Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.06-056 - Prosthetics Provider Manual Update Transmittal # 85

Procedure Code

M1

M2

TOS

Description

B4100

NU

H

Food thickener, administered orally, peroz.

B4100

NU

BA

H

Food thickener, administered enterally, peroz.

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 +

N

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 +

N

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 +

N

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 +

N

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 +

N

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 +

N

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

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 +

N

Purchase

A5512

NU

H

For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of % inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each

21 +

Y

Purchase

A5513

NU

H

For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of % inch material of shore a 35 durometerof 3/16 inch material of shore a 40 durometer (or higher), includes arch filler and other shaping material custom fabricated, each

21 +

Y

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

N

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

L0621

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

L0622

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

L0623

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

L0624

NU

EP

H

6

SO, 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, custom fabricated

All

N

Manually Priced

L0625

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

L0626

NU

EP

H

6

LO, sagittal control, with rigid posterior panel(s), 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

L0627

NU

EP

H

6

LO, sagittal control, with rigid anterior and posterior panel(s), 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

L0628

NU

EP

H

6

LSO, flexible, provides lumbosacral 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

L0629

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

L0630

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

L0631

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

L0632

NU

EP

H

6

LSO, sagittal control, with rigid anterior and posterior panels, 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

L0633

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

L0634

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/panel(s), 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

L0635

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/panel(s), 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

L0636

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

L0637

NU

EP

H

6

LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, 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

L0638

NU

EP

H

6

LSO, sagittal-coronal control, with rigid anterior and posterior frame/panels, 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

L0639

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 material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0640

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 material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated

All

N

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

L0859

NU

EP

H

6

Addition to halo procedure, magnetic resonance image compatible system, rings and pins, any material

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-sacra l-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 (llfled 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 elastic 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

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

EP

H

6

Addition to knee joint, ratchet lock for active and progressive knee extension, each joint

All

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 club foot 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, size81/2-12) 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, size81/2-12) 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 81/4-12) 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, size81/2-12) 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, size81/2-12) 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 81/4-12) 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, size81/2-12) 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, size81/2-12) 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 81/4-12) 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 81/4-12) 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, size81/2-12) 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, size81/2-12) 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, size81/2-12) 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, size81/2-12) 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 Plastazote (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

L3807

NU

EP

H

6

WHFO, without joint(s), prefabricated, includes fitting and adjustments, any type

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 LP.

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