Statutes, codes, and regulations
Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.08-004 - Prosthetics Update 115

016.06.08 Ark. Code R. 004

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Current through Register Vol. 49, No. 10, October, 2024
Rule 016.06.08-004 - Prosthetics Update 115
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 1/4 inch material of shore a 35 durometer of 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each

21+

Y

Purchase

A5513'

NU

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

21+

N

Purchase

L0120

NU EP

Cervical, flexible, nonadjustable (foam collar)

All

N

Purchase

L0130

NU EP

Cervical, flexible, thermoplastic collar, molded to patient

All

N

Purchase

L0140

NU EP

Cervical, semi-rigid, adjustable (plastic collar)

All

N

Purchase

L0150

NU EP

Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)

All

N

Purchase

L0160

NU EP

Cervical, semi-rigid, wire frame occipital/mandibular support

All

N

Purchase

L0170

NU EP

Cervical, collar, molded to patient model

All

N

Purchase

L0172

NU EP

Cervical, collar, semi-rigid thermoplastic foam, two piece

All

N

Purchase

L0174

NU EP

Cervical, collar, semi-rigid thermoplastic foam, two piece with thoracic extension

All

N

Purchase

L0180

NU EP

Cervical, multiple post collar, occipital/mandibular supports, adjustable

All

N

Purchase

L0190

NU EP

Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (SOMI, Guilford, Taylor types)

All

N

Purchase

L0200

NU EP

Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension

All

N

Purchase

L0210

NU EP

Thoracic, rib belt

All

N

Purchase

L0220

NU EP

Thoracic, rib belt, custom fabricated

All

N

Purchase

L0450

NU EP

TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment

All

N

Purchase

L0452

NU EP

TLSO, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated

All

N

Purchase

L0454

NU EP

TLSO, flexible, provides trunk support, extends from sacrococcygeal junction to above T-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, includes fitting and adjustment

All

N

Purchase

L0456

NU EP

TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, includes fitting and adjustment

All

N

Purchase

L0458

NU EP

TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

All

Y

Purchase

L0460

NU EP

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

All

Y

Purchase

L0462

NU EP

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

All

Y

Purchase

L0464

NU EP

TLSO, triplanar control modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, including straps and closures, prefabricated, includes fitting and adjustment

All

Y

Purchase

L0466

NU EP

TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

All

N

Purchase

L0468

NU EP

TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

All

N

Purchase

L0470

NU EP

TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal and transverse planes, produces intracavitary pressure to reduce load on intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

All

N

Purchase

L0472

NU EP

TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal) posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment

All

N

Purchase

L0480

NU EP

TLSO, triplanar control, one-piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

All

Y

Purchase

L0482

NU EP

TLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

All

Y

Purchase

L0484

NU EP

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

All

Y

Purchase

L0486

NU EP

TLSO, triplanar control, two-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated

All

Y

Purchase

L0488

NU EP

TLSO, triplanar control, one-piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal and transverse planes, prefabricated, includes fitting and adjustment

All

Y

Purchase

L0490

NU EP

TLSO, sagittal-coronal control, one-piece rigid plastic shell with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment

All

Y

Purchase

L0621

NU EP

Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0622

NU EP

Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

All

N

Purchase

L0623

NU EP

Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0624

NU EP

Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated

All

N

Manually Priced

L0625

NU EP

Lumbar orthosis, flexible, provides lumbar support, posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, includes fitting and adjustment

All

N

Purchase

L0626

NU EP

Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0627

NU EP

Lumbar orthosis, sagittal control, with rigid anterior and posterior panel(s), posterior extends from L-1 to below L-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0628

NU EP

Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0629

NU EP

Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated

All

N

Manually Priced

L0630

NU EP

Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0631

NU EP

Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0632

NU EP

Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated

All

N

Manually Priced

L0633

NU EP

Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0634

NU EP

Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated

All

N

Manually Priced

L0635

NU EP

Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0636

NU EP

Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated

All

N

Purchase

L0637

NU EP

Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0638

NU EP

Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated

All

N

Purchase

L0639

NU EP

Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment

All

N

Purchase

L0640

NU EP

Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to T-9 vertebra, anterior extends from symphysis pubis to xiphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated

All

N

Purchase

L0700

NU EP

Cervical-thoracic-lumbar-sacral orthoses (CTLSO), anterior-posterior-lateral control, molded to patient model (Minerva type)

All

Y

Purchase

L0710

NU EP

CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)

