	N	Purchase
L2192	NU EP	H 6	Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt	All	N	Purchase
L2200	NU EP	H 6	Additions to lower extremity, dorsiflexion and plantar flexion	All	N	Purchase
L2210	NU EP	H 6	Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint	All	N	Purchase
L2220	NU EP	H 6	Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint	All	N	Purchase

L2230	NU EP	H 6	Addition to lower extremity, split flat caliper stirrups and plate attachment	All	N	Purchase
L2232	NU EP	H 6	Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only	All	N	Manually Priced
L2240	NU EP	H 6	Addition to lower extremity, round caliper and plate attachment	All	N	Purchase
L2250	NU EP	H 6	Addition to lower extremity, foot plate, molded to patient model, stirrup attachment	All	N	Purchase
L2260	NU EP	H 6	Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)	All	N	Purchase
L2265	NU EP	H 6	Addition to lower extremity, long tongue stirrup	All	N	Purchase
L2270	NU EP	H 6	Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or malleolus pad	All	N	Purchase
L2275	NU	H	Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined	21+	N	Purchase
L2280	NU EP	H 6	Addition to lower extremity, molded inner boot	All	N	Purchase
L2300	NU EP	H 6	Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable	All	N	Purchase
L2310	NU EP	H 6	Addition to lower extremity, abduction bar straight	All	N	Purchase
L2320	NU EP	H 6	Addition to lower extremity, nonmolded lacer	All	N	Purchase
L2330	NU EP	H 6	Addition to lower extremity, lacer molded to patient model	All	N	Purchase
L2335	NU EP	H 6	Addition to lower extremity, anterior swing band	All	N	Purchase
L2340	NU EP	H 6	Addition to lower extremity, pretidial shell, molded to patient model	All	N	Purchase
L2350	NU EP	H 6	Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for "PTB" "AFO" orthoses)	All	Y	Purchase
L2360	NU EP	H 6	Addition to lower extremity, extended steel shank	All	N	Purchase

L2370	NU EP	H 6	Addition to lower extremity, Patten bottom	All	N	Purchase
L2375	NU EP	H 6	Addition to lower extremity, torsion control, ankle joint and half solid stirrup	All	N	Purchase
L2380	NU EP	H 6	Addition to lower extremity, torsion control, straight knee joint, each joint	All	N	Purchase
L2385	NU EP	H 6	Addition to lower extremity, straight knee joint, heavy duty, each joint	All	N	Purchase
L2390	NU EP	H 6	Addition to lower extremity, offset knee joint, each joint	All	N	Purchase
L2395	NU EP	H 6	Addition to lower extremity, offset knee joint, heavy duty, each joint	All	N	Purchase
L2397	NU	H	Addition to lower extremity orthosis, suspension sleeve	21+	N	Purchase
L2405	NU EP	H 6	Addition to knee joint, lock; drop, stance or swing phase, each joint	All	N	Purchase
L2415	NU EP	H 6	Addition to knee lock with integrated release mechanism, (bail, cable or equal, any material, each joint	All	N	Purchase
L2425	NU EP	H 6	Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint	All	N	Purchase
L2430	NU	H	Addition to knee joint, ratchet lock for active and progressive knee extension, each joint	21+	N	Purchase
L2492	NU EP	H 6	Addition to knee joint, lift loop for drop lock ring	All	N	Purchase
L2500	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, gulteal/ischial weight bearing, ring	All	N	Purchase
L2510	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, molded to patient model	All	N	Purchase
L2520	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, quadrilateral brim, custom fitted	All	N	Purchase
L2525	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model	All	N	Purchase

L2526	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted	All	N	Purchase
L2530	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, lacer, non-molded	All	N	Purchase
L2540	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model	All	N	Purchase
L2550	NU EP	H 6	Addition to lower extremity, thigh/weight bearing, high roll cuff	All	N	Purchase
L2570	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, clevis type two position joint, each	All	N	Purchase
L2580	NU EP	H 6	Addition to lower extremity, pelvic control, pelvic sling	All	N	Purchase
L2600	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing free, each	All	N	Purchase
L2610	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each	All	N	Purchase
L2620	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, heavy duty, each	All	N	Purchase
L2622	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each	All	N	Purchase
L2624	NU EP	H 6	Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each	All	N	Purchase
L2627	NU EP	H 6	Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables	All	N	Purchase
L2628	NU EP	H 6	Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables	All	N	Purchase
L2630	NU EP	H 6	Addition to lower extremity, pelvic control, band and belt unilateral	All	N	Purchase
L2640	NU EP	H 6	Addition to lower extremity, pelvic control, band and belt bilateral	All	N	Purchase

L2650	NU EP	H 6	Addition to lower extremity, pelvic and thoracic control, gluteal pad, each	All	N	Purchase
L2660	NU EP	H 6	Addition to lower extremity, thoracic control, thoracic band	All	N	Purchase
L2670	NU EP	H 6	Addition to lower extremity, thoracic control, paraspinal uprights	All	N	Purchase
L2680	NU EP	H 6	Addition to lower extremity, thoracic control, lateral support uprights	All	N	Purchase
L2750	NU EP	H 6	Addition to lower extremity orthosis, plating chrome or nickel, per bar	All	N	Purchase
L2755	NU	H	Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment	21+	N	Purchase
L2755	NU EP	H 6	***(Carbon composite ankles; addition to AFO) Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment	All	N	Manually Priced Purchase
L2760	NU EP	H 6	Addition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth)	All	N	Purchase
L2770	NU EP	H 6	Addition to lower extremity orthosis, any material, per bar or joint	All	N	Purchase
L2780	NU EP	H 6	Addition to lower extremity orthosis, non-corrosive finish, per bar	All	N	Purchase
L2785	NU EP	H 6	Addition to lower extremity orthosis, drop lock retainer, each	All	N	Purchase
L2795	NU EP	H 6	Addition to lower extremity orthosis, knee control, full kneecap	All	N	Purchase
L2800	NU EP	H 6	Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull	All	N	Purchase
L2810	NU EP	H 6	Addition to lower extremity orthosis, knee control, condylar pad	All	N	Purchase
L2810	EP	6	***(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) Addition to lower extremity orthosis, knee control, condylar pad	U21	N/A	Purchase
L2820	NU EP	H 6	Addition to lower extremity orthosis, soft interface for molded plastic, below knee section	All	N	Purchase

L2830	NU EP	H 6	Addition to lower extremity orthosis, soft interface for molded plastic, above knee section	All	N	Purchase
L2840	NU EP	H 6	Addition to lower extremity orthosis, tibial length sock, fracture or equal, each	All	N	Purchase
L2850	NU EP	H 6	Addition to lower extremity orthosis, femoral length sock, fracture or equal, each	All	N	Purchase
L2999	NU EP	H 6	Lower extremity orthoses, NOS	All	N	Manually Priced
L2999	NU EP	H 6	***(Unlisted prosthetic devices or orthotic appliances; the manufacturer's invoice must be attached to all claims.) Lower extremity orthoses, NOS	All	Y	Manually Priced
L3000	NU EP	H 6	Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each	All	N	Purchase
L3002	NU EP	H 6	Foot insert, removable, molded to patient model, Plastazote or equal, each	All	N	Manually Priced
L3010	NU EP	H 6	Foot insert, removable, molded to patient model, longitudinal arch support, each	All	N	Purchase
L3020	NU EP	H 6	Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each	All	N	Purchase
L3030	NU EP	H 6	Foot insert, removable, formed to patient foot, each	All	N	Purchase
L3040	NU EP	H 6	Foot, arch support, removable, premolded, longitudinal, each	All	N	Purchase
L3050	NU EP	H 6	Foot, arch support, removable, premolded, metatarsal, each	All	N	Purchase
L3060	NU EP	H 6	Foot, arch support, removable, premolded, longitudinal/metatarsal, each	All	N	Purchase
L3070	NU EP	H 6	Foot, arch support, non-removable, attached to shoe, longitudinal, each	All	N	Purchase
L3080	NU EP	H 6	Foot, arch support, non-removable, attached to shoe, metatarsal, each	All	N	Purchase
L3090	NU EP	H 6	Foot, arch support, non-removable, attached to shoe, longitudinal/metatarsal, each	All	N	Purchase

L3100	NU EP	H 6	Hallus-valgus night dynamic splint	All	N	Purchase
L3140	NU EP	UB	H 6	***(Bebox foot orthosis clubfood abduction orthosis) Foot, abduction rotation bar, including shoes	All	N	Manually Priced Purchase
L3140	NU	H	***(Don Joy knee orthosis) Foot, abduction rotation bar, including shoes	21+	Y	Manually Priced
L3150	NU EP	H 6	Foot, abduction rotation bar, without shoes	All	N	Purchase
L3150	EP	6	***(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) Foot, abduction rotation bar, without shoes	U21	N/A	Purchase
L3170	NU EP	H 6	Foot, plastic heel stabilizer	All	N	Purchase
L3202	EP	6	Orthopedic shoe, oxford with supinator or pronator, child	U21	N/A	Purchase
L3204	EP	6	Orthopedic shoe, high-top with supinator or pronator, infant	U21	N/A	Purchase
L3204	NU EP	H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU EP	U1	H 6	***(Straight last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Purchase
L3204	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3204	NU	H	***(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, infant	21+	N	Manually Priced

L3204	NU EP	U1	H 6	*******(Orthopedic shoe, high-top, normal last, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, infant	All	N	Manually Priced Purchase
L3206	NU EP	H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU EP	U1	H 6	***(Straight last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Purchase
L3206	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3206	NU	H	***(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, child	21+	N	Manually Priced
L3206	NU EP	U1	H 6	***(Orthopedic shoe, high-top, normal last, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, child	All	N	Manually Priced Purchase
L3207	NU EP	H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP	U1	H 6	***(Straight last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Purchase
L3207	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase

L3207	NU	H	*******(Orthopedic shoe, high-top, normal last, each, size 3-8) Orthopedic shoe, high-top with supinator or pronator, junior	21+	N	Manually Priced
L3207	NU EP	U1	H 6	***(Orthopedic shoe, high-top, normal last, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3207	NU EP	H 6	***(Orthopedic shoe, high-top, normal last, each, size 81/2-12) Orthopedic shoe, high-top with supinator or pronator, junior	All	N	Manually Priced Purchase
L3208	EP	6	Surgical boot, each, infant	U21	N/A	Purchase
L3209	EP	6	Surgical boot, each, child	U21	N/A	Purchase
L3215	NU EP	H 6	Orthopedic footwear, woman's shoes, oxford	All	Y	Manually Priced
L3216	NU EP	H 6	Orthopedic footwear, woman's shoes, depth inlay	All	Y	Purchase
L3217	NU EP	H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3217	NU EP	U1 U1	H 6	***(Straight last high-top shoe, each, size 81/2-12) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3217	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3217	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 81/2-12) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Purchase
L3217	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic footwear, woman's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3219	NU EP	H 6	Orthopedic footwear, man's shoes, oxford	All	Y	Manually Priced
L3221	NU EP	H 6	Orthopedic footwear, man's shoes, depth inlay	All	Y	Purchase
L3222	NU EP	H 6	***(Straight last high-top shoe, each, size 2-8) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase

L3222	NU EP	U1	H 6	***(Straight last high-top shoe, each, size 81/2-12) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3222	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 3-6) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3222	NU EP	U1	H 6	***(Regular last high-top shoe, each, size 81/2-12) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Purchase
L3222	NU EP	U1	H 6	***(Reverse last closed toe) Orthopedic footwear, man's shoes, high-top, depth inlay	All	N	Manually Priced Purchase
L3224	NU	H	Orthopedic footwear, woman's shoe, Oxford, used as an integral part of a brace (orthosis)	21+	N	Purchase
L3225	NU	H	Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)	21+	N	Purchase
L3230	NU EP	H 6	Orthopedic footwear, custom shoes, depth inlay	All	Y	Purchase
L3250	NU EP	H 6	Orthopedic footwear, custom molded shoe, removable inner molded, prosthetic shoe, each	All	Y	Manually Priced
L3253	NU EP	H 6	Foot, molded shoe Plastazate (or similar), custom fitted, each	All	Y	Purchase
L3257	NU EP	H 6	Orthopedic footwear, additional charge for split size	All	Y	Purchase
L3260	NU EP	H 6	Surgical boot/shoe, each	All	N	Purchase
L3265	NU EP	H 6	Plastazote sandal, each	All	N	Purchase
L3310	NU EP	H 6	Lift, elevation, heel and sole, neoprene, per inch	All	N	Purchase
L3332	NU EP	H 6	Lift, elevation, inside shoe, tapered, up to one-half inch	All	N	Purchase
L3334	NU EP	H 6	Lift, elevation, heel, per inch	All	N	Purchase
L3350	NU EP	H 6	Heel wedge	All	N	Purchase
L3360	NU EP	H 6	Sole wedge, outside sole	All	N	Purchase

