Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-004 - Prosthetics Update 115
Current through Register Vol. 49, No. 9, September, 2024
Section II Prosthetics
When billed either electronically or on paper, procedure codes found in this section must be billed with certain modifiers. Modifiers in the section are indicated by the headings M1 and M2. When only the NU modifier is shown in the M1 column, the procedure code may be billed for participants of all ages. When NU and EP are listed together in the M1 column, the NU modifier must be used when billing for beneficiaries age 21 and over, and the EP modifier must be used when billing for beneficiaries under age 21. When a modifier is listed in the M2 heading, that modifier must be used in conjunction with either NU or EP.
Prior authorization requirements are shown under the heading PA. .If prior authorization is needed, the information is indicated with a ?Y? in the column; if not, an ?N? is shown.
* Prior authorization is not required when other insurance pays at least 50% of the
Medicaid maximum allowable reimbursement amount.
***(?) This symbol, along with text in parentheses, indicates the Arkansas Medicaid description of the product.
Respiratory and Diabetic Equipment, All Ages (section 242.110)
|
Procedure Code |
M1 |
M2 |
Description |
PA |
Payment Method |
|
A4230 |
NU |
Infusion set for external insulin pump, nonneedle cannula type |
Y* |
Purchase |
|
|
A4231 |
NU |
Infusion set for external insulin pump, needle type |
Y* |
Purchase |
|
|
A4232 |
NU |
Syringe with needle for external insulin pump, sterile, 3 cc |
Y* |
Purchase |
|
|
A4627 |
NU |
UB |
***(Spacer bag or reservoir without mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler |
N |
Purchase |
|
A4627 |
NU |
***(Spacer bag or reservoir with mask, for use with metered dose inhaler) Spacer, bag or reservoir, with or without mask, for use with metered dose inhaler |
N |
Purchase |
|
|
A6021 |
NU |
Collagen dressing, pad size 16 sq. in. or less, each |
Y* |
Purchase |
|
|
A6022 |
NU |
Collagen dressing, pad size more than 16 sq. in. but less than or equal to 48 sq. in., each |
Y* |
Purchase |
|
|
A6023 |
NU |
Collagen dressing, pad size more than 48 sq. in., each |
Y* |
Purchase |
|
|
A6024 |
NU |
Collagen dressing wound filler, per 6 in. |
Y* |
Purchase |
|
|
A7034 |
NU |
RR |
***(CPAP Device Nasal Continuous Positive Airway Pressure (CPAP) Device; includes necessary accessory items) NOTE: Complete medical data pertinent to the request must be submitted with the prior authorization request. NOTE: Bill A7034 as the global daily rental service. Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap |
Y* |
Rental Only |
|
A7045 |
NU |
Exhalation port with or without swivel used with accessories for positive airway devices, replacement only |
N |
Purchase |
|
|
A9999 |
NU |
***(Unlisted Durable Medical Equipment. The manufacturer?s invoice must be attached to the claim form.) Misc. DME supply or accessory, not otherwise specified |
Y |
Manually Priced |
|
|
E0424 |
NU |
Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
Y* |
Rental Only |
|
|
E0430 |
NU |
Portable gaseous oxygen system, purchase, includes regulator, flowmeter, humidifier, cannula or mask, and tubing |
Y* |
Rental Only |
|
|
E0435 |
NU |
Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adapter |
Y* |
Rental Only |
|
|
E0439 |
NU |
Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
Y* |
Rental Only |
|
|
E0441 |
NU |
Oxygen contents, gaseous (for use with owned gaseous stationary systems or when both a stationary and portable gaseous system are owned), one month?s supply = I unit |
Y |
Purchase |
|
|
E0442 |
NU |
Oxygen contents, liquid (for use with owned liquid stationary systems or when both a stationary and portable liquid system are owned), one month?s supply = 1 unit |
Y |
Purchase |
|
|
E0443 |
NU |
Portable oxygen contents, gaseous (for use only with portable gaseous systems when no stationary gas or liquid system is used), one month?s supply=1 unit |
Y* |
Purchase |
|
|
E0444 |
NU |
Portable oxygen contents, liquid (for use only with portable liquid systems when no stationary gas or liquid system is used), one month?s supply=1 unit |
Y* |
Purchase |
|
|
E0470 |
NU EP |
RR RR |
***(BIPAP Device, Nasal Bi-level Positive Airway support system; includes necessary accessory items. NOTE: Complete medical data pertinent to the request must be submitted with the prior authorization request.) Respiratory assist device, bi-level pressure capacity, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
Y* Y* |
Rental Only |
|
E0471 |
NU EP |
RR RR |
Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
Y* Y* |
Rental Only |
|
E0472 |
NU EP |
RR RR |
Respiratory assist device, bi-level pressure capacity, with backup rate feature, used with invasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device) |
Y* Y* |
Rental Only |
|
E0483 |
NU |
RR |
***(Bronchial Drainage System) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each |
Y* |
Rental Only |
|
E0483 |
NU |
UB |
***(Pulmonary Vest. The manufacturer invoice must be attached to the claim form.) High-frequency chest wall oscillation air-pulse generator system (includes hoses and vest), each |
Y* |
Purchase |
|
E0560 |
NU UE |
Humidifier, durable for supplemental humidification during IPPB treatment or oxygen delivery |
N |
Purchase |
|
|
E0561 |
NU EP |
Humidifier, non-heated, used w/positive airway pressure device |
Y* Y* |
Purchase |
|
|
E0562 |
NU EP |
Humidifier, heated, used w/positive airway pressure device |
Y* Y* |
Purchase |
|
|
E0570 |
NU UE |
Nebulizer, with compressor |
Y* |
Purchase |
|
|
E0575 |
NU UE |
Nebulizer, ultrasonic, large volume |
Y* |
Capped Rental |
|
|
E0600 |
NU UE |
Respiratory suction pump, home model, portable or stationary, electric |
N |
Rental Only |
|
|
E0779 |
NU |
RR |
***(Ambulatory infusion device, payable only when services are provided to patients receiving chemotherapy, pain management or antibiotic treatment in the home) Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater |
Y* |
Rental Only |
|
E0784 |
NU |
External ambulatory infusion pump, insulin |
Y* |
Purchase |
|
|
E1340 |
NU |
***(DME Repair: Parts Only Repairs will not be approved for more than the allowed purchase price of new equipment. The manufacturer?s invoice must be attached to the repair claim for all parts.) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
N |
N/A |
|
|
E1340 |
NU |
U4 |
***(Maintenance for Capped Rental items) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
N |
N/A |
|
E1340 |
NU |
U1 |
***(Labor Only; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
N |
N/A |
|
E1340 |
EP |
U1 |
***(Labor Only; a maximum of twenty (20) units per date of service is allowable. 20 units = 5 hours of labor) Repair or non routine service for durable medical equipment requiring the skill of a technician, labor component, per 15 minutes |
N |
N/A |
|
E1390 |
NU |
Oxygen concentrator, single delivery port, capable of delivering 85 % or greater oxygen concentration at the prescribed flow rate |
Y* |
Rental Only |
|
|
E1391 |
NU |
O2 concentrator, dual delivery port, capable of delivering 85% or greater oxygen concentration at the prescribed flow rate, each |
Y* |
Rental Only |
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.