All

Y

Purchase

L0810

NU EP

Halo procedure, cervical halo incorporated into jacket vest

All

Y

Purchase

L0820

NU EP

Halo procedure, cervical halo incorporated into plaster body jacket

All

Y

Purchase

L0830

NU EP

Halo procedure, cervical halo incorporated into Milwaukee type orthosis

All

Y

Purchase

L0859

NU EP

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

All

Y

Purchase

L0960

NU EP

Torso support, post surgical support, pads for post surgical support

All

N

Purchase

L0970

NU EP

TLSO, corset front

All

N

Purchase

L0972

NU EP

LSO, corset front

All

N

Purchase

L0974

NU EP

TLSO, full corset

All

N

Purchase

L0976

NU EP

LSO, full corset

All

N

Purchase

L0978

NU EP

Axillary crutch extension

All

N

Purchase

L0980

NU EP

Peroneal straps, pair

All

N

Purchase

L0982

NU EP

Stocking supporter grips, set of four (4)

All

N

Purchase

L0984

NU

Protective body sock, each

21+

N

Purchase

L1000

NU EP

CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model

All

Y

Purchase

L1010

NU EP

Addition to CTLSO or scoliosis orthosis, axilla sling

All

N

Purchase

L1020

NU EP

Addition to CTLSO or scoliosis orthosis, kyphosis pad

All

N

Purchase

L1025

NU EP

Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating

All

N

Purchase

L1030

NU EP

Addition to CTLSO or scoliosis orthosis, lumbar bolster pad

All

N

Purchase

L1040

NU EP

Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad

All

N

Purchase

L1050

NU EP

Addition to CTLSO or scoliosis orthosis, sternal pad

All

N

Purchase

L1060

NU EP

Addition to CTLSO or scoliosis orthosis, thoracic pad

All

N

Purchase

L1070

NU EP

Addition to CTLSO or scoliosis orthosis, trapezius sling

All

N

Purchase

L1080

NU EP

Addition to CTLSO or scoliosis orthosis, outrigger

All

N

Purchase

L1085

NU EP

Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions

All

N

Purchase

L1090

NU EP

Addition to CTLSO or scoliosis orthosis, lumbar sling

All

N

Purchase

L1100

NU EP

Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather

All

N

Purchase

L1110

NU EP

Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model

All

N

Purchase

L1120

NU EP

Addition to CTLSO, scoliosis orthosis, cover for upright, each

All

N

Purchase

L1200

NU EP

Thoracic-lumbar-sacral-orthosis (TLSO), inclusive of furnishing initial orthosis only

All

Y

Purchase

L1210

NU EP

Addition to TLSO (low profile), lateral thoracic extension

All

N

Purchase

L1220

NU EP

Addition to TLSO (low profile), anterior thoracic extension

All

N

Purchase

L1230

NU EP

Addition to TLSO (low profile), Milwaukee type superstructure

All

N

Purchase

L1240

NU EP

Addition to TLSO (low profile), lumbar derotation pad

All

N

Purchase

L1250

NU EP

Addition to TLSO (low profile), anterior asis pad

All

N

Purchase

L1260

NU EP

Addition to TLSO (low profile), anterior thoracic derotation pad

All

N

Purchase

L1270

NU EP

Addition to TLSO (low profile), abdominal pad

All

N

Purchase

L1280

NU EP

Addition to TLSO (low profile), rib gusset (elastic), each

All

N

Purchase

L1290

NU EP

Addition to TLSO (low profile), lateral trochanteric pad

All

N

Purchase

L1300

NU EP

Other scoliosis procedure, body jacket molded to patient model

All

Y

Purchase

L1310

NU EP

Other scoliosis procedure, postoperative body jacket

All

Y

Purchase

L1499

NU EP

Spinal orthosis, not otherwise specified. ***(The manufacturer?s invoice must be attached to all claims.)

All

Y

Manually Priced

L1500

NU EP

THKAO, mobility frame (Newington, Parapodium types)

All

Y

Purchase

L1510

NU EP

THKAO, standing frame, with or without tray and accessories

All

Y

Purchase

L1520

NU EP

THKAO, swivel walker

All

Y

Purchase

L1600

NU EP

HO, abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment

All

N

Purchase

L1610

NU EP

HO, abduction control of hip joints, flexible (Frejka cover only), prefabricated, includes fitting and adjustment

All

N

Purchase

L1620

NU EP

HO, abduction control of hip joints, flexible (Pavlik harness), prefabricated, includes fitting and adjustment

All

N

Purchase

L1630

NU EP

HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated

All

N

Purchase

L1640

NU EP

HO, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated

All

N

Purchase

L1650

NU EP

HO, abduction control of hip joints, static, adjustable, custom fitted (Ilfled type), prefabricated, includes fitting and adjustment

All

N

Purchase

L1660

NU EP

HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment

All

N

Purchase

L1680

NU EP

HO; abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated

All

Y

Purchase

L1685

NU EP

HO, abduction control of hip joint, post operative hip abduction type, custom fabricated

All

Y

Purchase

L1686

NU EP

HO, abduction control of hip joint, post operative hip abduction type, prefabricated, includes fitting and adjustments