L3370	NU EP	H 6	Sole wedge, between sole	All	N	Purchase
L3400	NU EP	H 6	Metatarsal bar wedge, rocker	All	N	Purchase
L3420	NU EP	H 6	Full sole and heel wedge, between sole	All	N	Purchase
L3450	NU EP	H 6	Heel, SACH cushion type	All	N	Purchase
L3455	NU EP	H 6	Heel, new leather, standard	All	N	Purchase
L3465	NU EP	H 6	Heel, Thomas with wedge	All	N	Purchase
L3540	NU EP	H 6	Orthopedic shoe addition, sole full	All	N	Purchase
L3580	NU EP	H 6	Orthopedic shoe addition, convert instep to velcro closure	All	N	Purchase
L3590	NU EP	H 6	Orthopedic shoe addition, convert firm shoe counter to soft counter	All	N	Purchase
L3600	NU EP	H 6	Transfer for an orthosis from one shoe to another, caliper plate, existing	All	N	Purchase
L3620	NU EP	H 6	Transfer of an orthosis from one shoe to another, solid stirrup, existing	All	N	Purchase
L3630	NU EP	H 6	Transfer of an orthosis from one shoe to another, solid stirrup, new	All	N	Purchase
L3649	EP	6	Orthopedic shoe, modification, addition or transfer, NOS	U21	N/A	Manually Priced
L3649	NU EP	U1	H 6	***(Unlisted prosthetic devices or orthotic appliances; the manufacturer's invoice must be attached to all claims.) Orthopedic shoe, modification, addition or transfer, NOS	All	Y	Manually Priced Purchase
L3649	NU EP	H 6	***(Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, modification, addition or transfer, NOS	All	N	Manually Priced Purchase
L3650	NU EP	H 6	SO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment	All	N	Purchase

L3660	NU EP	H 6	SO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment	All	N	Purchase
L3670	NU EP	H 6	SO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustment	All	N	Purchase
L3675	NU	H	SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment	21+	N	Purchase
L3700	NU EP	H 6	Elbow orthoses (EO), elastic with stays, prefabricated, includes fitting and adjustment	All	N	Purchase
L3710	NU EP	H 6	EO, elastic with metal joints, prefabricated, includes fitting and adjustment	All	N	Purchase
L3720	NU EP	H 6	EO, double upright with forearm/arm cuffs, free motion, custom fabricated	All	N	Purchase
L3730	NU EP	H 6	EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated	All	Y	Purchase
L3740	NU EP	H 6	EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated	All	Y	Purchase
L3800	NU EP	H 6	WHFO, short opponens, no attachments, custom fabricated	All	N	Purchase
L3805	NU EP	H 6	WHFO, long opponens, no attachment, custom fabricated	All	N	Purchase
L3810	NU EP	H 6	WHFO, addition to short and long opponens, thumb abduction ("C") bar	All	N	Purchase
L3815	NU EP	H 6	WHFO, addition to short and long opponens, second M.P. abduction assist	All	N	Purchase
L3820	NU EP	H 6	WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop	All	N	Purchase
L3825	NU EP	H 6	WHFO, addition to short and long opponens, M.P. extension stop	All	N	Purchase
L3830	NU EP	H 6	WHFO, addition to short and long opponens, M.P. extension assist	All	N	Purchase
L3835	NU EP	H 6	WHFO, addition to short and long opponens, M.P. spring extension assist	All	N	Purchase

L3840	NU EP	H 6	WHFO, addition to short and long opponens, spring swivel thumb	All	N	Purchase
L3845	NU EP	H 6	WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop	All	N	Purchase
L3850	NU EP	H 6	WHO, addition to short and long opponens, action wrist with dorsiflexion assist	All	N	Purchase
L3855	NU EP	H 6	WHFO, addition to short and long opponens, adjustable M.P. flexion control	All	N	Purchase
L3860	NU EP	H 6	WHFO, addition to short and long opponens, adjustable M.P. flexion control and I.P.	All	N	Purchase
L3900	NU EP	H 6	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated	All	Y	Purchase
L3901	NU EP	H 6	WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated	All	Y	Purchase
L3902	NU EP	H 6	WHFO, external powered, compressed gas, custom fabricated	All	Y	Purchase
L3904	NU EP	H 6	WHFO, external powered, electric, custom fabricated	All	Y	Purchase
L3906**	NU EP	H 6	WHFO, wrist gauntlet, molded to patient model, custom fabricated	All	N	Purchase
L3907**	NU EP	H 6	WHFO, wrist gauntlet with thumb spica, molded to patient model, custom fabricated	All	N	Purchase
L3908	NU EP	H 6	WHFO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment	All	N	Purchase
L3910	NU EP	H 6	WHFO, Swanson design, prefabricated, includes fitting and adjustment	All	N	Purchase
L3912	NU EP	H 6	HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment	All	N	Purchase
L3914	NU EP	H 6	WHO, wrist extension (cock-up) prefabricated, includes fitting and adjustment	All	N	Purchase

L3916	NU EP	H 6	WHFO, wrist extension (cock-up), with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase
L3918	NU EP	H 6	HFO, knuckle bender prefabricated, includes fitting and adjustment	All	N	Purchase
L3920	NU EP	H 6	HFO, knuckle bender, with outrigger prefabricated, includes fitting and adjustment	All	N	Purchase
L3922	NU EP	H 6	HFO, knuckle bender, two segment to flex joints prefabricated, includes fitting and adjustment	All	N	Purchase
L3924	NU EP	H 6	WHFO, Oppenheimer, prefabricated, includes fitting and adjustment	All	N	Purchase
L3926	NU EP	H 6	WHFO, Thomas suspension, prefabricated, includes fitting and adjustment	All	N	Purchase
L3928	NU EP	H 6	HFO, finger extension, with lock spring, prefabricated, includes fitting and adjustment	All	N	Purchase
L3930	NU EP	H 6	WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment	All	N	Purchase
L3932	NU EP	H 6	FO, safety pin, spring wire, prefabricated, includes fitting and adjustment	All	N	Purchase
L3934	NU EP	H 6	FO, safety pin, modified, prefabricated, includes fitting and adjustment	All	N	Purchase
L3936	NU EP	H 6	WHFO, Palmer prefabricated, includes fitting and adjustment	All	N	Purchase
L3938	NU EP	H 6	WHFO, Dorsal wrist, prefabricated, includes fitting and adjustment	All	N	Purchase
L3940	NU EP	H 6	WHFO, Dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment	All	N	Purchase
L3942	NU EP	H 6	HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase
L3944	NU EP	H 6	HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment	All	N	Purchase
L3946	NU EP	H 6	HFO, composite elastic, prefabricated, includes fitting and adjustment	All	N	Purchase

L3948	NU EP	H 6	FO, finger knuckle bender, prefabricated, includes fitting and adjustment	All	N	Purchase
L3950	NU EP	H 6	WHFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3952	NU EP	H 6	WHFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment	All	N	Purchase
L3954	NU EP	H 6	HFO, spreading hand, prefabricated, includes fitting and adjustment	All	N	Purchase
L3956	NU	H	Addition of joint to upper extremity orthosis, any material; per joint	21+	N	Purchase
L3960	NU EP	H 6	SEWHO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3962	NU EP	H 6	SEWHO, abduction positioning, Erb's palsy design, prefabricated, includes fitting and adjustment	All	N	Purchase
L3963	NU EP	H 6	SEWHO, molded shoulder, arm, forearm, and wrist, with articulating elbow joint, custom fabricated	All	Y	Purchase
L3964	NU EP	H 6	SEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment	All	N	Purchase
L3965	NU EP	H 6	SEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3966	NU EP	H 6	SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment	All	Y	Purchase
L3968	NU EP	H 6	SEO, mobile arm support attached to wheelchair, balanced, friction arm support, (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment	All	Y	Purchase

L3969	NU EP	H 6	SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment	All	N	Purchase
L3970	NU EP	H 6	SEO, addition to mobile arm support elevating proximal arm	All	N	Purchase
L3972	NU EP	H 6	SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control	All	N	Purchase
L3974	NU EP	H 6	SEO, addition to mobile arm support, supinator	All	N	Purchase
L3980	NU EP	H 6	Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment	All	N	Purchase
L3982	NU EP	H 6	Upper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustment	All	N	Purchase
L3984	NU EP	H 6	Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment	All	N	Purchase
L3985	NU EP	H 6	Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated	All	N	Purchase
L3986	NU EP	H 6	Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example - Colles' fracture), custom fabricated	All	N	Purchase
L3995	NU EP	H 6	Addition to upper extremity orthosis sock, fracture or equal, each	All	N	Purchase
L3999	EP	6	Upper limb orthosis, NOS	U21	N/A	Manually Priced
L3999	NU EP	H 6	***(The manufacturer's invoice must be attached to all claims.) Upper limb orthosis, NOS	All	Y	Manually Priced Manually Priced
L4000	NU EP	H 6	Replace girdle for spinal orthosis (CTLSO or SO)	All	Y	Purchase
L4002	NU EP	H 6	Replace strap, any orthosis, includes all components, any length, any type	All	N	Manually Priced
L4010	NU EP	H 6	Replace trilateral socket brim	All	N	Purchase

L4020	NU EP	H 6	Replace quadrilateral socket brim, molded to patient model	All	N	Purchase
L4030	NU EP	H 6	Replace quadrilateral socket brim, custom fitted	All	N	Purchase
L4040	NU EP	H 6	Replace molded thigh lacer	All	N	Purchase
L4045	NU EP	H 6	Replace nonmolded thigh lacer	All	N	Purchase
L4050	NU EP	H 6	Replace molded calf lacer	All	N	Purchase
L4055	NU EP	H 6	Replace nonmolded calf lacer	All	N	Purchase
L4060	NU EP	H 6	Replace high roll cuff	All	N	Purchase
L4070	NU EP	H 6	Replace proximal and distal upright for KAFO	All	N	Purchase
L4080	NU EP	H 6	Replace metal bands KAFO, proximal thigh	All	N	Purchase
L4090	EP	6	A(Custom night "A" frame-KAFO, torsion control, bilateral night "A" frame) Replace metal bands KAFO-AFO, calf or distal thigh	U21	N/A	Purchase
L4090	NU EP	H 6	Replace metal bands KAFO-AFO, calf or distal thigh	All	N	Purchase
L4100	NU EP	H 6	Replace leather cuff KAFO, proximal thigh	All	N	Purchase
L4110	NU EP	H 6	Replace leather cuff KAFO-AFO, calf or distal thigh	All	N	Purchase
L4130	NU EP	H 6	Replace pretibial shell	All	N	Purchase
L4205	NU EP	H 6	Repair of orthotic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L4210	NU EP	H 6	Repair of orthotic device, repair or replace minor parts	All	Y	Manually Priced Purchase
L4350	NU EP	H 6	Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment	All	N	Purchase

L4360	NU EP	H 6	Walking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustment	All	N	Purchase
L4370	NU EP	H 6	Pneumatic full leg splint, prefabricated, includes fitting and adjustment	All	N	Purchase
L4380	NU EP	H 6	Pneumatic knee splint, prefabricated, includes fitting and adjustment	All	N	Purchase
L4392	Replacement soft interface material, static AFO	All	N	Purchase
L4394	NU	H	Replace soft interface material, foot drop splint	21+	N	Purchase
L4396	NU	H	Static AFO, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment	21+	N	Purchase
L4398	NU	H	Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment	21+	N	Purchase
L5999	NU EP	H 6	*(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.**) Lower extremity prosthesis, not otherwise specified	All	Y	Manually Priced Manually Priced
L7499	NU EP	H 6	*(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.**) Upper extremity prosthesis, not otherwise specified	All	Y	Manually Priced Manually Priced
L7510	NU EP	UB	H 6	Repair of prosthetic device, hourly rate	All	Y	Manually Priced Purchase
L7520	NU EP	H 6	Repair prosthetic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase

L8499

NU EP

H 6

***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Unlisted procedure for miscellaneous prosthetic services

All

Manually Priced

Purchase

242.190 Prosthetic Devices, All Ages

Procedure codes found in this section must be billed either electronically or on paper with modifier EP for beneficiaries under 21 years of age or modifier NU for individuals age 21 and older. When a second modifier is listed, that modifier must be used in conjunction with either EP or NU.

