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

Current through Register Vol. 49, No. 6, June, 2024
242.121
Food Thickeners, All
			 Ages
Food thickeners, including "Thick-It," "Thick-It II," "Simply
				Thick," "Thick and Easy" and "Thik and Clear" are not subject to the $250
				medical supply benefit limit.
The modifier NU must be used with the procedure code found in
				this section and when food thickeners are to be administered enterally, the
				modifier "BA" must be used in conjunction with the procedure code.
When food thickeners are billed, total units are to be
				calculated to the nearest full ounce. Partial units may not be rounded up. When
				a date span is billed, the product cannot be billed until the end date has
				elapsed.
The maximum number of units allowed for food thickeners is 16
				units per date of service.
Procedure Code
M1
M2
TOS
Description
B4100
NU
H
Food thickener, administered orally, peroz.
B4100
NU
BA
H
Food thickener, administered enterally,
						  peroz.
242.180
Orthotic Appliances, All
			 Ages
Procedure codes found in this section must be billed either
				electronically or on paper with modifier EP for beneficiaries under 21 years of
				age or modifier NU for beneficiaries age 21 and older. When a second modifier
				is listed, that modifier must be used in conjunction with either EP
				orNU.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code "6" for individuals under age 21 or
				TOS code "H" for individuals age 21 and older.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) code "6" for individuals under age 21 or
				TOS code "H" for individuals age 21 and older.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS.
Prior authorization requirements are shown under the heading
				PA. If prior authorization is needed for individuals age 21 and older, that
				information is indicated with a "Y" in the column; if not, an "N" is shown.
				When prior authorization is not applicable (for U21) that information is shown
				with an "N/A" in the column.
When codes are payable for all ages, "AN" is indicated in the
				column, "U21" is shown when the code is payable only for individuals underage
				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.
Effective for dates of service on and after March 1, 2006,
				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.
Orthotic Appliances, All Ages (section
				242.180 )
Procedure Code
M1
M2
TOS
Description
All U21 21 +
PA 21 +
Payment Method
A5500"
NU
H
For diabetics only, fitting (including follow-up)
						  custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to
						  accommodate multi-density insert(s), per shoe
21 +
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
All
N
Purchase
L4045
NU
EP
H
6
Replace nonmolded thigh lacer
All
N
Purchase
L4050
NU
EP
H
6
Replace molded calf lacer
All
N
Purchase
L4055
NU
EP
H
6
Replace nonmolded calf lacer
All
N
Purchase
L4060
NU
EP
H
6
Replace high roll cuff
All
N
Purchase
L4070
NU
EP
H
6
Replace proximal and distal upright for
						  KAFO
All
N
Purchase
L4080
NU
EP
H
6
Replace metal bands KAFO, proximal thigh
All
N
Purchase
L4090
EP
6
***(Custom night "A" frame-KAFO, torsion control,
						  bilateral night "A" frame) Replace metal bands KAFO-AFO, calf or distal
						  thigh
U21
N/A
Purchase
L4090
NU
EP
H
6
Replace metal bands KAFO-AFO, calf or distal
						  thigh
All
N
Purchase
L4100
NU
EP
H
6
Replace leather cuff KAFO, proximal thigh
All
N
Purchase
L4110
NU
EP
H
6
Replace leather cuff KAFO-AFO, calf or distal
						  thigh
All
N
Purchase
L4130
NU
EP
H
6
Replace pretibial shell
All
N
Purchase
L4205
NU
EP
H
6
Repair of orthotic device, labor component, per 15
						  minutes
All
Y
Manually Priced
Purchase
L4210
NU
EP
H
6
Repair of orthotic device, repair or replace minor
						  parts
All
Y
Manually Priced
Purchase
L4350
NU
EP
H
6
Ankle control orthosis, stirrup style, rigid, includes
						  any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L4360
NU
EP
H
6
Walking boot, pneumatic with or without joints, with or
						  without interface material, prefabricated, includes fitting and
						  adjustment
All
N
Purchase
L4370
NU
EP
H
6
Pneumatic full leg splint, prefabricated, includes
						  fitting and adjustment
All
N
Purchase
L4380
NU
EP
H
6
Pneumatic knee splint, prefabricated, includes fitting
						  and adjustment
All
N
Purchase
L4392
Replacement soft interface material, static AFO
21 +
N
Purchase
L4394
NU
H
Replace soft interface material, foot drop
						  splint
21 +
N
Purchase
L4396
NU
H
Static AFO, including soft interface material,
						  adjustable for fit, for positioning, pressure reduction, may be used for
						  minimal ambulation, prefabricated, includes fitting and adjustment
21 +
N
Purchase
L4398
NU
H
Foot drop splint, recumbent positioning device,
						  prefabricated, includes fitting and adjustment
21 +
N
Purchase
L5999
NU
EP
H
6
***(Unlisted Prosthetic Devices or Orthotic Appliances;
the manufacturer's invoice must be attached to all claims.)
Lower
						  extremity prosthesis, not otherwise specified
All
Y
Manually Priced
Manually Priced
L7499
NU
EP
H
6
***(Unlisted Prosthetic Devices or Orthotic Appliances;
the manufacturer's invoice must be attached to all claims.)