All

Y

Purchase

L1690

NU

Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment

21+

Y

Purchase

L1700

NU EP

Legg Perthes orthosis (Toronto type), custom fabricated

All

Y

Purchase

L1710

NU EP

Legg Perthes orthosis (Newington type), custom fabricated

All

Y

Purchase

L1720

NU EP

Legg Perthes orthosis, trilateral (Tachdijan type), custom fabricated

All

Y

Purchase

L1730

NU EP

Legg Perthes orthosis (Scottish Rite type) custom fabricated

All

Y

Purchase

L1755

NU EP

Legg Perthes orthosis (Patten bottom type), custom fabricated

All

Y

Purchase

L1800

NU EP

KO, elastic with stays, prefabricated, includes fitting and adjustment

All

N

Purchase

L1810

NU EP

KO, elastic with joints, prefabricated, includes fitting and adjustment

All

N

Purchase

L1815

NU EP

KO, elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment

All

N

Purchase

L1820

NU EP

KO, elastic with condyle pads and joints, prefabricated, includes fitting and adjustment

All

N

Purchase

L1825

NU EP

KO, elastic knee cap. prefabricated, includes fitting and adjustment

All

N

Purchase

L1830

NU EP

KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment

All

N

Purchase

L1832

NU EP

Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, includes fitting and adjustment

All

N

Purchase

L1834

NU EP

KO, without knee joint, rigid, custom fabricated

All

N

Purchase

L1840

NU EP

KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated

All

Y

Purchase

L1843

NU

Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment

21+

Y

Purchase

L1844

NU

Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated

21+

Y

Purchase

L1845

NU EP

Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control with or without varus/valgus adjustment, prefabricated, includes fitting and adjustment

All

Y

Purchase

L1846

NU EP

Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control with or without varus/valgus adjustment, custom fabricated

All

Y

Purchase

L1847

NU

Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s) prefabricated, includes fitting and adjustment

21+

N

Purchase

L1850

NU EP

KO, Swedish type, prefabricated, includes fitting and adjustment

All

N

Purchase

L1855

NU EP

KO, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated

All

Y

Purchase

L1858

NU EP

KO, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom fabricated

All

Y

Purchase

L1860

NU EP

KO, modification of supracondylar prosthetic socket, custom fabricated (SK)

All

Y

Purchase

L1870

NU EP

KO, double upright, thigh and calf lacers, with knee joints, custom fabricated

All

Y

Purchase

L1880

NU EP

KO, double upright, nonmolded thigh and calf cuff/lacers with knee joints, custom fabricated

All

N

Purchase

L1900

NU EP

AFO, spring wire, dorsiflexion assist calf band, custom fabricated

All

N

Purchase

L1902

NU EP

AFO, ankle gauntlet, prefabricated, includes fitting and adjustment

All

N

Purchase

L1904

NU EP

AFO, molded ankle gauntlet, custom fabricated

All

N

Purchase

L1906

NU EP

AFO, multiligamentus ankle support, prefabricated, includes fitting and adjustment

All

N

Purchase

L1907

NU EP

AFO, supramalleolar with straps, with or without interface/pads, custom fabricated

All

N

Purchase

L1910

NU EP

AFO, posterior, single bar, clasp attachment to shoe counter prefabricated, includes fitting and adjustment

All

N

Purchase

L1920

NU EP

AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated

All

N

Purchase

L1920

EP

***(Custom night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated

U21

N/A

Purchase

L1930

NU EP

AFO, plastic or other material, prefabricated, includes fitting and adjustment

All

N

Purchase

L1932

NU EP

AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment

All

N

Purchase

L1940

NU EP

AFO, plastic or other material, custom-fabricated

All

N

Purchase

L1945

NU EP

AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated

All

Y

Purchase

L1950

NU EP

AFO, spiral (Institute of Rehabilitative Medicine type), plastic, custom fabricated

All

N

Purchase

L1960

NU EP

AFO, posterior solid ankle, plastic, custom fabricated

All

N

Purchase

L1970

NU EP

AFO, plastic, with ankle joint, custom fabricated

All

N

Purchase

L1980

NU EP

AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar BK orthosis), custom fabricated

All

N

Purchase

L1990

NU EP

AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar BK orthosis), custom fabricated

All

N

Purchase

L2000

NU EP

KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), custom fabricated

All

Y

Purchase

L2005

NU EP

KAFO, any material, single or double upright, stance control, automatic lock and swing phase release, mechanical activation, includes ankle joint, any type, custom fabricated

All

N

Purchase

L2010

NU EP

KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar AK orthosis), without knee joint, custom fabricated

All

Y

Purchase

L2020

NU EP

KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar AK orthosis), custom fabricated

All

Y

Purchase

L2030

NU EP

KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar AK orthosis), without knee joint, custom fabricated

All

Y

Purchase

L2035

NU

Knee ankle foot orthosis, full plastic, static (pediatric size) without free motion ankle, prefabricated, includes fitting and adjustment