Additionally, when billed on paper, procedure codes must be billed with type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for beneficiaries age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. Type of service is indicated by the heading TOS.

Prior authorization requirements are shown under the heading PA. If prior authorization is needed for individuals age 21 and older, that information is indicated with a "Y" in the column; if not, an "N" is shown. When codes are payable for all ages, "All" is indicated in the column, "U21" is shown when the code is payable only for individuals under age 21 and "21+" is shown when the code is payable only for those individuals age 21 and older.

* Replacement only

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Prosthetic Devices, All Ages (section 242.190)

Procedure Code

TOS

Description

All

U21

21+

PA 21+

Payment Method

L1499

NU EP

H 6

***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Spinal orthosis, not otherwise specified

All

Manually Priced

L2999

NU EP

H 6

***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Lower extremity orthoses, NOS

All

Manually Priced

L3649	NU EP	U1	H 6	***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Orthopedic shoe, modification, addition or transfer, NOS	All	Y	Manually Priced Manually Priced
L3999	NU EP	H 6	***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Upper limb orthosis, NOS	All	Y	Manually Priced Manually Priced
L4205	NU EP	H 6	***(Orthotics and Prosthetics Repairs) Repair of orthotic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L4210	NU EP	H 6	***(Orthotics and Prosthetics Repairs) Repair of orthotic device, repair or replace minor parts	All	Y	Manually Priced Purchase
L5000	NU EP	H 6	Partial foot, shoe insert with longitudinal arch, toe filler	All	N	Purchase
L5010	NU EP	H 6	Partial foot, molded socket, ankle height, with toe filler	All	Y	Purchase
L5020	NU EP	H 6	Partial foot, molded socket, tibial tubercle height, with toe filler	All	Y	Purchase
L5050	NU EP	H 6	Ankle, Symes, molded socket, SACH foot	All	Y	Purchase
L5060	NU EP	H 6	Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot	All	Y	Purchase
L5100	NU EP	H 6	Below knee, molded socket, shin, SACH foot	All	Y	Purchase
L5105	NU EP	H 6	Below knee, plastic socket, joints and thigh lacer, SACH foot	All	Y	Purchase
L5150	NU EP	H 6	Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot	All	Y	Purchase
L5160	NU EP	H 6	Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot	All	Y	Purchase
L5200	NU EP	H 6	Above knee, molded socket, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5210	NU EP	H 6	Above knee, short prosthesis, no knee joint ("stubbies"), with foot blocks, no ankle joints, each	All	Y	Purchase

L5220	NU EP	H 6	Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each	All	Y	Purchase
L5230	NU EP	H 6	Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot	All	Y	Purchase
L5250	NU EP	H 6	Hip disarticulation, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5270	NU EP	H 6	Hip disarticulation, tilt table type, molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5280	NU EP	H 6	Hemipelvectomy, Canadian type, molded socket, hip joint, single axis constant friction knee, shin, SACH foot	All	Y	Purchase
L5301	NU EP	H 6	Below knee, molded socket, shin, SACH foot, endoskeletal system	All	Y	Purchase
L5311	NU EP	H 6	Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot, endoskeletal system	All	Y	Purchase
L5321	NU EP	H 6	Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee	All	Y	Purchase
L5331	NU EP	H 6	Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot	All	Y	Purchase
L5341	NU EP	H 6	Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot	All	Y	Purchase
L5400	NU EP	H 6	Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee	All	N	Purchase
L5410	NU EP	H 6	Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment	All	N	Purchase

L5420	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, and one cast change "AK" or knee disarticulation	All	Y	Purchase
L5430	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, "AK" or knee disarticulation, each additional cast change and realignment	All	N	Purchase
L5450	NU EP	H 6	Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee	All	N	Purchase
L5460	NU EP	H 6	Immediate post surgical or early fitting, application of nonweight bearing rigid dressing, above knee	All	N	Purchase
L5500	NU EP	H 6	Initial, below knee ("PTB" type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, direct formed	All	N	Purchase
L5505	NU EP	H 6	Initial, above knee-knee disarticulation (ischial level socket, non-alignable system, pylon, no cover, SACH foot plaster socket, direct formed	All	Y	Purchase
L5510	NU EP	H 6	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model	All	Y	Purchase
L5520	NU EP	H 6	Preparatory, below knee "PTB" type socket, non-alignable pylon, no cover, SACH foot, thermoplastic or equal, direct formed	All	Y	Purchase
L5530	NU EP	H 6	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model	All	Y	Purchase
L5535	NU EP	H 6	Preparatory, below knee "PTB" type socket, non-alignable system, pylon, no cover, SACH foot, prefabricated, adjustable open end socket	All	Y	Purchase
L5540	NU EP	H 6	Preparatory, below knee "PTB" type socket, non alignable, pylon, no cover, SACH foot, laminated socket, molded to model	All	Y	Purchase

L5560	NU EP	H 6	Preparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SACH foot, plaster socket, molded to model	All	Y	Purchase
L5570	NU EP	H 6	Preparatory, above knee-knee disarticulation ischial level socket, non-alignable system, pylon, no cover, SACH foot thermoplastic or equal, direct formed	All	Y	Purchase
L5580	NU EP	H 6	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model	All	Y	Purchase
L5585	NU EP	H 6	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket	All	Y	Purchase
L5590	NU EP	H 6	Preparatory, above knee-knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, SACH foot, laminated socket, molded to model	All	Y	Purchase
L5595	NU EP	H 6	Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model	All	Y	Purchase
L5600	NU EP	H 6	Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model	All	Y	Purchase
L5610	NU EP	H 6	Addition to lower extremity, endoskeletal system, above knee, hydracadence system	All	Y	Purchase
L5611	NU EP	H 6	Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with friction swing phase control	All	N	Purchase
L5613	NU EP	H 6	Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4-bar linkage, with hydraulic swing phase control	All	Y	Purchase

L5614	NU	H	Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with pneumatic swing phase control	21+	Y	Purchase
L5616	NU EP	H 6	Addition to lower extremity, endoskeletal system above knee, universal multiplex system, friction swing phase control	All	Y	Purchase
L5617	NU	H	Addition to lower extremity, quick change self-aligning unit, above or below knee, each	21+	Y	Purchase
L5618	NU EP	H 6	Addition to lower extremity, test socket, Symes	All	N	Purchase
L5620	NU EP	H 6	Addition to lower extremity, test socket, below knee	All	N	Purchase
L5622	NU EP	H 6	Addition to lower extremity, test socket, knee disarticulation	All	N	Purchase
L5624	NU EP	H 6	Addition to lower extremity, test socket, above knee	All	N	Purchase
L5626	NU EP	H 6	Addition to lower extremity, test socket, hip disarticulation	All	N	Purchase
L5628	NU EP	H 6	Addition to lower extremity, test socket, hemipelvectomy	All	N	Purchase
L5629	NU EP	H 6	Addition to lower extremity, below knee, acrylic socket	All	N	Purchase
L5630	NU EP	H 6	Addition to lower extremity, Symes type, expandable wall socket	All	N	Purchase
L5631	NU EP	H 6	Addition to lower extremity, above knee or knee disarticulation, acrylic socket	All	N	Purchase
L5632	NU EP	H 6	Addition to lower extremity, Symes type, "PTB" brim design socket	All	N	Purchase
L5634	NU EP	H 6	Addition to lower extremity, Symes type posterior opening (Canadian) socket	All	N	Purchase
L5636	NU EP	H 6	Additions to lower extremity, Symes type, medial opening socket	All	N	Purchase
L5637	NU EP	H 6	Addition to lower extremity, below knee, total contact	All	N	Purchase
L5638	NU EP	H 6	Addition to lower extremity, below knee, leather socket	All	N	Purchase
L5639	NU EP	H 6	Addition to lower extremity, below knee, wood socket	All	N	Purchase

L5640	NU EP	H 6	Addition to lower extremity, knee disarticulation, leather socket	All	N	Purchase
L5642	NU EP	H 6	Addition to lower extremity, above knee, leather socket	All	N	Purchase
L5643	NU EP	H 6	Addition to lower extremity, hip disarticulation, flexible inner socket, external frame	All	Y	Purchase
L5644	NU EP	H 6	Addition to lower extremity, above knee, wood socket	All	N	Purchase
L5645	NU EP	H 6	Addition to lower extremity, below knee, flexible inner socket, external frame	All	N	Purchase
L5646	NU EP	H 6	Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket	All	N	Purchase
L5647	NU EP	H 6	Addition to lower extremity, below knee suction socket	All	N	Purchase
L5648	NU EP	H 6	Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket	All	N	Purchase
L5649	NU EP	H 6	Addition to lower extremity, ischial containment/narrow M-L socket	All	Y	Purchase
L5650	NU EP	H 6	Addition to lower extremity, total contact, above knee or knee disarticulation socket	All	N	Purchase
L5651	NU EP	H 6	Addition to lower extremity, above knee, flexible inner socket, external frame	All	N	Purchase
L5652	NU EP	H 6	Addition to lower extremity, suction suspension, above knee or knee disarticulation, socket	All	N	Purchase
L5653	NU EP	H 6	Addition to lower extremity, knee disarticulation, expandable wall socket	All	N	Purchase
L5654	NU EP	H 6	Addition to lower extremity, socket insert, Symes, (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5655	NU EP	H 6	Addition to lower extremity, socket insert, below knee (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5656	NU EP	H 6	Addition to lower extremity, socket insert, knee disarticulation (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase

L5658	NU EP	H 6	Addition to lower extremity, socket insert, above knee (Kemblo, Pelite, Aliplast, Plastazote or equal)	All	N	Purchase
L5661	NU EP	H 6	Addition to lower extremity, socket insert, multi durometer Symes	All	N	Purchase
L5665	EP	6	Addition to lower extremity, socket insert, multo-durometer, below knee	U21	N/A	Purchase
L5666	NU EP	H 6	Additions to lower extremity, below knee, cuff suspension	All	N	Purchase
L5668	NU EP	H 6	Addition to lower extremity, below knee, molded distal cushion	All	N	Purchase
L5670	NU EP	H 6	Addition to lower extremity, below knee, molded supracondyular suspension ("PTS" or similar)	All	N	Purchase
L5672	NU EP	H 6	Addition to lower extremity, below knee, removable medial brim suspension	All	N	Purchase
L5676	NU EP	H 6	Addition to lower extremity, below knee, knee joints, single axis, pair	All	N	Purchase
L5677	NU EP	H 6	Addition to lower extremity, below knee, knee joints, polycentric, pair	All	N	Purchase
L5678	NU EP	H 6	Addition to lower extremity, below knee, joint covers, pair	All	N	Purchase
L5680	NU EP	H 6	Addition to lower extremity, below knee, thigh lacer, nonmolded	All	N	Purchase
L5682	NU EP	H 6	Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded	All	N	Purchase
L5684	NU EP	H 6	Addition to lower extremity, below knee, fork strap	All	N	Purchase
L5685	NU EP	H 6	Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each	All	N	Manually Priced
L5686	NU EP	H 6	Addition to lower extremity, below knee, back check (extension control)	All	N	Purchase
L5688	NU EP	H 6	Addition to lower extremity, below knee, waist belt, webbing	All	N	Purchase
L5690	NU EP	H 6	Addition to lower extremity, below knee, waist belt, padded and lined	All	N	Purchase
L5692	NU EP	H 6	Addition to lower extremity, above knee, pelvic control belt, light	All	N	Purchase