Modifiers in this section are indicated by the headings M1 and M2. 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.
This procedure code does not require prior authorization; however, the beneficiary?s medical condition must fall within the diagnosis range of 250.00 and 251.93.
This item is limited to one every twelve months for beneficiaries age 21 and over.
Orthotic Appliances, All Ages (section 242.180)
|
Procedure Code |
M1 |
M2 |
Description |
All U21 21+ |
PA 21+ |
Payment Method |
|
A5500' |
NU |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 |
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 1/4 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 |
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 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping material custom fabricated, each |
21+ |
N |
Purchase |
|
|
L0120 |
NU EP |
Cervical, flexible, nonadjustable (foam collar) |
All |
N |
Purchase |
|
|
L0130 |
NU EP |
Cervical, flexible, thermoplastic collar, molded to patient |
All |
N |
Purchase |
|
|
L0140 |
NU EP |
Cervical, semi-rigid, adjustable (plastic collar) |
All |
N |
Purchase |
|
|
L0150 |
NU EP |
Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) |
All |
N |
Purchase |
|
|
L0160 |
NU EP |
Cervical, semi-rigid, wire frame occipital/mandibular support |
All |
N |
Purchase |
|
|
L0170 |
NU EP |
Cervical, collar, molded to patient model |
All |
N |
Purchase |
|
|
L0172 |
NU EP |
Cervical, collar, semi-rigid thermoplastic foam, two piece |
All |
N |
Purchase |
|
|
L0174 |
NU EP |
Cervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extension |
All |
N |
Purchase |
|
|
L0180 |
NU EP |
Cervical, multiple post collar, occipital/mandibular supports, adjustable |
All |
N |
Purchase |
|
|
L0190 |
NU EP |
Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (SOMI, Guilford, Taylor types) |
All |
N |
Purchase |
|
|
L0200 |
NU EP |
Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension |
All |
N |
Purchase |
|
|
L0210 |
NU EP |
Thoracic, rib belt |
All |
N |
Purchase |
|
|
L0220 |
NU EP |
Thoracic, rib belt, custom fabricated |
All |
N |
Purchase |
|
|
L0450 |
NU EP |
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 |
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 |
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 |
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 |
N |
Purchase |
|
|
L0458 |
NU EP |
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 |
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 |
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 |
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 |
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 |
N |
Purchase |
|
|
L0468 |
NU EP |
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 |
N |
Purchase |
|
|
L0470 |
NU EP |
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 |
N |
Purchase |
|
|
L0472 |
NU EP |
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 |
|
|
L0480 |
NU EP |
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 |
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 |
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 |
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 |
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 |
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 T-9 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 |
Sacroiliac orthosis, 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 |
Sacroiliac orthosis, 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 |
Sacroiliac orthosis, 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 |
Sacroiliac orthosis, 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 |
Lumbar orthosis, 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 |
Lumbar orthosis, 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 |
Lumbar orthosis, 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 |
Lumbar-sacral orthosis, 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 |
|
|
L0629 |
NU EP |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Lumbar-sacral orthosis, 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 |
Cervical-thoracic-lumbar-sacral orthoses (CTLSO), anterior-posterior-lateral control, molded to patient model (Minerva type) |
All |
Y |
Purchase |
|
|
L0710 |
NU EP |
CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type) |
All |
Y |
Purchase |
|
|
L0810 |
NU EP |
Halo procedure, cervical halo incorporated into jacket vest |
All |
Y |
Purchase |
|
|
L0820 |
NU EP |
Halo procedure, cervical halo incorporated into plaster body jacket |
All |
Y |
Purchase |
|
|
L0830 |
NU EP |
Halo procedure, cervical halo incorporated into Milwaukee type orthosis |
All |
Y |
Purchase |
|
|
L0859 |
NU EP |
Addition to halo procedure, magnetic resonance image compatible system, rings and pins, any material |
All |
Y |
Purchase |
|
|
L0960 |
NU EP |
Torso support, post surgical support, pads for post surgical support |
All |
N |
Purchase |
|
|
L0970 |
NU EP |
TLSO, corset front |
All |
N |
Purchase |
|
|
L0972 |
NU EP |
LSO, corset front |
All |
N |
Purchase |
|
|
L0974 |
NU EP |
TLSO, full corset |
All |
N |
Purchase |
|
|
L0976 |
NU EP |
LSO, full corset |
All |
N |
Purchase |
|
|
L0978 |
NU EP |
Axillary crutch extension |
All |
N |
Purchase |
|
|
L0980 |
NU EP |
Peroneal straps, pair |
All |
N |
Purchase |
|
|
L0982 |
NU EP |
Stocking supporter grips, set of four (4) |
All |
N |
Purchase |
|
|
L0984 |
NU |
Protective body sock, each |
21+ |
N |
Purchase |
|
|
L1000 |
NU EP |
CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model |
All |
Y |
Purchase |
|
|
L1010 |
NU EP |
Addition to CTLSO or scoliosis orthosis, axilla sling |
All |
N |
Purchase |
|
|
L1020 |
NU EP |
Addition to CTLSO or scoliosis orthosis, kyphosis pad |
All |
N |
Purchase |
|
|
L1025 |
NU EP |
Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating |
All |
N |
Purchase |
|
|
L1030 |
NU EP |
Addition to CTLSO or scoliosis orthosis, lumbar bolster pad |
All |
N |
Purchase |
|
|
L1040 |
NU EP |
Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad |
All |
N |
Purchase |
|
|
L1050 |
NU EP |
Addition to CTLSO or scoliosis orthosis, sternal pad |
All |
N |
Purchase |
|
|
L1060 |
NU EP |
Addition to CTLSO or scoliosis orthosis, thoracic pad |