21+

N

Purchase

L2036

NU EP

Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated

All

Y

Purchase

L2037

NU EP

Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated

All

Y

Purchase

L2038

NU EP

Knee ankle foot orthosis, full plastic, with or without free motion knee, multi-axis ankle, custom fabricated

All

Y

Purchase

L2040

NU EP

HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated

All

N

Purchase

L2040

NU EP

U1 U1

***(Night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated

All

N

Manually Priced

Purchase

L2050

NU EP

HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated

All

N

Purchase

L2060

NU EP

HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated

All

N

Purchase

L2070

NU EP

HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated

All

N

Purchase

L2080

NU EP

HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated

All

N

Purchase

L2090

NU EP

HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated

All

N

Purchase

L2106

NU EP

AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated

All

N

Purchase

L2108

NU EP

AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated

All

Y

Purchase

L2112

NU EP

AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment

All

N

Purchase

L2114

NU EP

AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment

All

N

Purchase

L2116

NU EP

AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment

All

N

Purchase

L2126

NU EP

KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated

All

Y

Purchase

L2128

NU EP

KAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricated

All

Y

Purchase

L2132

NU EP

KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment

All

Y

Purchase

L2134

NU EP

KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid prefabricated, includes fitting and adjustment

All

Y

Purchase

L2136

NU EP

KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment

All

Y

Purchase

L2180

NU EP

Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints

All

N

Purchase

L2182

NU EP

Addition to lower extremity fracture orthosis, drop lock knee joint

All

N

Purchase

L2184

NU EP

Addition to lower extremity fracture orthosis, limited motion knee joint

All

N

Purchase

L2186

NU EP

Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type

All

N

Purchase

L2188

NU EP

Addition to lower extremity fracture orthosis, quadrilateral brim

All

N

Purchase

L2190

NU EP

Addition to lower extremity fracture orthosis, waist belt

All

N

Purchase

L2192

NU EP

Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt

All

N

Purchase

L2200

NU EP

Additions to lower extremity, limited ankle motion, each joint

All

N

Purchase

L2210

NU EP

Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

All

N

Purchase

L2220

NU EP

Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint

All

N

Purchase

L2230

NU EP

Addition to lower extremity, split flat caliper stirrups and plate attachment

All

N

Purchase

L2232

NU EP

Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only

All

N

Manually Priced

L2240

NU EP

Addition to lower extremity, round caliper and plate attachment

All

N

Purchase

L2250

NU EP

Addition to lower extremity, foot plate, molded to patient model, stirrup attachment

All

N

Purchase

L2260

NU EP

Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)

All

N

Purchase

L2265

NU EP

Addition to lower extremity, long tongue stirrup

All

N

Purchase

L2270

NU EP

Addition to lower extremity, varus/valgus correction (T) strap, padded/lined or malleolus pad

All

N

Purchase

L2275

NU EP

Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined

All

N

Purchase

L2280

NU EP

Addition to lower extremity, molded inner boot

All

N

Purchase

L2300

NU EP

Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable

All

N

Purchase

L2310

NU EP

Addition to lower extremity, abduction bar straight

All

N

Purchase

L2320

NU EP

Addition to lower extremity, nonmolded lacer, for custom fabricated orthosis only

All

N

Purchase

L2330

NU EP

Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

All

N

Purchase

L2335

NU EP

Addition to lower extremity, anterior swing band

All

N

Purchase

L2340

NU EP

Addition to lower extremity, pretibial shell, molded to patient model

All

N

Purchase

L2350

NU EP

Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for PTB, AFO orthoses)

All

Y

Purchase

L2360

NU EP

Addition to lower extremity, extended steel shank

All

N

Purchase

L2370

NU EP

Addition to lower extremity, Patten bottom

All

N

Purchase

L2375

NU EP

Addition to lower extremity, torsion control, ankle joint and half solid stirrup

All

N

Purchase

L2380

NU EP

Addition to lower extremity, torsion control, straight knee joint, each joint

All

N

Purchase

L2385

NU EP

Addition to lower extremity, straight knee joint, heavy duty, each joint

All

N

Purchase

L2390

NU EP

Addition to lower extremity, offset knee joint, each joint

All

N

Purchase

L2395

NU EP

Addition to lower extremity, offset knee joint, heavy duty, each joint

All

N

Purchase

L2397

NU

Addition to lower extremity orthosis, suspension sleeve

21+

N

Purchase

L2405

NU EP

Addition to knee joint, drop lock, each

All

N

Purchase

L2415

NU EP

Addition to knee lock with integrated release mechanism, (bail, cable or equal, any material, each joint