L5694	NU EP	H 6	Addition to lower extremity, above knee, pelvic control belt, padded and lined	All	N	Purchase
L5695	NU EP	H 6	Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each	All	N	Purchase
L5696	NU EP	H 6	Addition to lower extremity, above knee or knee disarticulation, pelvic joint	All	N	Purchase
L5697	NU EP	H 6	Addition to lower extremity, above knee or knee disarticulation, pelvic band	All	N	Purchase
L5698	NU EP	H 6	Addition to lower extremity, above knee or knee disarticulation, silesian bandage	All	N	Purchase
L5699	NU EP	H 6	All lower extremity prosthesis, shoulder harness	All	N	Purchase
L5700	NU	H	Replacement, socket, below knee, molded to patient model	21+	Y	Purchase
L5701	NU	H	Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model	21+	Y	Purchase
L5702	NU	H	Replacement, socket, hip disarticulation, including hip joint, molded to patient model	21+	Y	Purchase
L5704	NU	H	Custom shaped protective cover, below knee	21+	N	Purchase
L5705	NU	H	Custom shaped protective cover, above knee	21+	N	Purchase
L5706	NU	H	Custom shaped protective cover, knee disarticulation	21+	N	Purchase
L5707	NU	H	Custom shaped protective cover, hip disarticulation	21+	N	Purchase
L5710	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, manual lock	All	N	Purchase
L5711	NU EP	H 6	Addition exoskeletal knee-shin system, single axis, manual lock, ultra-light material	All	N	Purchase
L5712	NU EP	H 6	Addition exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)	All	N	Purchase

L5714	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control	All	N	Purchase
L5716	NU EP	H 6	Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock	All	N	Purchase
L5718	NU EP	H 6	Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control	All	N	Purchase
L5722	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control	All	N	Purchase
L5724	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, fluid swing phase control	All	Y	Purchase
L5726	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control	All	Y	Purchase
L5728	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control	All	Y	Purchase
L5780	NU EP	H 6	Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control	All	N	Purchase
L5785	NU EP	H 6	Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5790	NU EP	H 6	Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5795	NU EP	H 6	Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5810	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, manual lock	All	N	Purchase
L5811	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material	All	N	Purchase
L5812	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)	All	N	Purchase
L5816	NU EP	H 6	Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock	All	N	Purchase

L5818	NU EP	H 6	Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase control	All	N	Purchase
L5822	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control	All	Y	Purchase
L5824	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, fluid swing phase control	All	Y	Purchase
L5826	NU	H	Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control with miniature high activity frame	21+	Y	Purchase
L5828	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control	All	Y	Purchase
L5830	NU EP	H 6	Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control	All	Y	Purchase
L5840	NU	H	Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control	21+	N	Purchase
L5845	NU	H	Addition, endoskeletal knee-shin system, stance flexion feature, adjustable	21+	Y	Purchase
L5850	NU EP	H 6	Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist	All	N	Purchase
L5855	NU EP	H 6	Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist	All	N	Purchase
L5910	NU EP	H 6	Addition, endoskeletal system, below knee, alignable system	All	N	Purchase
L5920	NU EP	H 6	Addition, endoskeletal system, above knee or hip disarticulation, alignable system	All	N	Purchase
L5925	NU	H	Addition, endoskeletal system, above knee, knee disarticulation, manual lock	21+	N	Purchase
L5930	NU	H	Addition, endoskeletal system, high activity knee control frame	21+	Y	Purchase
L5940	NU EP	H 6	Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase

L5950	NU EP	H 6	Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5960	NU EP	H 6	Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)	All	N	Purchase
L5962	NU	H	Addition, endoskeletal system, below knee, flexible protective outer surface covering system	21+	N	Purchase
L5964	NU	H	Addition, endoskeletal system, above knee, flexible protective outer surface covering system	21+	N	Purchase
L5966	NU	H	Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system	21+	N	Purchase
L5968	NU	H	Addition to lower limb prostheses, multiaxial ankle with swing phase active dorsiflexion feature	21+	Y	Purchase
L5970	NU EP	H 6	All lower extremity prostheses, foot, external keel, SACH foot	All	N	Purchase
L5972	NU EP	H 6	All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic or equal)	All	N	Purchase
L5974	NU EP	H 6	All lower extremity prostheses, foot, single axis ankle/foot	All	N	Purchase
L5975	NU	H	All lower extremity prosthesis, combination single axis ankle and flexible keel foot	21+	N	Purchase
L5976	NU EP	H 6	All lower extremity prostheses, energy storing foot (Seattle Carbon Copy II or equal)	All	N	Purchase
L5978	NU EP	H 6	All lower extremity prostheses, foot, multiaxial ankle/foot	All	N	Purchase
L5979	NU	H	All lower extremity prostheses, multi-axial ankle, dynamic response foot, one piece system	21+	Y	Purchase
L5980	NU EP	H 6	All lower extremity prostheses, flex-foot system	All	Y	Purchase
L5981	NU	H	All lower extremity prostheses, flex-walk system or equal	21+	Y	Purchase
L5982	NU EP	H 6	All exoskeletal lower extremity prostheses, axial rotation unit	All	N	Purchase

L5984	NU EP	H 6	All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability	All	N	Purchase
L5985	NU	H	All endoskeletal lower extremity prostheses, dynamic prosthetic pylon	21+	N	Purchase
L5986	NU EP	H 6	All lower extremity prostheses, multi-axial rotation unit ("MCP" or equal)	All	N	Purchase
L5987	NU	H	All lower extremity prostheses, shank foot system with vertical loading pylon	21+	Y	Purchase
L5988	NU	H	Addition to lower limb prosthesis, vertical shock reducing pylon feature	21+	Y	Purchase
L5999	NU EP	H 6	***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Lower extremity prosthesis, not otherwise specified	All	Y	Manually Priced Manually Priced
L6000	NU EP	H 6	Partial hand, Robin-Aids, thumb remaining (or equal)	All	N	Purchase
L6010	NU EP	H 6	Partial hand, Robin-Aids, little and/or ring finger remaining (or equal)	All	N	Purchase
L6020	NU EP	H 6	Partial hand, Robin-Aids, no finger remaining (or equal)	All	N	Purchase
L6050	NU EP	H 6	Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad	All	Y	Purchase
L6055	NU EP	H 6	Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad	All	Y	Purchase
L6100	NU EP	H 6	Below elbow, molded socket, flexible elbow hinge, triceps pad	All	Y	Purchase
L6110	NU EP	H 6	Below elbow, molded socket (Muenster or Northwestern suspension types)	All	Y	Purchase
L6120	NU EP	H 6	Below elbow, molded double wall split socket, step-up hinges, half cuff	All	Y	Purchase
L6130	NU EP	H 6	Below elbow, molded double wall split socket, stump activated locking hinge, half cuff	All	Y	Purchase
L6200	NU EP	H 6	Elbow disarticulation, molded socket, outside locking hinge, forearm	All	Y	Purchase
L6205	NU EP	H 6	Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm	All	Y	Purchase

L6250	NU EP	H 6	Above elbow, molded double wall socket, internal locking elbow, forearm	All	Y	Purchase
L6300	NU EP	H 6	Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	All	Y	Purchase
L6310	NU EP	H 6	Shoulder disarticulation, passive restoration (complete prosthesis)	All	Y	Purchase
L6320	NU EP	H 6	Shoulder disarticulation, passive restoration (shoulder cap only)	All	Y	Purchase
L6350	NU	H	Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm	21+	Y	Purchase
L6360	NU EP	H 6	Interscapular thoracic, passive restoration (complete prosthesis)	All	Y	Purchase
L6370	NU EP	H 6	Interscapular thoracic, passive restoration (shoulder cap only)	All	Y	Purchase
L6380	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow	All	N	Purchase
L6382	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow	All	N	Purchase
L6384	NU EP	H 6	Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic	All	Y	Purchase
L6386	NU EP	H 6	Immediate postsurgical or early fitting, each additional cast change and realignment	All	N	Purchase
L6388	NU EP	H 6	Immediate postsurgical or early fitting, application of rigid dressing only	All	N	Purchase

L6400	NU EP	H 6	Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6450	NU EP	H 6	Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6500	NU EP	H 6	Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6550	NU EP	H 6	Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping	All	Y	Purchase
L6570	NU EP	H 6	Interscapular thoracic, molded socket, endoskeletal system including soft prosthetic tissue shaping	All	Y	Purchase
L6580	NU EP	H 6	Preparatory, wrist disarticulation or below elbow, single wall plastic socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, molded to patient model	All	Y	Purchase
L6582	NU EP	H 6	Preparatory, wrist disarticulation or below elbow, single wall socket, friction wrist, flexible elbow hinges, figure of eight harness, humeral cuff, Bowden cable control, "USMC" or equal pylon, no cover, direct formed	All	N	Purchase
L6584	NU EP	H 6	Preparatory, elbow disarticulation or above elbow, single wall plastic socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient model	All	Y	Purchase
L6586	NU EP	H 6	Preparatory, elbow disarticulation or above elbow, single wall socket, friction wrist, locking elbow, figure of eight harness, fair lead cable control, "USMC" or equal pylon, no cover, direct formed	All	Y	Purchase

L6588	NU EP	H 6	Preparatory, shoulder disarticulation or interscapular thoracic, single wall plastic socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, molded to patient model	All	Y	Purchase
L6590	NU EP	H 6	Preparatory, shoulder disarticulation or interscapular thoracic, single wall socket, shoulder joint, locking elbow, friction wrist, chest strap, fair lead cable control, "USMC" or equal pylon, no cover, direct formed	All	Y	Purchase
L6600	NU EP	H 6	Upper extremity additions, polycentric hinge, pair	All	N	Purchase
L6605	NU EP	H 6	Upper extremity additions, single pivot hinge, pair	All	N	Purchase
L6610	NU EP	H 6	Upper extremity additions, flexible metal hinge, pair	All	N	Purchase
L6615	NU EP	H 6	Upper extremity addition, disconnect locking wrist unit	All	N	Purchase
L6616	NU EP	H 6	Upper extremity addition, additional disconnect insert for locking wrist unit, each	All	N	Purchase
L6620	NU EP	H 6	Upper extremity addition, flexion/extension wrist unit, with or without friction	All	N	Purchase
L6623	NU EP	H 6	Upper extremity addition, spring assisted rotational wrist unit with latch release	All	N	Purchase
L6625	NU EP	H 6	Upper extremity addition, rotation wrist unit with cable lock	All	N	Purchase
L6628	NU EP	H 6	Upper extremity addition, quick disconnect hook adapter, Otto Bock or equal	All	N	Purchase
L6629	NU EP	H 6	Upper extremity addition, quick disconnect lamination collar with coupling piece, Otto Bock or equal	All	N	Purchase
L6630	NU EP	H 6	Upper extremity addition, stainless steel, any wrist	All	N	Purchase
L6632	NU EP	H 6	Upper extremity addition, latex suspension sleeve, each	All	N	Purchase
L6635	NU EP	H 6	Upper extremity additions, lift assist for elbow	All	N	Purchase