All |
N |
Purchase |
|
|
L1070 |
NU EP |
Addition to CTLSO or scoliosis orthosis, trapezius sling |
All |
N |
Purchase |
|
|
L1080 |
NU EP |
Addition to CTLSO or scoliosis orthosis, outrigger |
All |
N |
Purchase |
|
|
L1085 |
NU EP |
Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions |
All |
N |
Purchase |
|
|
L1090 |
NU EP |
Addition to CTLSO or scoliosis orthosis, lumbar sling |
All |
N |
Purchase |
|
|
L1100 |
NU EP |
Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather |
All |
N |
Purchase |
|
|
L1110 |
NU EP |
Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model |
All |
N |
Purchase |
|
|
L1120 |
NU EP |
Addition to CTLSO, scoliosis orthosis, cover for upright, each |
All |
N |
Purchase |
|
|
L1200 |
NU EP |
Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis only |
All |
Y |
Purchase |
|
|
L1210 |
NU EP |
Addition to TLSO (low profile), lateral thoracic extension |
All |
N |
Purchase |
|
|
L1220 |
NU EP |
Addition to TLSO (low profile), anterior thoracic extension |
All |
N |
Purchase |
|
|
L1230 |
NU EP |
Addition to TLSO (low profile), Milwaukee type superstructure |
All |
N |
Purchase |
|
|
L1240 |
NU EP |
Addition to TLSO (low profile), lumbar derotation pad |
All |
N |
Purchase |
|
|
L1250 |
NU EP |
Addition to TLSO (low profile), anterior asis pad |
All |
N |
Purchase |
|
|
L1260 |
NU EP |
Addition to TLSO (low profile), anterior thoracic derotation pad |
All |
N |
Purchase |
|
|
L1270 |
NU EP |
Addition to TLSO (low profile), abdominal pad |
All |
N |
Purchase |
|
|
L1280 |
NU EP |
Addition to TLSO (low profile), rib gusset (elastic), each |
All |
N |
Purchase |
|
|
L1290 |
NU EP |
Addition to TLSO (low profile), lateral trochanteric pad |
All |
N |
Purchase |
|
|
L1300 |
NU EP |
Other scoliosis procedure, body jacket molded to patient model |
All |
Y |
Purchase |
|
|
L1310 |
NU EP |
Other scoliosis procedure, postoperative body jacket |
All |
Y |
Purchase |
|
|
L1499 |
NU EP |
Spinal orthosis, not otherwise specified. ***(The manufacturer?s invoice must be attached to all claims.) |
All |
Y |
Manually Priced |
|
|
L1500 |
NU EP |
THKAO, mobility frame (Newington, Parapodium types) |
All |
Y |
Purchase |
|
|
L1510 |
NU EP |
THKAO, standing frame, with or without tray and accessories |
All |
Y |
Purchase |
|
|
L1520 |
NU EP |
THKAO, swivel walker |
All |
Y |
Purchase |
|
|
L1600 |
NU EP |
HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1610 |
NU EP |
HO, abduction control of hip joints, flexible (Frejka cover only), prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1620 |
NU EP |
HO, abduction control of hip joints, flexible (Pavlik harness), prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1630 |
NU EP |
HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated |
All |
N |
Purchase |
|
|
L1640 |
NU EP |
HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated |
All |
N |
Purchase |
|
|
L1650 |
NU EP |
HO, abduction control of hip joints, static, adjustable, custom fitted (Ilfled type), prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1660 |
NU EP |
HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1680 |
NU EP |
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 |
HO, abduction control of hip joint, post operative hip abduction type, custom fabricated |
All |
Y |
Purchase |
|
|
L1686 |
NU EP |
HO, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustments |
All |
Y |
Purchase |
|
|
L1690 |
NU |
Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment |
21+ |
Y |
Purchase |
|
|
L1700 |
NU EP |
Legg Perthes orthosis (Toronto type), custom fabricated |
All |
Y |
Purchase |
|
|
L1710 |
NU EP |
Legg Perthes orthosis (Newington type), custom fabricated |
All |
Y |
Purchase |
|
|
L1720 |
NU EP |
Legg Perthes orthosis, trilateral (Tachdijan type), custom fabricated |
All |
Y |
Purchase |
|
|
L1730 |
NU EP |
Legg Perthes orthosis (Scottish Rite type) custom fabricated |
All |
Y |
Purchase |
|
|
L1755 |
NU EP |
Legg Perthes orthosis (Patten bottom type), custom fabricated |
All |
Y |
Purchase |
|
|
L1800 |
NU EP |
KO, elastic with stays, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1810 |
NU EP |
KO, elastic with joints, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1815 |
NU EP |
KO, elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1820 |
NU EP |
KO, elastic with condyle pads and joints, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1825 |
NU EP |
KO, elastic knee cap. prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1830 |
NU EP |
KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1832 |
NU EP |
Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1834 |
NU EP |
KO, without knee joint, rigid, custom fabricated |
All |
N |
Purchase |
|
|
L1840 |
NU EP |
KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated |
All |
Y |
Purchase |
|
|
L1843 |
NU |
Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment |
21+ |
Y |
Purchase |
|
|
L1844 |
NU |
Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated |
21+ |
Y |
Purchase |
|
|
L1845 |
NU EP |
Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment |
All |
Y |
Purchase |
|
|
L1846 |
NU EP |
Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control with or without varus/valgus adjustment, custom fabricated |
All |
Y |
Purchase |
|
|
L1847 |
NU |
Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment |
21+ |
N |
Purchase |
|
|
L1850 |
NU EP |
KO, Swedish type, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1855 |
NU EP |
KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated |
All |
Y |
Purchase |
|
|
L1858 |
NU EP |
KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated |
All |
Y |
Purchase |
|
|
L1860 |
NU EP |
KO, modification of supracondylar prosthetic socket, custom fabricated (SK) |
All |
Y |
Purchase |
|
|
L1870 |
NU EP |
KO, double upright, thigh and calf lacers, with knee joints, custom fabricated |
All |
Y |
Purchase |
|
|
L1880 |
NU EP |
KO, double upright, nonmolded thigh and calf cuff/lacers with knee joints, custom fabricated |
All |
N |
Purchase |
|
|
L1900 |
NU EP |
AFO, spring wire, dorsiflexion assist calf band, custom fabricated |
All |
N |
Purchase |
|
|
L1902 |
NU EP |
AFO, ankle gauntlet, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1904 |