All

N

Purchase

L2425

NU EP

Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint

All

N

Purchase

L2430

NU EP

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

All

N

Purchase

L2492

NU EP

Addition to knee joint, lift loop for drop lock ring

All

N

Purchase

L2500

NU EP

Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring

All

N

Purchase

L2510

NU EP

Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model

All

N

Purchase

L2520

NU EP

Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted

All

N

Purchase

L2525

NU EP

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model

All

N

Purchase

L2526

NU EP

Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted

All

N

Purchase

L2530

NU EP

Addition to lower extremity, thigh/weight bearing, lacer, non-molded

All

N

Purchase

L2540

NU EP

Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model

All

N

Purchase

L2550

NU EP

Addition to lower extremity, thigh/weight bearing, high roll cuff

All

N

Purchase

L2570

NU EP

Addition to lower extremity, pelvic control, hip joint, Clevis type two position joint, each

All

N

Purchase

L2580

NU EP

Addition to lower extremity, pelvic control, pelvic sling

All

N

Purchase

L2600

NU EP

Addition to lower extremity, pelvic control, hip joint, Clevis type, or thrust bearing, free, each

All

N

Purchase

L2610

NU EP

Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each

All

N

Purchase

L2620

NU EP

Addition to lower extremity, pelvic control, hip joint, heavy duty, each

All

N

Purchase

L2622

NU EP

Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each

All

N

Purchase

L2624

NU EP

Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each

All

N

Purchase

L2627

NU EP

Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables

All

N

Purchase

L2628

NU EP

Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables

All

N

Purchase

L2630

NU EP

Addition to lower extremity, pelvic control, band and belt unilateral

All

N

Purchase

L2640

NU EP

Addition to lower extremity, pelvic control, band and belt bilateral

All

N

Purchase

L2650

NU EP

Addition to lower extremity, pelvic and thoracic control, gluteal pad, each

All

N

Purchase

L2660

NU EP

Addition to lower extremity, thoracic control, thoracic band

All

N

Purchase

L2670

NU EP

Addition to lower extremity, thoracic control, paraspinal uprights

All

N

Purchase

L2680

NU EP

Addition to lower extremity, thoracic control, lateral support uprights

All

N

Purchase

L2750

NU EP

Addition to lower extremity orthosis, plating chrome or nickel, per bar

All

N

Purchase

L2755

NU EP

***(Carbon composite ankles; addition to AFO) Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only

All

N

Purchase

L2760

NU EP

Addition to lower extremity orthosis, extension, per extension, per bar (for linear adjustment for growth)

All

N

Purchase

L2770

NU EP

Addition to lower extremity orthosis, any material, per bar or joint

All

N

Purchase

L2780

NU EP

Addition to lower extremity orthosis, non-corrosive finish, per bar

All

N

Purchase

L2785

NU EP

Addition to lower extremity orthosis, drop lock retainer, each

All

N

Purchase

L2795

NU EP

Addition to lower extremity orthosis, knee control, full kneecap

All

N

Purchase

L2800

NU EP

Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull, for use with custom fabricated orthosis only

All

N

Purchase

L2810

NU EP

Addition to lower extremity orthosis, knee control, condylar pad

All

N

Purchase

L2810

EP

***(Custom night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) Addition to lower extremity orthosis, knee control, condylar pad

U21

N/A

Purchase

L2820

NU EP

Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

All

N

Purchase

L2830

NU EP

Addition to lower extremity orthosis, soft interface for molded plastic, above knee section

All

N

Purchase

L2840

NU EP

Addition to lower extremity orthosis, tibial length sock, fracture or equal, each

All

N

Purchase

L2850

NU EP

Addition to lower extremity orthosis, femoral length sock, fracture or equal, each

All

N

Purchase

L2999

EP

Lower extremity orthoses, NOS

All

N

Manually Priced

L2999

NU EP

***(Unlisted prosthetic devices or orthotic appliances; the manufacturer?s invoice must be attached to all claims.) Lower extremity orthoses, NOS

All

Y

Manually Priced

L3000

NU EP

Foot insert, removable, molded to patient model, UCB type, Berkeley shell, each

All

N

Purchase

L3002

NU EP

Foot insert, removable, molded to patient model, Plastazote or equal, each

All

N

Manually Priced

L3010

NU EP

Foot insert, removable, molded to patient model, longitudinal arch support, each

All

N

Purchase

L3020

NU EP

Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each

All

N

Purchase

L3030

NU EP

Foot insert, removable, formed to patient foot, each

All

N

Purchase

L3040

NU EP

Foot, arch support, removable, premolded, longitudinal, each

All

N

Purchase

L3050

NU EP

Foot, arch support, removable, premolded, metatarsal, each

All

N

Purchase

L3060

NU EP

Foot, arch support, removable, premolded, longitudinal/metatarsal, each

All

N

Purchase

L3070

NU EP

Foot, arch support, non-removable, attached to shoe, longitudinal, each

All

N

Purchase

L3080

NU EP

Foot, arch support, non-removable, attached to shoe, metatarsal, each

All

N

Purchase

L3090

NU EP

Foot, arch support, non-removable, attached to shoe, longitudinal/metatarsal, each