Upper
						  extremity prosthesis, not otherwise specified
All
Y
Manually Priced
Manually Priced
L7510
NU
EP
UB
H
6
Repair of prosthetic device, hourly rate
All
Y
Manually Priced
Purchase
L7520
NU
EP
H
6
Repair prosthetic device, labor component, per 15
						  minutes
All
Y
Manually Priced
Purchase
L8499
NU
EP
H
6
***(Unlisted Prosthetic Devices or Orthotic Appliances;
the manufacturer's invoice must be attached to all claims.)
Unlisted procedure for miscellaneous prosthetic services
All
Y
Manually Priced
Purchase
242.193
Augmentative Communication Device, All Ages
The augmentative communication device must be billed using the
				procedure code assigned to each component. The specific components will be
				reimbursed, as needed, for the procedure codes listed below and will count
				toward the lifetime limit of $7,500 per beneficiary.
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 over. When a second modifier is
				listed, that modifier must be used in conjunction with either EP orNU.
Additionally, when billed on paper, procedure codes must be
				billed with a type of service (TOS) "6" for individuals under age 21 or TOS "H"
				for individuals age 21 and over.
Modifiers in this section are indicated by the headings M1 and
				M2. Type of service is indicated by the heading TOS. Prior authorization
				requirements are shown under the heading PA. If prior authorization is needed,
				that information is indicated with a "Y" in the column; if not, an "N" is
				shown.
NOTE: Attach a manufacturer's invoice to the claim and
				indicate the item or parts billed on the invoice. A description and the amount
				billed for each item must be attached to the claim. If more than one item is
				billed under a procedure code, the description and billed amount of each item
				must be listed separately under each procedure code and attached to the claim.
				The total billed for each procedure code should be reflected in field
				24F.
* 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.
Augmentative Communication Device, All Ages (section
				242.193)
Procedure Code
M1
M2
TOS
PA
Description
Payment Method
E2500
NU
EP
H
6
Y*
***(Light Technology Communication Aids -communication
						  aids that do not have the memory component to store the information. They are
						  often used in conjunction with higher tech devices as part of a multi-modal
						  communication system.) Speech-generating device, digitized speech, using
						  pre-recorded messages less than or equal to 8 minutes recording
						  time
Purchase
E2502
NU
EP
H
6
Y4
***(Simple Voice Output Device - simple devices with
						  limited storage capacity and voice output only.) Speech-generating device,
						  digitized speech, using pre-recorded messages, greater than 8 minutes but less
						  than or equal to 20 minutes recording time
Purchase
E2504
NU
EP
H
6
Y*
***(Simple Voice Output Device - simple devices with
						  limited storage capacity and voice output only) Speech-generating device,
						  digitized speech, using pre-recorded messages, greater than 20 minutes but less
						  than or equal to 40 minutes recording time
Purchase
E2506
NU
EP
H
6
Y*
***(Simple Voice Output Device - simple devices with
						  limited storage capacity and voice output only) Speech-generating device,
						  digitized speech, using pre-recorded messages, greater than 40 minutes
						  recording time.
Purchase
E2508
NU
EP
H
6
Y*
***(More Advanced Voice Output Communication Aids -
						  offer more storage capacity and often have other output methods in addition to
						  voice output; e.g., LED display) Speech-generating device, synthesized speech,
						  requiring message formulation by spelling and access by physical contact with
						  the device
Purchase
E2510
NU
EP
6
Y4
***(Higher Technology Voice Output Communication Aids -
						  offer greater memory capabilities, various types of output, computer interface
						  options, etc.) Speech-generating device synthesized speech, permitting multiple
						  methods of message formulation and multiple methods of device
						  access
Purchase
E2510
NU
EP
H
6
Y*
***(State-of-the-Art Voice Output Communication Aids -
						  represents state-of-the-art communication aid technology. Have extensive memory
						  capabilities, various output methods, computer interface options; offer a
						  variety of input methods in a single device and advanced functions such as
						  auditory scanning, icon and word prediction, etc.) Speech-generating device
						  synthesized speech, permitting multiple methods of message formulation and
						  multiple methods of device access
Purchase
E2511
NU
EP
H
6
Y*
***(Software - often recommended for augmentative
						  communication device. Software may change as the child matures.)
						  Speech-generating software program, for personal computer or personal digital
						  assistant
Purchase
E2512
NU
EP
H
6
Y
Accessory for speech generating device, mounting
						  system
Manually Priced
E2599
NU
EP
H
6
Y*
***(Switches - used with training aids and augmentative
						  communication devices as a means of access) Accessory for speech generating
						  device, not otherwise classified
Manually Priced
V5336
NU
EP
H
6
Y
***(Augmentative Communication Device Repair -
parts only)
Repair/modification of augmentative communicative
						  system or device (excludes adaptive hearing aid)
N/A
V5336
NU
EP
H
6
Y
***(Augmentative Communication Device Repair -
labor only)
Repair/modification of augmentative communicative
						  system or device (excludes adaptive hearing aid)
N/A
Note: When repair charges for both parts and labor of the
				ACD is provided and/or billed on the same date of service, only one detail
				(parts only or labor only) of procedure code V5336 may be billed per
				beneficiary per date of service. Information must be specified on the paper
				claim to clarify the charges billed by the provider. Parts and labor charges
				must be itemized by narrative and documentation.
A.
The charge for parts must be clearly
			 documented. A manufacturer's invoice for the parts must be
			 attached.
B.
The labor
			 charge and the time represented by the labor charge must be clearly
			 documented.