NU EP |
AFO, molded ankle gauntlet, custom fabricated |
All |
N |
Purchase |
|
|
L1906 |
NU EP |
AFO, multiligamentus ankle support, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1907 |
NU EP |
AFO, supramalleolar with straps, with or without interface/pads, custom fabricated |
All |
N |
Purchase |
|
|
L1910 |
NU EP |
AFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1920 |
NU EP |
AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated |
All |
N |
Purchase |
|
|
L1920 |
EP |
***(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 |
AFO, plastic or other material, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1932 |
NU EP |
AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L1940 |
NU EP |
AFO, plastic or other material, custom-fabricated |
All |
N |
Purchase |
|
|
L1945 |
NU EP |
AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated |
All |
Y |
Purchase |
|
|
L1950 |
NU EP |
AFO, spiral (Institute of Rehabilitative Medicine type), plastic, custom fabricated |
All |
N |
Purchase |
|
|
L1960 |
NU EP |
AFO, posterior solid ankle, plastic, custom fabricated |
All |
N |
Purchase |
|
|
L1970 |
NU EP |
AFO, plastic, with ankle joint, custom fabricated |
All |
N |
Purchase |
|
|
L1980 |
NU EP |
AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar BK orthosis), custom fabricated |
All |
N |
Purchase |
|
|
L1990 |
NU EP |
AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar BK orthosis), custom fabricated |
All |
N |
Purchase |
|
|
L2000 |
NU EP |
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 |
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 |
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 |
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 |
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 |
Knee ankle foot orthosis, full plastic, static (pediatric size) without free motion ankle, prefabricated, includes fitting and adjustment |
21+ |
N |
Purchase |
|
|
L2036 |
NU EP |
Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
All |
Y |
Purchase |
|
|
L2037 |
NU EP |
Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated |
All |
Y |
Purchase |
|
|
L2038 |
NU EP |
Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated |
All |
Y |
Purchase |
|
|
L2040 |
NU EP |
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 |
|
L2050 |
NU EP |
HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated |
All |
N |
Purchase |
|
|
L2060 |
NU EP |
HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated |
All |
N |
Purchase |
|
|
L2070 |
NU EP |
HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated |
All |
N |
Purchase |
|
|
L2080 |
NU EP |
HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated |
All |
N |
Purchase |
|
|
L2090 |
NU EP |
HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated |
All |
N |
Purchase |
|
|
L2106 |
NU EP |
AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated |
All |
N |
Purchase |
|
|
L2108 |
NU EP |
AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated |
All |
Y |
Purchase |
|
|
L2112 |
NU EP |
AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L2114 |
NU EP |
AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L2116 |
NU EP |
AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L2126 |
NU EP |
KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated |
All |
Y |
Purchase |
|
|
L2128 |
NU EP |
KAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricated |
All |
Y |
Purchase |
|
|
L2132 |
NU EP |
KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment |
All |
Y |
Purchase |
|
|
L2134 |
NU EP |
KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid prefabricated, includes fitting and adjustment |
All |
Y |
Purchase |
|
|
L2136 |
NU EP |
KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment |
All |
Y |
Purchase |
|
|
L2180 |
NU EP |
Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints |
All |
N |
Purchase |
|
|
L2182 |
NU EP |
Addition to lower extremity fracture orthosis, drop lock knee joint |
All |
N |
Purchase |
|
|
L2184 |
NU EP |
Addition to lower extremity fracture orthosis, limited motion knee joint |
All |
N |
Purchase |
|
|
L2186 |
NU EP |
Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type |
All |
N |
Purchase |
|
|
L2188 |
NU EP |
Addition to lower extremity fracture orthosis, quadrilateral brim |
All |
N |
Purchase |
|
|
L2190 |
NU EP |
Addition to lower extremity fracture orthosis, waist belt |
All |
N |
Purchase |
|
|
L2192 |
NU EP |
Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt |
All |
N |
Purchase |
|
|
L2200 |
NU EP |
Additions to lower extremity, limited ankle motion, each joint |
All |
N |
Purchase |
|
|
L2210 |
NU EP |
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint |
All |
N |
Purchase |
|
|
L2220 |
NU EP |
Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint |
All |
N |
Purchase |
|
|
L2230 |
NU EP |
Addition to lower extremity, split flat caliper stirrups and plate attachment |
All |
N |
Purchase |
|
|
L2232 |
NU EP |
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 |
Addition to lower extremity, round caliper and plate attachment |
All |
N |
Purchase |
|
|
L2250 |
NU EP |
Addition to lower extremity, foot plate, molded to patient model, stirrup attachment |
All |
N |
Purchase |
|
|
L2260 |
NU EP |
Addition to lower extremity, reinforced solid stirrup (Scott-Craig type) |
All |
N |
Purchase |
|
|
L2265 |
NU EP |
Addition to lower extremity, long tongue stirrup |
All |
N |
Purchase |
|
|
L2270 |
NU EP |
Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus pad |
All |
N |
Purchase |
|
|
L2275 |
NU EP |
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined |
All |
N |
Purchase |
|
|
L2280 |
NU EP |
Addition to lower extremity, molded inner boot |
All |
N |
Purchase |
|
|
L2300 |
NU EP |
Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable |
All |
N |
Purchase |
|
|
L2310 |
NU EP |
Addition to lower extremity, abduction bar straight |
All |
N |
Purchase |
|
|
L2320 |
NU EP |
Addition to lower extremity, nonmolded lacer, for custom fabricated orthosis only |
All |
N |
Purchase |
|
|
L2330 |
NU EP |
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only |
All |
N |
Purchase |
|
|
L2335 |
NU EP |
Addition to lower extremity, anterior swing band |