All

N

Purchase

L3100

NU EP

Hallus?valgus night dynamic splint

All

N

Purchase

L3140

NU EP

UB

***(Bebox foot orthosis club foot abduction orthosis) Foot, abduction rotation bar, including shoes

All

Y

Purchase

L3140

NU

***(Don Joy knee orthosis) Foot, abduction rotation bar, including shoes

21+

Y

Purchase

L3150

NU

Foot, abduction rotation bar, without shoes

21+

N

Purchase

L3150

EP

***(Custom night ?A? frame-KAFO, torsion control, bilateral night ?A? frame) Foot, abduction rotation bar, without shoes

U21

N

Purchase

L3170

NU EP

Foot, plastic, silicone or equal, heel stabilizer, each

All

N

Purchase

L3202

EP

Orthopedic shoe, Oxford with supinator or pronator, child

U21

N/A

Purchase

L3204

NU EP

***(Straight last hightop shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, infant

All

N

Purchase

L3204

NU EP

U1

***(Straight last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, infant

All

N

Purchase

L3204

NU EP

U1

***(Regular last hightop shoe, each, size 3-6) Orthopedic shoe, hightop with supinator or pronator, infant

All

N

Purchase

L3204

NU EP

U1

***(Regular last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, infant

All

N

Purchase

L3204

NU EP

U1

***(Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, infant

All

N

Purchase

L3204

NU

***(Orthopedic shoe, hightop, normal last, each, size 3-8) Orthopedic shoe, hightop with supinator or pronator, infant

21+

N

Purchase

L3204

NU EP

U1

***(Orthopedic shoe, hightop, normal last, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, infant

All

N

Purchase

L3206

NU EP

***(Straight last hightop shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, child

All

N

Purchase

L3206

NU EP

U1

***(Straight last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, child

All

N

Purchase

L3206

NU EP

U1

***(Regular last hightop shoe, each, size 3-6) Orthopedic shoe, hightop with supinator or pronator, child

All

N

Purchase

L3206

NU EP

U1

***(Regular last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, child

All

N

Purchase

L3206

NU EP

U1

***(Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, child

All

N

Purchase

L3206

NU

***(Orthopedic shoe, hightop, normal last, each, size 3-8) Orthopedic shoe, hightop with supinator or pronator, child

21+

N

Purchase

L3206

NU EP

U1

***(Orthopedic shoe, hightop, normal last, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, child

All

N

Purchase

L3207

NU EP

***(Straight last hightop shoe, each, size 2-8) Orthopedic shoe, hightop with supinator or pronator, junior

All

N

Purchase

L3207

NU EP

U1

***(Straight last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, junior

All

N

Purchase

L3207

NU EP

U1

***(Regular last hightop shoe, each, size 3-6) Orthopedic shoe, hightop with supinator or pronator, junior

All

N

Purchase

L3207

NU EP

U1

***(Regular last hightop shoe, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, junior

All

N

Purchase

L3207

NU EP

U1

***(Reverse last closed toe) Orthopedic shoe, hightop with supinator or pronator, junior

All

N

Purchase

L3207

NU

***(Orthopedic shoe, hightop, normal last, each, size 3-8) Orthopedic shoe, hightop with supinator or pronator, junior

21+

N

Purchase

L3207

NU EP

U1

***(Orthopedic shoe, hightop, normal last, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, junior

All

N

Purchase

L3207

NU EP

***(Orthopedic shoe, hightop, normal last, each, size 81/2-12) Orthopedic shoe, hightop with supinator or pronator, junior