L6637	NU EP	H 6	Upper extremity addition, nudge control elbow lock	All	N	Purchase
L6640	NU EP	H 6	Upper extremity additions, shoulder abduction joint, pair	All	N	Purchase
L6641	NU EP	H 6	Upper extremity addition, excursion amplifier, pulley type	All	N	Purchase
L6642	NU EP	H 6	Upper extremity addition, excursion amplifier, lever type	All	N	Purchase
L6645	NU EP	H 6	Upper extremity addition, shoulder flexion-abduction joint, each	All	N	Purchase
L6650	NU EP	H 6	Upper extremity addition, shoulder universal joint, each	All	N	Purchase
L6655	NU EP	H 6	Upper extremity addition, standard control cable, extra	All	N	Purchase
L6660	NU EP	H 6	Upper extremity addition, heavy duty control cable	All	N	Purchase
L6665	NU EP	H 6	Upper extremity addition, teflon, or equal, cable lining	All	N	Purchase
L6670	NU EP	H 6	Upper extremity addition, hook to hand cable adapter	All	N	Purchase
L6672	NU EP	H 6	Upper extremity addition, harness, chest or shoulder, saddle type	All	N	Purchase
L6675	NU EP	H 6	Upper extremity addition, harness, (e.g., figure of eight type), single cable design	All	N	Purchase
L6676	NU EP	H 6	Upper extremity additions, harness, (e.g., figure of eight type), dual cable design	All	N	Purchase
L6680	NU EP	H 6	Upper extremity addition, test socket, wrist disarticulation or below elbow	All	N	Purchase
L6682	NU EP	H 6	Upper extremity addition, test socket, elbow disarticulation or above elbow	All	N	Purchase
L6684	NU EP	H 6	Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic	All	N	Purchase
L6686	NU EP	H 6	Upper extremity addition, suction socket	All	N	Purchase
L6687	NU EP	H 6	Upper extremity addition, frame type socket, below elbow or wrist disarticulation	All	N	Purchase
L6688	NU EP	H 6	Upper extremity addition, frame type socket, above elbow or elbow disarticulation	All	N	Purchase

L6689	NU EP	H 6	Upper extremity addition, frame type socket, shoulder disarticulation	All	N	Purchase
L6690	NU EP	H 6	Upper extremity addition, frame type socket, interscapular-thoracic	All	N	Purchase
L6691	NU EP	H 6	Upper extremity addition, removable insert, each	All	N	Purchase
L6692	NU EP	H 6	Upper extremity addition, silicone gel insert or equal, each	All	N	Purchase
L6693	NU	H	Upper extremity addition, locking elbow, forearm counterbalance	21+	Y	Purchase
L6700	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 3	All	N	Purchase
L6705	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 3	All	N	Purchase
L6710	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 5x	All	N	Purchase
L6715	NU EP	H 6	Terminal device, hook, Dorrance or equal, Model # 5xa	All	N	Purchase
L6720	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 6	All	N	Purchase
L6725	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 7	All	N	Purchase
L6730	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 7LO	All	N	Purchase
L6735	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 8	All	N	Purchase
L6740	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 8x	All	N	Purchase
L6745	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 88x	All	N	Purchase
L6750	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 10P	All	N	Purchase
L6755	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 10x	All	N	Purchase
L6765	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 12P	All	N	Purchase
L6770	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 99x	All	N	Purchase
L6775	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # 555	All	N	Purchase
L6780	NU EP	H 6	Terminal device, hook, Dorrance or equal, model # SS555	All	N	Purchase

L6790	NU EP	H 6	Terminal device, hook-Accu hook or equal	All	N	Purchase
L6795	NU EP	H 6	Terminal device, hook 2 load or equal	All	N	Purchase
L6800	NU EP	H 6	Terminal device, hook-APRL VC or equal	All	N	Purchase
L6805	NU EP	H 6	Terminal device, modifier wrist flexion unit	All	N	Purchase
L6806	NU EP	H 6	Terminal device, hook, TRS grip, Grip III, VC, or equal	All	Y	Purchase
L6807	NU EP	H 6	Terminal device, hook, Grip I, Grip II, VC, or equal	All	N	Purchase
L6808	NU EP	H 6	Terminal device, hook, TRS Adept, infant or child, VC, or equal	All	N	Purchase
L6809	NU EP	H 6	Terminal device, hook, TRS Super Sport, passive	All	N	Purchase
L6810	NU EP	H 6	Terminal device, pincher tool, Otto Bock or equal	All	N	Purchase
L6825	NU EP	H 6	Terminal device, hand, Dorrance, VO	All	N	Purchase
L6830	NU EP	H 6	Terminal device, hand, APRL, VC	All	N	Purchase
L6835	NU EP	H 6	Terminal device, hand, Sierra, VO	All	N	Purchase
L6840	NU EP	H 6	Terminal device, hand, Becker Imperial	All	N	Purchase
L6845	NU EP	H 6	Terminal device, hand, Becker Lock Grip	All	N	Purchase
L6850	NU EP	H 6	Terminal device, hand, Becker Plylite	All	N	Purchase
L6855	NU EP	H 6	Terminal device, hand, Robin-Aids, VO	All	N	Purchase
L6860	NU EP	H 6	Terminal device, hand, Robin-Aids, VO soft	All	N	Purchase
L6865	NU EP	H 6	Terminal device, hand, passive hand	All	N	Purchase
L6867	NU EP	H 6	Terminal device, hand, Detroit Infant Hand (mechanical)	All	N	Purchase
L6868	NU EP	H 6	Terminal device, hand, passive infant hand, Steeper, Hosmer or equal	All	N	Purchase
L6870	NU EP	H 6	Terminal device, hand, child mitt	All	N	Purchase

L6872	NU EP	H 6	Terminal device, hand, NYU child hand	All	N	Purchase
L6873	NU EP	H 6	Terminal device, hand, mechanical infant hand, Steeper or equal	All	N	Purchase
L6875	NU EP	H 6	Terminal device, hand, Bock, VC	All	N	Purchase
L6880	NU EP	H 6	Terminal device, hand, Bock, VO	All	N	Purchase
L6890	NU EP	H 6	Terminal device, gloves for above hands, production glove	All	N	Purchase
L6895	NU EP	H 6	Terminal device, glove for above hands, custom glove	All	N	Purchase
L6900	NU EP	H 6	Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining	All	N	Purchase
L6905	NU EP	H 6	Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining	All	N	Purchase
L6910	NU EP	H 6	Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining	All	N	Purchase
L6915	NU EP	H 6	Hand restoration (shading and measurements included), replacement glove for above	All	N	Purchase
L6920*	NU EP	H 6	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal, switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase
L6925*	NU EP	H 6	Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6930*	NU EP	H 6	Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase

L6935*	NU EP	H 6	Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6940*	NU EP	H 6	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase
L6945*	NU EP	H 6	Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6950*	NU EP	H 6	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase
L6955*	NU EP	H 6	Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6960*	NU EP	H 6	Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase

L6965*	NU EP	H 6	Shoulder disarticulation, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L6970*	NU EP	H 6	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal switch, cables, two batteries and one charger, switch control of terminal device	All	Y	Purchase
L6975*	NU EP	H 6	Interscapular-thoracic, external power, molded inner socket, removable shoulder shell, shoulder bulkhead, humeral section, mechanical elbow, forearm, Otto Bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device	All	Y	Purchase
L7010*	NU EP	H 6	Electronic hand, Otto Bock, Steeper or equal, switch controlled	All	Y	Purchase
L7015*	NU EP	H 6	Electronic hand, System Teknik, Variety Village or equal, switch controlled	All	Y	Purchase
L7020*	NU EP	H 6	Electronic greifer, Otto Bock or equal, switch controlled	All	Y	Purchase
L7025*	NU EP	H 6	Electronic hand, Otto Bock or equal, myoelectronically controlled	All	Y	Purchase
L7030*	NU EP	H 6	Electronic hand, System Teknik, Variety Village or equal, myoelectronically controlled	All	Y	Purchase
L7035*	NU EP	H 6	Electronic greifer, Otto Bock or equal, myoelectronically controlled	All	Y	Purchase
L7040*	NU EP	H 6	Prehensile actuator, Hosmer or equal, switch controlled	All	Y	Purchase
L7045*	NU EP	H 6	Electronic hook, child, Michigan or equal, switch controlled	All	Y	Purchase
L7170*	NU EP	H 6	Electronic elbow, Hosmer or equal, switch controlled	All	Y	Purchase

L7180*	NU EP	H 6	Electronic elbow, Utah or equal, myoelectronically controlled	All	Y	Purchase
L7185	EP	6	Electronic elbow, adolescent, Variety Village or equal, switch controlled	U21	N/A	Purchase
L7186	EP	6	Electronic elbow, child, Variety Village or equal, switch controlled	U21	N/A	Purchase
L7190	EP	6	Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled	U21	N/A	Purchase
L7191	EP	6	Electronic elbow, child, Variety Village or equal, myoelectronically controlled	U21	N/A	Purchase
L7260*	NU EP	H 6	Electronic wrist rotator, Otto Bock or equal	All	Y	Purchase
L7261*	NU EP	H 6	Electronic wrist rotator, for Utah arm	All	Y	Purchase
L7266*	NU EP	H 6	Servo control, Steeper or equal	All	N	Purchase
L7272*	NU EP	H 6	Analogue control, UNB or equal	All	Y	Purchase
L7274*	NU EP	H 6	Proportional control, 6-12 volt, Liberty, Utah or equal	All	Y	Purchase
L7360*	NU EP	H 6	Six volt battery, Otto Bock or equal, each	All	N	Purchase
L7362*	NU EP	H 6	Battery charger, six volt, Otto Bock or equal	All	N	Purchase
L7364*	NU EP	H 6	Twelve volt battery, Utah or equal, each	All	N	Purchase
L7366*	NU EP	H 6	Battery charger, twelve volt, Utah or equal	All	N	Purchase
L7499	NU EP	H 6	***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Upper extremity prosthesis, NOS	All	Y	Manually Priced Manually Priced
L7510	NU EP	UB	H 6	***(Orthotics and Prosthetics Repairs) Repair of prosthetic device, repair or replace minor parts	All	Y	Manually Priced Purchase
L7510	NU EP	H 6	***(Twister cables - repair/replace) Repair of prosthetic device, repair or replace minor parts	All	N	Manually Priced Purchase

L7520	NU EP	H 6	***(Orthotics and Prosthetics Repairs) Repair prosthetic device, labor component, per 15 minutes	All	Y	Manually Priced Purchase
L8000	NU EP	H 6	Breast prosthesis, mastectomy bra	All	N	Purchase
L8010	NU EP	H 6	Breast prosthesis, mastectomy sleeve	All	N	Purchase
L8015	NU	H	External breast prosthesis garment, with mastectomy form, post-mastectomy	21+	N	Purchase
L8020	NU EP	H 6	Breast prosthesis, mastectomy form	All	N	Purchase
L8030	NU EP	H 6	Breast prosthesis, silicone or equal	All	N	Purchase
L8100	NU EP	H 6	Gradient support compression stocking, below knee, 18-30 mmhg, each	All	N	Purchase
L8300	NU EP	H 6	Truss, single with standard pad	All	N	Purchase
L8310	NU EP	H 6	Truss, double with standard pads	All	N	Purchase
L8320	NU EP	H 6	Truss, addition to standard pad, water pad	All	N	Purchase
L8330	NU EP	H 6	Truss, addition to standard pad, scrotal pad	All	N	Purchase
L8400	NU EP	H 6	Prosthetic sheath, below knee, each	All	N	Purchase
L8410	NU EP	H 6	Prosthetic sheath, above knee, each	All	N	Purchase
L8415	NU EP	H 6	Prosthetic sheath, upper limb, each	All	N	Purchase
L8417	NU	H	Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each	21+	N	Purchase
L8420	NU EP	H 6	Prosthetic sock, multiple ply, below knee, each	All	N	Purchase
L8430	NU EP	H 6	Prosthetic sock, multiple ply, above knee, each	All	N	Purchase
L8435	NU EP	H 6	Prosthetic sock, multiple ply upper limb, each	All	N	Purchase
L8440	NU EP	H 6	Prosthetic shrinker, below knee, each	All	N	Purchase

L8460	NU EP	H 6	Prosthetic shrinker, above knee, each	All	N	Purchase
L8465	NU EP	H 6	Prosthetic shrinker, upper limb, each	All	N	Purchase
L8470	NU EP	H 6	Prosthetic sock, single ply, fitting below knee, each	All	N	Purchase
L8480	NU EP	H 6	Prosthetic sock, single ply fitting, above knee, each	All	N	Purchase
L8485	NU	H	Prosthetic sock, single ply, fitting, upper limb, each	21+	N	Purchase
L8499	NU EP	H 6	***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer's invoice must be attached to all claims.) Unlisted procedure for miscellaneous prosthetic services	All	Y	Manually Priced Manually Priced
L8500	NU EP	H 6	Artificial larynx, any type	All	N	Purchase
L8501	NU EP	H 6	Tracheostomy speaking valve	All	N	Purchase
L8600	NU EP	H 6	Implantable breast prosthesis, silicone or equal	All	N	Manually Priced

242.191 Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult

Additionally, when billed on paper, procedure codes found in this section must be billed with a type of service (TOS) code "6" for individuals under age 21 or TOS code "H" for individuals age 21 and older.