All |
N |
Purchase |
|
|
L2340 |
NU EP |
Addition to lower extremity, pretibial shell, molded to patient model |
All |
N |
Purchase |
|
|
L2350 |
NU EP |
Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses) |
All |
Y |
Purchase |
|
|
L2360 |
NU EP |
Addition to lower extremity, extended steel shank |
All |
N |
Purchase |
|
|
L2370 |
NU EP |
Addition to lower extremity, Patten bottom |
All |
N |
Purchase |
|
|
L2375 |
NU EP |
Addition to lower extremity, torsion control, ankle joint and half solid stirrup |
All |
N |
Purchase |
|
|
L2380 |
NU EP |
Addition to lower extremity, torsion control, straight knee joint, each joint |
All |
N |
Purchase |
|
|
L2385 |
NU EP |
Addition to lower extremity, straight knee joint, heavy duty, each joint |
All |
N |
Purchase |
|
|
L2390 |
NU EP |
Addition to lower extremity, offset knee joint, each joint |
All |
N |
Purchase |
|
|
L2395 |
NU EP |
Addition to lower extremity, offset knee joint, heavy duty, each joint |
All |
N |
Purchase |
|
|
L2397 |
NU |
Addition to lower extremity orthosis, suspension sleeve |
21+ |
N |
Purchase |
|
|
L2405 |
NU EP |
Addition to knee joint, drop lock, each |
All |
N |
Purchase |
|
|
L2415 |
NU EP |
Addition to knee lock with integrated release mechanism, (bail, cable or equal, any material, each joint |
All |
N |
Purchase |
|
|
L2425 |
NU EP |
Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint |
All |
N |
Purchase |
|
|
L2430 |
NU EP |
Addition to knee joint, ratchet lock for active and progressive knee extension, each joint |
All |
N |
Purchase |
|
|
L2492 |
NU EP |
Addition to knee joint, lift loop for drop lock ring |
All |
N |
Purchase |
|
|
L2500 |
NU EP |
Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring |
All |
N |
Purchase |
|
|
L2510 |
NU EP |
Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model |
All |
N |
Purchase |
|
|
L2520 |
NU EP |
Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted |
All |
N |
Purchase |
|
|
L2525 |
NU EP |
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model |
All |
N |
Purchase |
|
|
L2526 |
NU EP |
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted |
All |
N |
Purchase |
|
|
L2530 |
NU EP |
Addition to lower extremity, thigh/weight bearing, lacer, non-molded |
All |
N |
Purchase |
|
|
L2540 |
NU EP |
Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model |
All |
N |
Purchase |
|
|
L2550 |
NU EP |
Addition to lower extremity, thigh/weight bearing, high roll cuff |
All |
N |
Purchase |
|
|
L2570 |
NU EP |
Addition to lower extremity, pelvic control, hip joint, Clevis type two position joint, each |
All |
N |
Purchase |
|
|
L2580 |
NU EP |
Addition to lower extremity, pelvic control, pelvic sling |
All |
N |
Purchase |
|
|
L2600 |
NU EP |
Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each |
All |
N |
Purchase |
|
|
L2610 |
NU EP |
Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each |
All |
N |
Purchase |
|
|
L2620 |
NU EP |
Addition to lower extremity, pelvic control, hip joint, heavy duty, each |
All |
N |
Purchase |
|
|
L2622 |
NU EP |
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each |
All |
N |
Purchase |
|
|
L2624 |
NU EP |
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each |
All |
N |
Purchase |
|
|
L2627 |
NU EP |
Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables |
All |
N |
Purchase |
|
|
L2628 |
NU EP |
Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables |
All |
N |
Purchase |
|
|
L2630 |
NU EP |
Addition to lower extremity, pelvic control, band and belt unilateral |
All |
N |
Purchase |
|
|
L2640 |
NU EP |
Addition to lower extremity, pelvic control, band and belt bilateral |
All |
N |
Purchase |
|
|
L2650 |
NU EP |
Addition to lower extremity, pelvic and thoracic control, gluteal pad, each |
All |
N |
Purchase |
|
|
L2660 |
NU EP |
Addition to lower extremity, thoracic control, thoracic band |
All |
N |
Purchase |
|
|
L2670 |
NU EP |
Addition to lower extremity, thoracic control, paraspinal uprights |
All |
N |
Purchase |
|
|
L2680 |
NU EP |
Addition to lower extremity, thoracic control, lateral support uprights |
All |
N |
Purchase |
|
|
L2750 |
NU EP |
Addition to lower extremity orthosis, plating chrome or nickel, per bar |
All |
N |
Purchase |
|
|
L2755 |
NU EP |
***(Carbon composite ankles; addition to AFO) Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only |
All |
N |
Purchase |
|
|
L2760 |
NU EP |
Addition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth) |
All |
N |
Purchase |
|
|
L2770 |
NU EP |
Addition to lower extremity orthosis, any material, per bar or joint |
All |
N |
Purchase |
|
|
L2780 |
NU EP |
Addition to lower extremity orthosis, non-corrosive finish, per bar |
All |
N |
Purchase |
|
|
L2785 |
NU EP |
Addition to lower extremity orthosis, drop lock retainer, each |
All |
N |
Purchase |
|
|
L2795 |
NU EP |
Addition to lower extremity orthosis, knee control, full kneecap |
All |
N |
Purchase |
|
|
L2800 |
NU EP |
Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull, for use with custom fabricated orthosis only |
All |
N |
Purchase |
|
|
L2810 |
NU EP |
Addition to lower extremity orthosis, knee control, condylar pad |
All |
N |
Purchase |
|
|
L2810 |
EP |
***(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 |
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section |
All |
N |
Purchase |
|
|
L2830 |
NU EP |
Addition to lower extremity orthosis, soft interface for molded plastic, above knee section |
All |
N |
Purchase |
|
|
L2840 |
NU EP |
Addition to lower extremity orthosis, tibial length sock, fracture or equal, each |
All |
N |
Purchase |
|
|
L2850 |
NU EP |
Addition to lower extremity orthosis, femoral length sock, fracture or equal, each |
All |
N |
Purchase |
|
|
L2999 |
EP |
Lower extremity orthoses, NOS |
All |
N |
Manually Priced |
|
|
L2999 |
NU EP |
***(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 |
Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each |
All |
N |
Purchase |
|
|
L3002 |
NU EP |
Foot insert, removable, molded to patient model, Plastazote or equal, each |
All |
N |
Manually Priced |
|
|
L3010 |
NU EP |
Foot insert, removable, molded to patient model, longitudinal arch support, each |
All |
N |
Purchase |
|
|
L3020 |
NU EP |
Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each |