All

N

Purchase

L3208

EP

Surgical boot, each, infant

U21

N/A

Purchase

L3209

EP

Surgical boot, each, child

U21

N/A

Purchase

L3215

NU EP

Orthopedic footwear, woman?s shoes, oxford, each

All

Y

Purchase

L3216

NU EP

Orthopedic footwear, woman?s shoes, depth inlay, each

All

Y

Purchase

L3217

NU EP

***(Straight last hightop shoe, each, size 2-8) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each

All

N

Purchase

L3217

NU EP

U1 U1

***(Straight last hightop shoe, each, size 81/2-12) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each

All

N

Purchase

L3217

NU EP

U1

***(Regular last hightop shoe, each, size 3-6) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each

All

N

Purchase

L3217

NU EP

U1

***(Regular last hightop shoe, each, size 81/2-12) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each

All

N

Purchase

L3217

NU EP

U1

***(Reverse last closed toe) Orthopedic footwear, woman?s shoes, hightop, depth inlay, each

All

N

Purchase

L3219

NU EP

Orthopedic footwear, man?s shoes, oxford, each

All

Y

Purchase

L3221

NU EP

Orthopedic footwear, man?s shoes, depth inlay, each

All

Y

Purchase

L3222

NU EP

***(Straight last hightop shoe, each, size 2-8) Orthopedic footwear, man?s shoes, hightop, depth inlay, each

All

N

Purchase

L3222

NU EP

U1

***(Straight last hightop shoe, each, size 81/2-12) Orthopedic footwear, man?s shoes, hightop, depth inlay, each

All

N

Purchase

L3222

NU EP

U1

***(Regular last hightop shoe, each, size 3-6) Orthopedic footwear, man?s shoes, high-top, depth inlay, each

All

N

Purchase

L3222

NU EP

U1

***(Regular last hightop shoe, each, size 81/2-12) Orthopedic footwear, man?s shoes, hightop, depth inlay, each

All

N

Purchase

L3222

NU EP

U1

***(Reverse last closed toe) Orthopedic footwear, man?s shoes, hightop, depth inlay, each

All

N

Purchase

L3224

NU

Orthopedic footwear, woman?s shoe, Oxford, used as an integral part of a brace (orthosis)

21+

N

Purchase

L3225

NU

Orthopedic footwear, man?s shoe, oxford, used as an integral part of a brace (orthosis)

21+

N

Purchase

L3230

NU EP

Orthopedic footwear, custom shoes, depth inlay, each

All

Y

Purchase

L3250

NU EP

Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each

All

Y

Purchase

L3253

NU EP

Foot, molded shoe Plastazote (or similar), custom fitted, each

All

Y

Purchase

L3257

NU EP

Orthopedic footwear, additional charge for split size

All

Y

Purchase

L3260

NU EP

Surgical boot/shoe, each

All

N

Manually Priced

Purchase

L3265

NU EP

Plastazote sandal, each

All

N

Purchase

L3310

NU EP

Lift, elevation, heel and sole, neoprene, per in.

All

N

Purchase

L3332

NU EP

Lift, elevation, inside shoe, tapered, up to one-half in.

All

N

Purchase

L3334

NU EP

Lift, elevation, heel, per inch

All

N

Purchase

L3350

NU EP

Heel wedge

All

N

Purchase

L3360

NU EP

Sole wedge, outside sole

All

N

Purchase

L3370

NU EP

Sole wedge, between sole

All

N

Purchase

L3400

NU EP

Metatarsal bar wedge, rocker

All

N

Purchase

L3420

NU EP

Full sole and heel wedge, between sole

All

N

Purchase

L3450

NU EP

Heel, SACH cushion type

All

N

Purchase

L3455

NU EP

Heel, new leather, standard

All

N

Purchase

L3465

NU EP

Heel, Thomas with wedge

All

N

Purchase

L3540

NU EP

Orthopedic shoe addition, sole, full

All

N

Purchase

L3580

NU EP

Orthopedic shoe addition, convert instep to Velcro closure

All

N

Purchase

L3590

NU EP

Orthopedic shoe addition, convert firm shoe counter to soft counter

All

N

Purchase

L3600

NU EP

Transfer of an orthosis from one shoe to another, caliper plate, existing

All

N

Purchase

L3620

NU EP

Transfer of an orthosis from one shoe to another, solid stirrup, existing

All

N

Purchase

L3630

NU EP

Transfer of an orthosis from one shoe to another, solid stirrup, new

All

N

Purchase

L3649

EP

Orthopedic shoe, modification, addition or transfer, NOS

U21

N/A

Purchase

L3649

NU EP

U1

***(Unlisted prosthetic devices or orthotic appliances; the manufacturer?s invoice must be attached to all claims.) Orthopedic shoe, modification, addition or transfer, NOS

All

Y

Manually Priced

L3649

NU EP

***(Orthopedic footwear, wooden sole shoe, each) Orthopedic shoe, modification, addition or transfer, NOS

All

N

Manually Priced

Purchase

L3650

NU EP

SO, figure of eight design abduction re-strainer prefabricated, includes fitting and adjustment

All

N

Purchase

L3660

NU EP

SO, figure of eight design, abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment

All

N

Purchase

L3670

NU EP

SO, acromio/clavicular (canvas and webbing type) prefabricated, includes fitting and adjustment

All

N

Purchase

L3675

NU

SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment

21+

N

Purchase

L3700

NU EP

Elbow orthoses (EO), elastic with stays, prefabricated, includes fitting and adjustment