Modifiers in this section are indicated by the headings M1 and M2. The type of service code is indicated by the heading TOS. Prior authorization requirements are shown under the heading PA. If prior authorization is needed, that information is indicated with a "Y" in the column; if not, an "N" is shown.

Other coding information found in the chart:

1 The purchase of this wheelchair component for individuals age 21 and older is limited to one per five-year period.

2 The purchase of this wheelchair component for individuals under age 21 is limited to one per two-year period.

* The purchase of wheelchairs for individuals age 21 and older is limited to one per five-year period.

** Bill only for TOS code "6."

# This procedure code is payable for individuals ages 2 through 20, using TOS code "6." Prior authorization is required through Utilization Review.

**** Items listed require prior authorization (PA) when used in combination with other items listed and the total combined value exceeds the $1,000.00 Medicaid maximum allowable reimbursement limit.

* Prior authorization is not required when another insurance pays at least 50% of the Medicaid maximum allowable reimbursement amount.

Note: W/C or w/c indicates wheelchair.

***(...) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.

Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191)

Procedure Code	M1	M2	TOS	Description	PA	Payment Method
E0700	NU EP	U2 U2	H 6	*******(Travel restraint auto safe harness, E-Z on vest, no known comparable product) Safety equipment, e.g., belt, harness or vest	N****	Purchase
E0950	NU EP	U7 U7	H 6	Wheelchair accessory, tray, each	N	Purchase
E0950	NU EP	U2 U2	H 6	***(ABS tray, 4-SM 5-LG) W/C accessory, tray, each	N****	Purchase
E0950	NU EP	U5 U5	H 6	***(Clear upper Ex support system) W/C accessory, tray, each	N****	Purchase
E0950	NU EP	U4 U4	H 6	***(Tray, customized) W/C accessory, tray, each	N	Purchase
E0950	NU EP	H 6	***(Tray for W/C) W/C accessory, tray, each	N	Purchase
E0950	NU EP UE	U7 U7	H 6 U	***(Removable Hinged Overlay for Tray) W/C accessory, tray, each	N****	Purchase
E0950	NU EP	U8 U8	H 6	***(Lap Tray for Switch Array) Wheelchair accessory, tray, each	Y	Purchase
E0950	NU EP	U6 U6	H 6	***(Lap Tray Switch Array) Wheelchair accessory, tray, each	N****	Purchase
E0950	NU EP	U3 U3	H 6	***(W/C Tray, Custom) W/C accessory, tray, each	N****	Purchase
E0951	NU EP	H 6	Heel loop/holder, with or without ankle strap, each	N****	Purchase
E0952	NU EP	H 6	Toe loop/holder, each	N****	Purchase

E0953	NU EP	H 6	*******(8" x 2" for manual W/C, each, replacement) Pneumatic tire, each	N	Purchase
E0954	NU EP	H 6	Semi-pneumatic caster, each	N****	Purchase
E0955	NU EP	H 6	W/C accessory, headrest, cushioned, prefabricated, w/fixed mounting hardware, each	N	Purchase
E0956	NU EP	H 6	***(Trunk supports for any W/C, other than travel, with hardware) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each	N****	Purchase
E0956	NU EP	U1 U1	H 6	***(Lateral trunk supports, swing away, ea.) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each	N****	Purchase
E0956	NU EP	U2 U2	H 6	***(Med. Chest Panel Support) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each	N****	Purchase
E0956	NU EP	U3 U3	H 6	***(Chest/Thoracic Supports) W/C accessory, lateral trunk or hip support, prefabricated w/fixed mounting hardware, each	N****	Purchase
E0957	NU EP	H 6	W/C accessory, medial thigh support, prefabricated, w/fixed mounting hardware, each	N	Purchase
E0958	NU EP	H 6	Manual W/C accessory, one-arm drive attachment, each	N****	Purchase
E0959	NU EP	U1 U1	H 6	Manual W/C accessory, adapter for amputee, each	N	Purchase
E0959	NU EP	H 6	***(Amputee adapters for conventional chair, ea.) Manual W/C accessory, adapter for amputee, each	N****	Purchase
E0959	NU EP	H 6	***(Amputee axle plate for high performance manual W/C, ea.) Manual W/C accessory, adapter for amputee, each	N****	Purchase
E0960	NU EP	H 6	W/C accessory, shoulder harness/straps or chest strap including any type mounting hardware	N	Purchase
E0961	NU EP	H 6	Manual W/C accessory, wheel lock brake extension (handle), each	N****	Purchase

E0966	NU EP	H 6	***(Headrest/Fixture, O.B., 46-LG 45-SM) Manual W/C accessory, headrest extension, each	N****	Purchase
E0967	NU EP	H 6	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	N****	Purchase
E0967	NU EP	U1 U1	H 6	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	N****	Purchase
E0967	NU EP	U2 U2	H 6	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	N****	Purchase
E0967	NU EP	U3 U3	H 6	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	N****	Purchase
E0967	NU EP	U4 U4	H 6	***(Hand rim, any type) Manual W/C accessory, hand rim w/projections, any type, replacement only, each	N****	Purchase
E0970	NU EP	H 6	No. 2 footplates, except for elevating legrest	N****	Purchase
E0971	NU EP	H 6	Anti-tipping device W/C	N****	Purchase
E0972	NU EP	U1 U1	H 6	***(Wood transfer board) W/C accessory, transfer board or device, each	N	Purchase
E0972	NU EP	H 6	***(Plastic transfer board) W/C accessory, transfer board or device, each	N	Purchase
E0973	NU EP	H 6	W/C accessory, adjustable height, detachable armrest, complete assembly, each	N****	Purchase
E0973	NU EP	U1 U1	H 6	***(Height Adj. Arms, replacement) W/C accessory, adjustable height, detachable armrest, complete assembly, each	N****	Purchase
E0974	NU EP	H 6	Manual W/C accessory, anti-rollback device, each	N****	Purchase
E0978	NU EP	U2	H 6	W/C accessory, safety belt/pelvic strap, each	N****	Purchase
E0978	NU EP	U1	H 6	***(Belt, safety or chest, w/pad) W/C accessory, safety belt/ pelvic strap, each	N**** N	Purchase
E0980	NU EP	H 6	***(Chest panel, 21-SM 22-LG) Safety vest, W/C	N****	Purchase
E0980	NU EP	U1 U1	H 6	***(Shoulder retractors) Safety vest, W/C	N****	Purchase

E0981	NU EP	H 6	W/C accessory, seat upholstery, replacement only, each	N	Purchase
E0982	NU EP	U1 U1	H 6	*******(Standard back upholstery replacement) W/C accessory, back upholstery, replacement only, each	N****	Purchase
E0990	EP	6	***(Elevating foot, leg rest) W/C accessory, elevating leg rest, complete assembly, each	N****	Purchase
E0990	NU EP	U1 U1	H 6	***(Elevating Leg Rest 90 Degree, 12" -16" Width) W/C accessory, elevating leg rest, complete assembly, each	N****	Purchase
E0992	NU EP	H 6	Manual w/c accessory, solid seat insert	N****	Purchase
E0992	NU EP	U3 U3	H 6	***(Foam & Plywood Seat, MPI Like) Manual w/c access, solid seat insert	N****	Purchase
E0992	NU EP	U2 U2	H 6	***(Foam and Plywood Flat Side) Manual w/c access, solid seat insert	N****	Purchase
E0992	NU EP	U4 U4	H 6	***(Adjustable solid standard seat w/hardware) Manual w/c accessory, solid seat insert	N****	Purchase
E0992	NU EP	U1 U1	H 6	AManual w/c accessory, solid seat insert (Large adjustable solid seat w/hardware)	N****	Purchase
E0994	NU EP	H 6	Armrest, each	N****	Purchase
E1001	NU	H	Wheel, single	N	Manually Priced
E1002	NU EP	H 6	W/C accessory, power seating system, tilt only	Y	Purchase
E1002	NU EP	H 6	W/C accessory power seating system, tilt only	Y*	Purchase
E1004	NU EP	H 6	W/C accessory, power seat system, recline only, w/mechanical shear reduction	Y	Purchase
E1004	NU EP	H 6	W/C accessory, power seating system, recline only, with mechanical shear reduction	Y*	Purchase
E1006	NU EP	H 6	W/C accessory, power seating system, combination tilt and recline, w/o shear reduction	Y	Purchase
E1006	NU EP	U1 U1	H 6	***(Power tilt and recline system with zero sheer) W/C accessory, power seating system, combination tilt and recline, without mechanical shear reduction	Y*	Purchase

E1010	NU EP	H 6	W/C accessory, addition to power seating system, power leg elevation system, including leg rest, each	Y	Purchase
E1019	NU EP	H 6	W/C accessory, power seating, heavy duty feature, patient weight capacity greater than 250 lbs, and less than or equal to 400 lbs	Y	Purchase
E1020	NU EP	H 6	***(Adjustable Contour Lateral Thigh Support) Residual limb support system for W/C	N****	Purchase
E1026	EP	6	***(Adjustable Contour Back, 10" - 12" Frame) Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware)	N****	Purchase
E1026	EP	U1	6	***(Adjustable Contour Back, 14" - 16" Frame) Lateral thoracic support, contoured, for pediatric W/C, each (includes hardware)	N****	Purchase
E1029	NU EP	H 6	***(Ventilator Tray Wth Battery Tray) Wheelchair accessory, ventilator tray, fixed	Y	Purchase
E1030	NU EP	H 6	Wheelchair accessory, ventilator tray, gimbaled	Y	Purchase
E1050*	NU EP	H 6	Full reclining W/C, fixed full-length arms, swing-away, detachable elevating legrests	N****	Purchase
E1060*	NU EP	H 6	Full reclining W/C, detachable arms, desk or full-length, swing-away detachable, elevating legrests	Y*	Purchase
E1065*	NU EP	H 6	Power attachment (to convert any W/C to motorized W/C, e.g., Solo)	Y*	Purchase
E1070#	6	*******(A maximum use of three months only) Fully reclining W/C, detachable arms, desk or full-length, swing-away, detachable footrests	Y	Rental only
E1084*	NU EP	H 6	Hemi-W/C; detachable arms, desk or full-length, swing-away, detachable, elevating leg rests	N****	Purchase
E1086*	NU EP	U1 U1	H 6	Hemi W/C, detachable arms, desk or full-length, swing-away detachable footrests	Y*	Purchase
E1086*	NU EP	H 6	Hemi W/C; detachable arms, desk or full-length, swing-away, detachable footrests	N****	Purchase