All |
N |
Purchase |
|
|
L3030 |
NU EP |
Foot insert, removable, formed to patient foot, each |
All |
N |
Purchase |
|
|
L3040 |
NU EP |
Foot, arch support, removable, premolded, longitudinal, each |
All |
N |
Purchase |
|
|
L3050 |
NU EP |
Foot, arch support, removable, premolded, metatarsal, each |
All |
N |
Purchase |
|
|
L3060 |
NU EP |
Foot, arch support, removable, premolded, longitudinal/metatarsal, each |
All |
N |
Purchase |
|
|
L3070 |
NU EP |
Foot, arch support, non-removable, attached to shoe, longitudinal, each |
All |
N |
Purchase |
|
|
L3080 |
NU EP |
Foot, arch support, non-removable, attached to shoe, metatarsal, each |
All |
N |
Purchase |
|
|
L3090 |
NU EP |
Foot, arch support, non-removable, attached to shoe, longitudinal/metatarsal, each |
All |
N |
Purchase |
|
|
L3100 |
NU EP |
Hallus?valgus night dynamic splint |
All |
N |
Purchase |
|
|
L3140 |
NU EP |
UB |
***(Bebox foot orthosis club foot abduction orthosis) Foot, abduction rotation bar, including shoes |
All |
Y |
Purchase |
|
L3140 |
NU |
***(Don Joy knee orthosis) Foot, abduction rotation bar, including shoes |
21+ |
Y |
Purchase |
|
|
L3150 |
NU |
Foot, abduction rotation bar, without shoes |
21+ |
N |
Purchase |
|
|
L3150 |
EP |
***(Custom night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) Foot, abduction rotation bar, without shoes |
U21 |
N |
Purchase |
|
|
L3170 |
NU EP |
Foot, plastic, silicone or equal, heel stabilizer, each |
All |
N |
Purchase |
|
|
L3202 |
EP |
Orthopedic shoe, Oxford with supinator or pronator, child |
U21 |
N/A |
Purchase |
|
|
L3204 |
NU EP |
***(Straight last hightop shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, infant |
All |
N |
Purchase |
|
|
L3204 |
NU EP |
U1 |
***(Straight last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, infant |
All |
N |
Purchase |
|
L3204 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 3-6) Orthopedic shoe, hightop with supinator or pronator, infant |
All |
N |
Purchase |
|
L3204 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, infant |
All |
N |
Purchase |
|
L3204 |
NU EP |
U1 |
***(Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, infant |
All |
N |
Purchase |
|
L3204 |
NU |
***(Orthopedic shoe, hightop, normal last, each, size 3-8) Orthopedic shoe, hightop with supinator or pronator, infant |
21+ |
N |
Purchase |
|
|
L3204 |
NU EP |
U1 |
***(Orthopedic shoe, hightop, normal last, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, infant |
All |
N |
Purchase |
|
L3206 |
NU EP |
***(Straight last hightop shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, child |
All |
N |
Purchase |
|
|
L3206 |
NU EP |
U1 |
***(Straight last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, child |
All |
N |
Purchase |
|
L3206 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 3-6) Orthopedic shoe, hightop with supinator or pronator, child |
All |
N |
Purchase |
|
L3206 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, child |
All |
N |
Purchase |
|
L3206 |
NU EP |
U1 |
***(Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, child |
All |
N |
Purchase |
|
L3206 |
NU |
***(Orthopedic shoe, hightop, normal last, each, size 3-8) Orthopedic shoe, hightop with supinator or pronator, child |
21+ |
N |
Purchase |
|
|
L3206 |
NU EP |
U1 |
***(Orthopedic shoe, hightop, normal last, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, child |
All |
N |
Purchase |
|
L3207 |
NU EP |
***(Straight last hightop shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, junior |
All |
N |
Purchase |
|
|
L3207 |
NU EP |
U1 |
***(Straight last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, junior |
All |
N |
Purchase |
|
L3207 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 3-6) Orthopedic shoe, hightop with supinator or pronator, junior |
All |
N |
Purchase |
|
L3207 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, junior |
All |
N |
Purchase |
|
L3207 |
NU EP |
U1 |
***(Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, junior |
All |
N |
Purchase |
|
L3207 |
NU |
***(Orthopedic shoe, hightop, normal last, each, size 3-8) Orthopedic shoe, hightop with supinator or pronator, junior |
21+ |
N |
Purchase |
|
|
L3207 |
NU EP |
U1 |
***(Orthopedic shoe, hightop, normal last, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, junior |
All |
N |
Purchase |
|
L3207 |
NU EP |
***(Orthopedic shoe, hightop, normal last, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, junior |
All |
N |
Purchase |
|
|
L3208 |
EP |
Surgical boot, each, infant |
U21 |
N/A |
Purchase |
|
|
L3209 |
EP |
Surgical boot, each, child |
U21 |
N/A |
Purchase |
|
|
L3215 |
NU EP |
Orthopedic footwear, woman?s shoes, oxford, each |
All |
Y |
Purchase |
|
|
L3216 |
NU EP |
Orthopedic footwear, woman?s shoes, depth inlay, each |
All |
Y |
Purchase |
|
|
L3217 |
NU EP |
***(Straight last hightop shoe, each, size 2-8) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each |
All |
N |
Purchase |
|
|
L3217 |
NU EP |
U1 U1 |
***(Straight last hightop shoe, each, size 81/2-12) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each |
All |
N |
Purchase |
|
L3217 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 3-6) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each |
All |
N |
Purchase |
|
L3217 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 81/2-12) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each |
All |
N |
Purchase |
|
L3217 |
NU EP |
U1 |
***(Reverse last closed toe) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each |
All |
N |
Purchase |
|
L3219 |
NU EP |
Orthopedic footwear, man?s shoes, oxford, each |
All |
Y |
Purchase |
|
|
L3221 |
NU EP |
Orthopedic footwear, man?s shoes, depth inlay, each |
All |
Y |
Purchase |
|
|
L3222 |
NU EP |
***(Straight last hightop shoe, each, size 2-8) Orthopedic footwear, man?s shoes, hightop, depth inlay, each |
All |
N |
Purchase |
|
|
L3222 |
NU EP |
U1 |
***(Straight last hightop shoe, each, size 81/2-12) Orthopedic footwear, man?s shoes, hightop, depth inlay, each |
All |
N |
Purchase |
|
L3222 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 3-6) Orthopedic footwear, man?s shoes, high-top, depth inlay, each |
All |
N |
Purchase |
|
L3222 |
NU EP |
U1 |
