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. 6, June, 2024
Section II
Prosthetics
242.110
Respiratory and Diabetic
			 Equipment, All Ages 4-1-08
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
242.180
Orthotic Appliances, All Ages
			 4-1-08
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 ¼ 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
						  8½-12) 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 8½-12)
						  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
						  8½-12) 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
						  8½-12) 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 8½-12)
						  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
						  8½-12) 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
						  8½-12) 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 8½-12)
						  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
						  8½-12) Orthopedic shoe, hightop with supinator or pronator,
						  junior
All
N
Purchase
L3207
NU EP
***(Orthopedic shoe, hightop, normal last, each, size
						  8½-12) 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
						  8½-12) 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 8½-12)
						  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
						  8½-12) 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 8½-12)
						  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