E1088*	NU EP	H 6	High strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Y*	Purchase
E1090	NU EP	H 6	High-strength lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests	N****	Purchase
E1091**	EP	UB	6	Youth stroller	N****	Purchase
E1091	NU EP	H 6	Youth positioning stroller	N	Purchase
E1091	NU EP	U1 U1	H 6	Youth positioning stroller	N	Manually Priced
E1092*	NU EP	H 6	Wide, heavy-duty W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Y*	Purchase
E1093*	NU EP	H 6	Wide, heavy-duty W/C; detachable arms, desk or full-length arms, swing-away, detachable footrests	Y*	Purchase
E1110*	NU EP	H 6	Semi-reclining W/C; detachable arms, desk or full-length, elevating legrest	Y*	Purchase
E1161	NU EP	H 6	Manual adult size W/C, includes tilt in space	Y*	Purchase
E1170*	NU EP	H 6	Amputee W/C; fixed full-length arms, swing-away, detachable, elevating legrests	N****	Purchase
E1172*	NU EP	H 6	Amputee W/C; detachable arms, desk or full-length, without footrests or legrests	Y*	Purchase
E1180*	NU EP	H 6	Amputee W/C; detachable arms, desk or full-length, swing-away, detachable footrests	Y*	Purchase
E1200*	NU EP	H 6	Amputee W/C; fixed full-length arms, swing-away, detachable footrests	N**** *	Purchase
E1211*	NU EP	H 6	Motorized W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrests	Y*	Purchase
E1213*	NU EP	H 6	Motorized W/C; detachable arms, desk or full-length, swing-away, detachable footrests	Y*	Purchase
E1220*	NU EP	H 6	W/C, specially sized or constructed (indicate brand name, model number, if any, and justification)	Y	Manually Priced

E1225	NU EP	H 6	***(Folding Backrest, 8 Degree Bend, Low, 15" - 16") Manual W/C accessory, semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each	N****	Purchase
E1226*	NU EP	H 6	Manual w/c accessory, fully reclining back, each	Y	Purchase
E1228	NU EP	U2 U2	H 6	***(Positioning tall back) Special back height for W/C	N****	Purchase
E1228	NU EP	H 6	***(Folding Backrest, Tall, 19" - 20") Special back height for W/C	N****	Purchase
E1228	NU EP	H 6	***(Folding Straight Backrest, Low, (15" -16") Special back height for W/C	N****	Purchase
E1228	NU EP	H 6	***(Folding Straight Backrest, Tall, 19" -20") Special back height for W/C	N****	Purchase
E1228	NU EP	U1 U1	H 6	***(High back contour seat) Special back height for W/C	N****	Purchase
E1230*	NU EP	H 6	Power operated vehicle (three- or four-wheel nonhighway), specify brand name and model number	Y*	Purchase
E1232*	EP	6	W/C, pediatric size, tilt-in-space, folding, adjustable, with seating system	Y*	Purchase
E1233*	EP	6	W/C, pediatric size, tilt-in-space, rigid, adjustable, without seating system	Y*	Purchase
E1234*	EP	6	W/C, pediatric size, tilt-in-space, folding, adjustable, without seating system	Y*	Purchase
E1235*	NU EP	H 6	W/C, pediatric size, rigid, adjustable, with seating system	Y*	Purchase
E1235	NU EP	H 6	***(Snug Seat I Mobility System) W/C, pediatric size, rigid, adjustable, with seating system	Y*	Purchase
E12351,2	EP	U1 U1	6	***(Rigid W/C Frame) W/C, pediatric size, rigid, adjustable with seating system	Y	Purchase
E1236	EP	6	Wheelchair, pediatric size, folding, adjustable, with seating system	Y	Purchase
E1237*	NU EP	H 6	W/C, pediatric size, rigid, adjustable, without seating system	Y*	Purchase
E1238*	NU EP	H 6	W/C, pediatric size, folding, adjustable, without seating system	Y*	Purchase
E1240*	NU EP	H 6	Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable, elevating legrest	Y*	Purchase

E1260*	NU EP	H 6	Lightweight W/C; detachable arms, desk or full-length, swing-away, detachable footrests	N****	Purchase
E1280*	NU EP	H 6	Heavy-duty W/C; detachable arms, desk or full-length, elevating legrests	Y*	Purchase
E1290*	NU EP	H 6	Heavy-duty W/C; detachable arms, swing-away, detachable footrests	Y*	Purchase
E1340	NU EP	U1 U1	H 6	***(Labor Only; a maximum of twenty [20] units [20 units = 5 hours of labor] per date of service is allowable.) Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes	Y	Manually Priced
E1340	NU EP	U3 U3	H 6	*(Unlisted Repairs/Parts Only Wheelchairs; applicable pages from the manufacturer's catalog must be attached to the claim form.)** Repair or nonroutine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes	N****	Manually Priced
E2201	NU EP	U3 U3	H 6	Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN]24 inches	N****	Manually Priced
E2201	NU EP	U1 U1	H 6	***(Frame Width 14"-15") Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches	N****	Manually Priced (21+) Purchase
E2201	NU EP	U2 U2	H 6	***(Frame Wdth 19"-20") Manual w/c accessory, nonstandard seat frame width[GREATER THAN]than or equal to 20 inches and [LESS THAN]24 inches	N****	Manually Priced (21+) Purchase
E2201	NU EP	H 6	***(Seat Wdth 20") Manual w/c accessory, nonstandard seat frame width [GREATER THAN] than or equal to 20 inches and [LESS THAN] 24 inches	N****	Manually Priced Purchase
E2203	NU EP	U4 U4	H 6	Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	N	Manually Priced Purchase
E2203	NU EP	U2 U2	H 6	***(Frame, Long; 16", 17"3, 18", 19"3, 20" Depth) Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	N****	Manually Priced (21+) Purchase

E2203	NU EP	U3 U3	H 6	***(Seat Depth 19" - 20") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	N****	Manually Priced Purchase
E2203	NU EP	H 6	***(Seat Depth 15") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	N****	Manually Priced Purchase
E2203	NU EP	U1 U1	H 6	***(Seat Depth 17" - 18") Manual w/c accessory, nonstandard seat frame depth, 20 to less than 22 inches	N****	Manually Priced Purchase
E2206	NU EP	H 6	Manual wheelchair accessory, wheel lock assembly, complete, each	N	Purchase
E2291	EP	6	Back, planar, for pediatric-size wheelchair, including fixed attaching hardware	N	Manually Priced
E2292	EP	6	Seat, planar, for pediatric-size wheelchair, including fixed attaching hardware	N	Manually Priced
E2293	EP	6	Back, contoured, for pediatric-size wheelchair, including fixed attaching hardware	N	Manually Priced
E2294	EP	6	Seat, contoured, for pediatric-size wheelchair, including fixed attaching hardware	N	Manually Priced
E2310	NU EP	H 6	Power w/c accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware	Y	Purchase
E2311	NU EP	H 6	Power w/c accessory, electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware	Y	Purchase
E2320	NU EP	H 6	Power w/c accessory, hand or chin control interface, remote joystick or touchpad, proportional, including all related electronics and fixed mounting hardware	Y	Purchase

E2322	NU EP	H 6	Power w/c accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware	Y	Purchase
E2323	NU EP	H 6	Power w/c accessory, specialty joystick handle for hand control interface, prefabricated	N	Purchase
E2324	NU EP	H 6	Power w/c accessory, chin cup for chin control interface	N	Purchase
E2325	NU EP	H 6	Power w/c accessory, sip & puff interface nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware	Y	Purchase
E2326	NU EP	H 6	Power w/c accessory, breath tube kit for sip & puff interface	Y	Purchase
E2327	NU EP	H 6	Power w/c accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware	Y	Purchase
E2360	NU EP	H 6	Power w/c accessory, 22 NF non-sealed lead acid battery, each	N	Purchase
E2361	NU EP	H 6	Power w/c accessory, 22 NF sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)	N	Purchase
E2362	NU EP	H 6	Power wheelchair accessory, group 24 non-sealed lead acid battery, each	N	Purchase
E2363	EP	6	***(Group 24 Gel Batteries) Power W/C accessory, group 24 sealed lead acid battery, each, e.g., gel cell, absorbed glassmat	N****	Purchase
E2363	NU EP	H 6	Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)	N	Purchase
E2363	NU EP	U1 U1	H 6	Power w/c accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat)	N	Purchase
E2364	NU EP	H 6	Power wheelchair accessory, U-1 non-sealed lead acid battery, each	N	Purchase
E2365	NU EP	H 6	***(U-1 gel cell battery, each) Power wheelchair accessory, U-1 sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat)	N	Purchase

E2365	NU EP	H 6	Power w/c accessory, U-1 sealed lead acid battery, each, gel cell	N	Purchase
E2365	NU EP	U1 U1	H 6	Power w/c accessory, U-1 sealed lead acid battery, each, gel cell	N	Purchase
E2366	NU EP	H 6	***(24-Volt Battery Charger - Standard, Replacement) Power w/c accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each	N	Purchase
E2367	NU EP	H 6	***(24-Volt Battery Charger - Dual Mode, Replacement) Power w/c accessory, battery charger, dual mode, sealed or non-sealed, each	N	Purchase
E2368	NU EP	H 6	Power wheelchair component, motor, replacement only	N	Purchase
E2369	NU EP	H 6	Power wheelchair component, gear box, replacement only	N	Purchase
E2601	NU EP UE	H 6 H	General use wheelchair seat cushion, width less than 22 in., any depth	N	Purchase
E2602	NU EP UE	H 6 H	General use wheelchair seat cushion, width 22 in. or greater, any depth	N	Purchase
E2611	NU EP UE	H 6 H	General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware	N	Purchase
E2612	NU EP UE	H 6 H	General use wheelchair back cushion, width 22 in. or greater, any height, including any type mounting hardware	N	Purchase
E2618	NU EP	H 6	Wheelchair accessory, solid seat support base (replaces sling seat), for use with manual wheelchair or lightweight power wheelchair, including any type mounting hardware	N	Manually Priced
E2619	NU EP	H 6	Replacement cover for wheelchair seat cushion or back cushion, each	N	Purchase
E2620	NU	H	Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware	N****	Purchase
E2621	NU	H	Positioning wheelchair back cushion, planar back with lateral supports, width 22 in. or greater, any height, including any type mounting hardware	N****	Purchase

K0004	NU EP	H 6	High-strength lightweight wheelchair	Y****	Purchase
K0005*	NU EP	H 6	***(High-performance manual W/C-adult) Ultralightweight W/C	Y*	Purchase
K0005*	NU EP	U1 U1	H 6	***(High-performance manual W/C with growth adjustability-child) Ultralightweight W/C	Y*	Purchase
K0010	NU EP	H 6	***(Motorized, standard frame, DA, swing away footrests) Standard weight frame motorized/power W/C	Y*	Purchase
K0010	NU EP	U1 U1	H 6	***(Motorized, standard frame, DA, swing away ELR) Standard weight frame motorized/power W/C	Y*	Purchase
K0011	NU EP	H 6	***(Motorized, power base or conventional frame w/c DA/swing away footrests, programmable electronics and custom options) Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking	Y*	Purchase
K0011	NU EP	U1 U1	H 6	***(Motorized, power base or conventional frame w/c DA/swing away footrests, programmable electronics and custom options) Standard-weight frame motorized/power, W/C with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking	Y*	Purchase
K0012	NU EP	H 6	***(Motorized folding frame, DA, swing away footrests) Lightweight portable motorized/power W/C	Y*	Purchase
K0012	NU EP	U1 U1	H 6	***(Motorized folding frame, DA, swing away ELR) Lightweight portable motorized/power W/C	Y*	Purchase
K00141,2	NU EP	U1 U1	H 6	***(Center Drive power base) Other motorized/ power W/C base	Y	Purchase
K0017	NU EP	U1 U1	H 6	***(Dual post and adjustable height DA) Detachable, adjustable height armrest, base, each	N****	Purchase
K0017	NU EP	H 6	***(Receiver for height adj. arms, replacement) Detachable, adjustable height armrest, base, each	N****	Purchase
K0019	NU EP	H 6	Arm pad, each	N	Purchase