***(Regular last hightop shoe, each, size 81/2-12) Orthopedic footwear, man?s shoes, hightop, depth inlay, each |
All |
N |
Purchase |
|
L3222 |
NU EP |
U1 |
***(Reverse last closed toe) Orthopedic footwear, man?s shoes, hightop, depth inlay, each |
All |
N |
Purchase |
|
L3224 |
NU |
Orthopedic footwear, woman?s shoe, Oxford, used as an integral part of a brace (orthosis) |
21+ |
N |
Purchase |
|
|
L3225 |
NU |
Orthopedic footwear, man?s shoe, oxford, used as an integral part of a brace (orthosis) |
21+ |
N |
Purchase |
|
|
L3230 |
NU EP |
Orthopedic footwear, custom shoes, depth inlay, each |
All |
Y |
Purchase |
|
|
L3250 |
NU EP |
Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each |
All |
Y |
Purchase |
|
|
L3253 |
NU EP |
Foot, molded shoe Plastazote (or similar), custom fitted, each |
All |
Y |
Purchase |
|
|
L3257 |
NU EP |
Orthopedic footwear, additional charge for split size |
All |
Y |
Purchase |
|
|
L3260 |
NU EP |
Surgical boot/shoe, each |
All |
N |
Manually Priced Purchase |
|
|
L3265 |
NU EP |
Plastazote sandal, each |
All |
N |
Purchase |
|
|
L3310 |
NU EP |
Lift, elevation, heel and sole, neoprene, per in. |
All |
N |
Purchase |
|
|
L3332 |
NU EP |
Lift, elevation, inside shoe, tapered, up to one-half in. |
All |
N |
Purchase |
|
|
L3334 |
NU EP |
Lift, elevation, heel, per inch |
All |
N |
Purchase |
|
|
L3350 |
NU EP |
Heel wedge |
All |
N |
Purchase |
|
|
L3360 |
NU EP |
Sole wedge, outside sole |
All |
N |
Purchase |
|
|
L3370 |
NU EP |
Sole wedge, between sole |
All |
N |
Purchase |
|
|
L3400 |
NU EP |
Metatarsal bar wedge, rocker |
All |
N |
Purchase |
|
|
L3420 |
NU EP |
Full sole and heel wedge, between sole |
All |
N |
Purchase |
|
|
L3450 |
NU EP |
Heel, SACH cushion type |
All |
N |
Purchase |
|
|
L3455 |
NU EP |
Heel, new leather, standard |
All |
N |
Purchase |
|
|
L3465 |
NU EP |
Heel, Thomas with wedge |
All |
N |
Purchase |
|
|
L3540 |
NU EP |
Orthopedic shoe addition, sole, full |
All |
N |
Purchase |
|
|
L3580 |
NU EP |
Orthopedic shoe addition, convert instep to Velcro closure |
All |
N |
Purchase |
|
|
L3590 |
NU EP |
Orthopedic shoe addition, convert firm shoe counter to soft counter |
All |
N |
Purchase |
|
|
L3600 |
NU EP |
Transfer of an orthosis from one shoe to another, caliper plate, existing |
All |
N |
Purchase |
|
|
L3620 |
NU EP |
Transfer of an orthosis from one shoe to another, solid stirrup, existing |
All |
N |
Purchase |
|
|
L3630 |
NU EP |
Transfer of an orthosis from one shoe to another, solid stirrup, new |
All |
N |
Purchase |
|
|
L3649 |
EP |
Orthopedic shoe, modification, addition or transfer, NOS |
U21 |
N/A |
Purchase |
|
|
L3649 |
NU EP |
U1 |
***(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 |
|
L3649 |
NU EP |
***(Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, modification, addition or transfer, NOS |
All |
N |
Manually Priced Purchase |
|
|
L3650 |
NU EP |
SO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3660 |
NU EP |
SO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3670 |
NU EP |
SO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3675 |
NU |
SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment |
21+ |
N |
Purchase |
|
|
L3700 |
NU EP |
Elbow orthoses (EO), elastic with stays, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3710 |
NU EP |
EO, elastic with metal joints, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3720 |
NU EP |
EO, double upright with forearm/arm cuffs, free motion, custom fabricated |
All |
N |
Purchase |
|
|
L3730 |
NU EP |
EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated |
All |
Y |
Purchase |
|
|
L3740 |
NU EP |
EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated |
All |
Y |
Purchase |
|
|
L3800 |
NU EP |
WHFO, short opponens, no attachments, custom fabricated |
All |
N |
Purchase |
|
|
L3805 |
NU EP |
WHFO, long opponens, no attachment, custom fabricated |
All |
N |
Purchase |
|
|
L3807 |
NU EP |
WHFO, without joint(s), prefabricated, includes fitting and adjustments, any type |
All |
N |
Purchase |
|
|
L3810 |
NU EP |
WHFO, addition to short and long opponens, thumb abduction (C) bar |
All |
N |
Purchase |
|
|
L3815 |
NU EP |
WHFO, addition to short and long opponens, second M.P. abduction assist |
All |
N |
Purchase |
|
|
L3820 |
NU EP |
WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop |
All |
N |
Purchase |
|
|
L3825 |
NU EP |
WHFO, addition to short and long opponens, M.P. extension stop |
All |
N |
Purchase |
|
|
L3830 |
NU EP |
WHFO, addition to short and long opponens, M.P. extension assist |
All |
N |
Purchase |
|
|
L3835 |
NU EP |
WHFO, addition to short and long opponens, M.P. spring extension assist |
All |
N |
Purchase |
|
|
L3840 |
NU EP |
WHFO, addition to short and long opponens, spring swivel thumb |
All |
N |
Purchase |
|
|
L3845 |
NU EP |
WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop |
All |
N |
Purchase |
|
|
L3850 |
NU EP |
WHFO, addition to short and long opponens, action wrist with dorsiflexion assist |
All |
N |
Purchase |
|
|
L3855 |
NU EP |
WHFO, addition to short and long opponens, adjustable M.P. flexion control |
All |
N |
Purchase |
|
|
L3860 |
NU EP |
WHFO, addition to short and long opponens, adjustable M.P. flexion control and I.P. |
All |
N |
Purchase |
|
|
L3900 |
NU EP |
WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated |
All |
Y |
Purchase |
|
|
L3901 |
NU EP |
WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated |
All |
Y |
Purchase |
|
|
L3904 |
NU EP |
WHFO, external powered, electric, custom fabricated |
All |
Y |
Purchase |
|
|
L3906** |
NU EP |
Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3907** |
NU EP |
WHFO, wrist gauntlet with thumb spica, molded to patient model, custom fabricated |
All |
N |
Purchase |
|
|
L3908 |
NU EP |
WHO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3910 |
NU EP |
WHFO, Swanson design, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3912 |
NU EP |
HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3915+ |
NU EP |
Wrist, hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment |
All |
N |
Manually Priced |
|
|
L3916 |
NU EP |
WHFO, wrist extension cock-up, with outrigger, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3918 |
NU EP |
HFO, knuckle bender prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3920 |
NU EP |
HFO, knuckle bender, with outrigger prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3922 |
NU EP |
HFO, knuckle bender, two segment to flex joints prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3924 |
NU EP |
WHFO, Oppenheimer, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3926 |
NU EP |
WHFO, Thomas suspension, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3928 |
NU EP |
HFO, finger extension, with clock spring, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3930 |
NU EP |
WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3932 |
NU EP |
FO, safety pin, spring wire, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3934 |
NU EP |
FO, safety pin, modified, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3936 |
NU EP |
WHFO, Palmer prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3938 |
NU EP |
WHFO, dorsal wrist, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3940 |
NU EP |
WHFO, dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3942 |
NU EP |
HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3944 |
NU EP |
HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3946 |
NU EP |
HFO, composite elastic, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3948 |
NU EP |
FO, finger knuckle bender, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3950 |
NU EP |
WHFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3952 |
NU EP |
WHFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3954 |
NU EP |
HFO, spreading hand, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3956 |
NU |
Addition of joint to upper extremity orthosis, any material; per joint |
21+ |
N |
Manually Priced |
|
|
L3960 |
NU EP |
SEWHO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustment |
All |
Y |
Purchase |
|
|
L3962 |
NU EP |
SEWHO, abduction positioning, Erb?s palsy design, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3964 |
NU EP |
SEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3965 |
NU EP |
SEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment |
All |
Y |
Purchase |
|
|
L3966 |
NU EP |
SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment |
All |
Y |
Purchase |
|
|
L3968 |
NU EP |
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 |
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 |
SEO, addition to mobile arm support elevating proximal arm |
All |
N |
Purchase |
|
|
L3972 |
NU EP |
SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control |
All |
N |
Purchase |
|
|
L3974 |
NU EP |
SEO, addition to mobile arm support, supinator |
All |
N |
Purchase |
|
|
L3980 |
NU EP |
Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3982 |
NU EP |
Upper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3984 |
NU EP |
Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L3985 |
NU EP |
Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated |
All |
N |
Purchase |
|
|
L3986 |
NU EP |
Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example ? Colles? fracture), custom fabricated |
All |
N |
Purchase |
|
|
L3995 |
NU EP |
Addition to upper extremity orthosis sock, fracture or equal, each |
All |
N |
Purchase |
|
|
L3999 |
EP |
Upper limb orthosis, NOS |
U21 |
N/A |
Manually Priced |
|
|
L3999 |
NU EP |
***(The manufacturer?s invoice must be attached to all claims.) Upper limb orthosis, NOS |
All |
Y |
Manually Priced Manually Priced |
|
|
L4000 |
NU EP |
Replace girdle for spinal orthosis (CTLSO or SO) |
All |
Y |
Purchase |
|
|
L4002 |
NU EP |
Replace strap, any orthosis, includes all components, any length, any type |
All |
N |
Manually Priced |
|
|
L4010 |
NU EP |
Replace trilateral socket brim |
All |
N |
Purchase |
|
|
L4020 |
NU EP |
Replace quadrilateral socket brim, molded to patient model |
All |
N |
Purchase |
|
|
L4030 |
NU EP |
Replace quadrilateral socket brim, custom fitted |
All |
N |
Purchase |
|
|
L4040 |
NU EP |
Replace molded thigh lacer, for custom fabricated orthosis only |
All |
N |
Purchase |
|
|
L4045 |
NU EP |
Replace nonmolded thigh lacer, for custom fabricated orthosis only |
All |
N |
Purchase |
|
|
L4050 |
NU EP |
Replace molded calf lacer, for custom fabricated orthosis only |
All |
N |
Purchase |
|
|
L4055 |
NU EP |
Replace nonmolded calf lacer, for custom fabricated orthosis only |
All |
N |
Purchase |
|
|
L4060 |
NU EP |
Replace high roll cuff |
All |
N |
Purchase |
|
|
L4070 |
NU EP |
Replace proximal and distal upright for KAFO |
All |
N |
Purchase |
|
|
L4080 |
NU EP |
Replace metal bands KAFO, proximal thigh |
All |
N |
Purchase |
|
|
L4090 |
EP |
***(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 |
Replace metal bands KAFO-AFO, calf or distal thigh |
All |
N |
Purchase |
|
|
L4100 |
NU EP |
Replace leather cuff KAFO, proximal thigh |
All |
N |
Purchase |
|
|
L4110 |
NU EP |
Replace leather cuff KAFO-AFO, calf or distal thigh |
All |
N |
Purchase |
|
|
L4130 |
NU EP |
Replace pretibial shell |
All |
N |
Purchase |
|
|
L4205 |
NU EP |
Repair of orthotic device, labor component, per 15 minutes |
All |
Y |
Purchase |
|
|
L4210 |
NU EP |
Repair of orthotic device, repair or replace minor parts |
All |
Y |
Purchase |
|
|
L4350 |
NU EP |
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 |
Walking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L4370 |
NU EP |
Pneumatic full leg splint, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L4380 |
NU EP |
Pneumatic knee splint, prefabricated, includes fitting and adjustment |
All |
N |
Purchase |
|
|
L4392 |
NU |
Replacement soft interface material, static AFO |
21+ |
N |
Purchase |
|
|
L4394 |
NU |
Replace soft interface material, foot drop splint |
21+ |
N |
Purchase |
|
|
L4396 |
NU |
Static ankle foot orthosis, 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 |
Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment |
21+ |
N |
Purchase |
|
|
L5999 |
NU EP |
***(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 |
***(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 |
Repair of prosthetic device, hourly rate |
All |
Y |
Purchase |
|
L7520 |
NU EP |
Repair prosthetic device, labor component, per 15 minutes |
All |
Y |
Purchase |
|
|
L8499 |
NU EP |
***(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 |