K0020	NU EP	H 6	Fixed, adjustable height armrest, pair	N****	Purchase
K0038	NU EP	H 6	***(Single leg strap, each) Leg strap, each	N****	Purchase
K0038	NU EP	U2 U2	H 6	***(Foot straps, pair) Leg strap, each	N****	Purchase
K0038**	EP	U1	6	***(Knee strap) Leg strap, each	N	Purchase
K0039	NU EP	H 6	Leg strap, H style, each	N****	Purchase
K0040	NU EP	H 6	Adjustable angle footplate, each	N****	Purchase
K0043	NU EP	H 6	***(SWFR, replacement) Footrest, lower extension tube, each	N	Purchase
K0044	NU EP	H 6	***(SWFR Hanger bracket, replacement) Footrest, upper hanger bracket, each	N****	Purchase
K0045	NU EP	H 6	***(Padded custom foot box) Footrest, complete assembly	N****	Purchase
K0047	NU EP	H 6	Elevating legrest, upper hanger bracket, each	N****	Purchase
K0056	NU EP	H 6	Seat height less than 17 inches or equal to or greater than 21 inches for a high-strength, lightweight, or ultralightweight W/C	N****	Manually Priced
K0056	NU EP	U1 U1	H 6	***(Seat height 19.5"5) Seat height less than 17 inches or equal to or greater than 21 inches for a high strength, lightweight or ultralightweight W/C	N****	Purchase
K0064	NU EP	H 6	***(Zero pressure tube or wheel insert, each, rear wheels) Zero pressure tube (flat free insert), any size, each	N****	Purchase
K0064	NU EP	U1 U1	H 6	***(12" or 14" flat free insert for power base, ea.) Zero pressure tube (flat free insert), any size, each	N****	Purchase
K0065	NU EP	H 6	Spoke protectors, each	N****	Purchase
K0066	NU EP	H 6	***(20-26" Tires for manual W/C, ea., replacement) Solid tire, any size, each	N	Purchase
K0067	NU EP	H 6	***(Pneumatic Caster 8 X 2 with Airless Insert) Pneumatic tire, any size	N****	Purchase
K0068	NU EP	H 6	***(20-26" for manual W/C, ea., replacement) Pneumatic tire tube, each	N	Purchase

K0070	NU EP	H 6	***(Wheel assembly, complete with pneumatic tires, 20"/22"/24"/26"/ea. replacement) Rear wheel assembly, complete with pneumatic tire, spokes or molded, each	N****	Purchase
K0071	NU EP	U1 U1	H 6	***(Wheel assembly with pneumatic tires, 22", pair, rear wheels) Front caster assembly, complete, with pneumatic tire, each	N****	Purchase
K0071	NU EP	H 6	***(Polyeurethane casters, 5", pair, front casters) Front caster assembly, complete, with pneumatic tire, each	N****	Purchase
K0072	NU EP	H 6	***(Polyeurethane casters, 5", pair, front casters) Front caster assembly, complete, with semipneumatic tire, each	N****	Purchase
K0073	NU EP	H 6	Caster pin lock, each	N****	Purchase
K0074	NU EP	H 6	***(Pneumatic casters 8 x 1 1/4", each, front casters) Pneumatic caster tire, any size each	N****	Purchase
K0074	NU EP	H 6	***(Pneumatic casters 8 x 1 1/4", each, front casters) Pneumatic caster tire, any size each	N****	Purchase
K0074	NU EP	U2 U2	H 6	*******(9 x 2 3/4" pneumatic caster for power base W/C) Pneumatic caster tire, any size each	N****	Purchase
K0074	NU EP	U1 U1	H 6	***(6"-8" tires for manual W/C, ea., replacement) Pneumatic caster tire, any size, each	N	Purchase
K0074	NU EP	U3 U3	H 6	***(Pneumatic Caster 8 X 2) Pneumatic caster tire, any size, each	N****	Purchase
K0075	NU EP	H 6	Semipneumatic caster tire, any size, each	N	Purchase
K0076	NU EP	U1 U1	H 6	***(10" x 3" Rear Wheel for Power W/C, ea., replacement) Solid caster tire, any size, each	N	Purchase
K0076	NU EP	H 6	*******(9" x 3" Caster Tire for Power W/C, ea., replacement) Solid caster tire, any size, each	N	Purchase
K0076	NU EP	U2 U2	H 6	***(Polyurethane 5", replacement) Solid caster tire, any size, each	N****	Purchase
K0077	NU EP	H 6	Front caster assembly, complete, with solid tire, each	N	Purchase

K0078	NU EP	H 6	***(6"-8" for manual W/C, each, replacement) Pneumatic caster tire tube, each	N	Purchase
K0078	NU EP	U1 U1	H 6	APneumatic caster tire tube, each	N	Purchase
K0078	NU EP	U2 U2	H 6	*******(9" x 3" for Power W/C, ea., replacement) Pneumatic caster tire tube, each	N	Purchase
K0091	NU EP	U1 U1	H 6	***(20" x 2 1/8" tubes for power W/C, ea., replacement) Rear wheel tire tube other than zero pressure for power W/C, any size, each	N	Purchase
K0091	NU EP	H 6	***(10" x 3" Rear Wheel Caster Tube for Power W/C, ea., replacement) Rear wheel tire tube other than zero pressure for power W/C, any size, each	N	Purchase
K0092	NU EP	H 6	Rear wheel assembly for power wheelchair, complete, each	N	Purchase
K0093	NU EP	H 6	***(Zero pressure insert for rear wheel for power w/c, ea.) Rear wheel zero pressure tire tube (flat free insert) for power W/C any size, each	N****	Purchase
K0093	NU EP	U1 U1	H 6	***(Mag. Airless Insert, Drive Wheel) Rear wheel zero pressure tire tube (flat free insert) for power W/C, any size, each	N****	Purchase
K0094	NU EP	H 6	***(20" x 2 1/8" replacement) Wheel tire for power base, any size, each	N	Purchase
K0097	NU EP	H 6	Wheel, zero pressure tire tube (flat free insert) for power base, any size, each	N****	Purchase
K0099	NU EP	H 6	*******(9 x 2 3/4" foam filled caster for power base W/C) Front caster for power W/C	N****	Purchase
K0102	NU EP	H 6	Crutch and cane holder, each	N****	Purchase
K0104	NU EP	H 6	Cylinder tank carrier, each	N	Purchase
K0106	NU EP	H 6	Arm trough, each	N****	Purchase
K0108	NU EP	H 6	*(W/C miscellaneous equipment; applicable pages from the manufacturer's catalog must be attached to the claim form.)** Other accessories	N****	Manually Priced

K0195	NU EP	H 6	Elevating legrest, pair (for use with capped rental wheelchair base)	N	Rental Only
K0452	NU EP	U1 U1	H 6	***(Rear Wheel Stem, replacement) W/C bearings, any type	N	Purchase
K0452	NU EP	H 6	***(Caster Bearing, replacement) W/C bearings, any type	N	Purchase
K0452	NU EP	U2 U2	H 6	***(Power Base Wheel Bearing, replacement) W/C bearings, any type	N****	Purchase
S1002	NU EP	H 6	***(Wheelchair, custom molded seating system only) Customized item, list in addition to code for basic item	N****	Manually Priced
S1002	NU EP	U1 U1	H 6	***(Foam-in-place seat, Pindot quick foam contour system) Customized item, list in addition to code for basic item	N****	Manually Priced

The following procedure codes may only be billed on paper. Specialized Wheelchairs and Wheelchair Seating Systems for Individuals Age Two Through Adult (section 242.191)

No National Code	M1	M2	TOS	Local Code	Description	PA	Payment Method
Bill on paper	H 6	Z1613	One-piece footboard (each)	N****	Purchase
Bill on paper	H 6	Z1663	Group 27 deep cycle battery (each)	N	Purchase
Bill on paper	H 6	Z1785	W/C Mounting Kit, O.B.	N****	Purchase
Bill on paper	H 6	Z1789	Custom Headrest	N****	Purchase
Bill on paper	H 6	Z1793	Custom foot platform	N****	Purchase
Bill on paper	6	Z1824**	PC Car Seat/Snug Seat	Y	Purchase
Bill on paper	H 6	Z2137	Adjustable Rem. Abductor w/hardware (ea)	N****	Purchase
Bill on paper	H 6	Z2138	Adjustable Flip Down Abductor w/hardware (ea)	N****	Purchase
Bill on paper	H 6	Z2139	Lateral Hip/Thigh support w/hardware (ea)	N****	Purchase
Bill on paper	H 6	Z2140	Adductor - no hardware	N****	Purchase

Bill on paper	H 6	Z2141	Abductor - no hardware	N****	Purchase
Bill on paper	H 6	Z2142	Hip guides - no hardware	N	Purchase
Bill on paper	H 6	Z2143	Fluid supplement	N	Purchase
Bill on paper	H 6	Z2145	Laterals - no hardware	N****	Purchase
Bill on paper	H 6	Z2159	Fluid Flo-lite pad (Replacement)	N	Purchase
Bill on paper	H Z2175 6		Power W/C Sleeve Top or Bottom Stem Bearing (Replacement)	N****	Purchase
Bill on paper	H 6	Z2178	SWFR Pivot Saddle (Replacement)	N	Purchase
Bill on paper	H 6	Z2180	SWFR Latch Block (Replacement)	N	Purchase
Bill on paper	H 6	Z2181	SWFR Composite Foot Plate (Replacement)	N****	Purchase
Bill on paper	H 6	Z2183	Shoe Holders S/M/L/XL	N****	Purchase
Bill on paper	H 6	Z2184	X-Tube Assembly Folding W/C (Replacement)	N****	Purchase
Bill on paper	H 6	Z2185	Rigid Wheelchair Growth Kit	N	Purchase
Bill on paper	H 6	Z2186	Rigid Side Guard	N****	Purchase
Bill on paper	H 6	Z2187	Fabric Side Guard	N****	Purchase
Bill on paper	H 6	Z2188	Sub Occipital Three Piece Head Set W/REM Hardware	N****	Purchase
Bill on paper	H 6	Z2189	Forehead Strap System	N****	Purchase
Bill on paper	H 6	Z2190	Regular Links	N****	Purchase
Bill on paper	H 6	Z2192	Pneumatic or Semi Casters (Replacement) 8 x 1 1/4 (ea) or 8 x 1 3/4 (ea)	N****	Purchase
Bill on paper	H 6	Z2196	Swing Away Adj. Stroller Handles	N****	Purchase

Bill on paper	H 6	Z2200	Support Fixture for Head Rest	N****	Purchase
Bill on paper	H 6	Z2202	Lg. Chest Panel Support	N****	Purchase
Bill on paper	H 6	Z2203	Elbow Block w/Bracket	N****	Purchase
Bill on paper	H 6	Z2554	Swing Away Retractable Joystick Mount	N****	Purchase
Bill on paper	H 6	Z2571	Power Elevating Leg Rest With Calf Pads	N****	Purchase
Bill on paper	H 6	Z2582	Quick Release Axle	N****	Purchase
Bill on paper	H 6	Z2585	Growing Seat Pan	N****	Purchase
Bill on paper	H	Z2586	Growing Back Upholstery	N****	Purchase
Bill on paper	H 6	Z2588	Deep Contour Back 20" Width	N****	Purchase
Bill on paper	H 6	Z2589	Adjustable Contour Lateral Pelvic Support	N****	Purchase
Bill on paper	H 6	Z25911	Heavy Duty Motor Pack 350 Pounds	N	Purchase
Bill on paper	H 6	Z2592	Remote Joystick Module	N****	Purchase
Bill on paper	H	Z2596	Adjustable Contour Seat Attaching Hardware	N****	Purchase
Bill on paper	H 6	Z2599	Transit Option	N****	Purchase
Bill on paper	H 6	Z2604	Adjustable Back Upholstery	N****	Purchase
Bill on paper	H 6	Z2607	Lateral/Posterior Pelvic Support	N****	Purchase
Bill on paper	H 6	Z2608	Shoulder Harness Guide Kit	N****	Purchase
Bill on paper	H 6	Z2609	Universal Head Rest Kit	N****	Purchase
Bill on paper	H 6	Z2615	Remote Joystick With 1/8" Jacks	N****	Purchase
Bill on paper	H 6	Z2616	Swing Away Mount (Joystick)	N****	Purchase

Disclaimer: These regulations may not be the most recent version. Arkansas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.

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Arkansas Administrative CodeAgency 016 - DEPARTMENT OF HUMAN SERVICESDivision 06 - Medical ServicesRule 016.06.05-061 - Prosthetics Provider Manual Update Transmittal #72

Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.05-061 - Prosthetics Provider Manual Update Transmittal #72