All

N

Purchase

L3710

NU EP

EO, elastic with metal joints, prefabricated, includes fitting and adjustment

All

N

Purchase

L3720

NU EP

EO, double upright with forearm/arm cuffs, free motion, custom fabricated

All

N

Purchase

L3730

NU EP

EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated

All

Y

Purchase

L3740

NU EP

EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated

All

Y

Purchase

L3800

NU EP

WHFO, short opponens, no attachments, custom fabricated

All

N

Purchase

L3805

NU EP

WHFO, long opponens, no attachment, custom fabricated

All

N

Purchase

L3807

NU EP

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

All

N

Purchase

L3810

NU EP

WHFO, addition to short and long opponens, thumb abduction (C) bar

All

N

Purchase

L3815

NU EP

WHFO, addition to short and long opponens, second M.P. abduction assist

All

N

Purchase

L3820

NU EP

WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop

All

N

Purchase

L3825

NU EP

WHFO, addition to short and long opponens, M.P. extension stop

All

N

Purchase

L3830

NU EP

WHFO, addition to short and long opponens, M.P. extension assist

All

N

Purchase

L3835

NU EP

WHFO, addition to short and long opponens, M.P. spring extension assist

All

N

Purchase

L3840

NU EP

WHFO, addition to short and long opponens, spring swivel thumb

All

N

Purchase

L3845

NU EP

WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop

All

N

Purchase

L3850

NU EP

WHFO, addition to short and long opponens, action wrist with dorsiflexion assist

All

N

Purchase

L3855

NU EP

WHFO, addition to short and long opponens, adjustable M.P. flexion control

All

N

Purchase

L3860

NU EP

WHFO, addition to short and long opponens, adjustable M.P. flexion control and I.P.

All

N

Purchase

L3900

NU EP

WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated

All

Y

Purchase

L3901

NU EP

WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated

All

Y

Purchase

L3904

NU EP

WHFO, external powered, electric, custom fabricated

All

Y

Purchase

L3906**

NU EP

Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

All

N

Purchase

L3907**

NU EP

WHFO, wrist gauntlet with thumb spica, molded to patient model, custom fabricated

All

N

Purchase

L3908

NU EP

WHO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment

All

N

Purchase

L3910

NU EP

WHFO, Swanson design, prefabricated, includes fitting and adjustment

All

N

Purchase

L3912

NU EP

HFO, flexion glove with elastic finger control, prefabricated, includes fitting and adjustment

All

N

Purchase

L3915+

NU EP

Wrist, hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment

All

N

Manually Priced

L3916

NU EP

WHFO, wrist extension cock-up, with outrigger, prefabricated, includes fitting and adjustment

All

N

Purchase

L3918

NU EP

HFO, knuckle bender prefabricated, includes fitting and adjustment

All

N

Purchase

L3920

NU EP

HFO, knuckle bender, with outrigger prefabricated, includes fitting and adjustment

All

N

Purchase

L3922

NU EP

HFO, knuckle bender, two segment to flex joints prefabricated, includes fitting and adjustment

All

N

Purchase

L3924

NU EP

WHFO, Oppenheimer, prefabricated, includes fitting and adjustment

All

N

Purchase

L3926

NU EP

WHFO, Thomas suspension, prefabricated, includes fitting and adjustment

All

N

Purchase

L3928

NU EP

HFO, finger extension, with clock spring, prefabricated, includes fitting and adjustment

All

N

Purchase

L3930

NU EP

WHFO, finger extension, with wrist support, prefabricated, includes fitting and adjustment

All

N

Purchase

L3932

NU EP

FO, safety pin, spring wire, prefabricated, includes fitting and adjustment

All

N

Purchase

L3934

NU EP

FO, safety pin, modified, prefabricated, includes fitting and adjustment

All

N

Purchase

L3936

NU EP

WHFO, Palmer prefabricated, includes fitting and adjustment

All

N

Purchase

L3938

NU EP

WHFO, dorsal wrist, prefabricated, includes fitting and adjustment

All

N

Purchase

L3940

NU EP

WHFO, dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment

All

N

Purchase

L3942

NU EP

HFO, reverse knuckle bender, prefabricated, includes fitting and adjustment

All

N

Purchase

L3944

NU EP

HFO, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment

All

N

Purchase

L3946

NU EP

HFO, composite elastic, prefabricated, includes fitting and adjustment

All

N

Purchase

L3948

NU EP

FO, finger knuckle bender, prefabricated, includes fitting and adjustment

All

N

Purchase

L3950

NU EP

WHFO, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment

All

N

Purchase

L3952

NU EP

WHFO, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment

All

N

Purchase

L3954

NU EP

HFO, spreading hand, prefabricated, includes fitting and adjustment

All

N

Purchase

L3956

NU

Addition of joint to upper extremity orthosis, any material; per joint

21+

N

Manually Priced

L3960

NU EP

SEWHO, abduction, positioning, airplane design, prefabricated, includes fitting and adjustment

All

Y

Purchase

L3962

NU EP

SEWHO, abduction positioning, Erb?s palsy design, prefabricated, includes fitting and adjustment

All

N

Purchase

L3964

NU EP

SEO, mobile arm supports attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment

All

N

Purchase

L3965

NU EP

SEO mobile arm support attached to wheelchair, balanced, adjustable Rancho type, prefabricated, includes fitting and adjustment

All

Y

Purchase

L3966

NU EP

SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment

All

Y

Purchase

L3968

NU EP

SEO, mobile arm support attached to wheelchair, balanced, friction arm support, (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment

All

Y

Purchase

L3969

NU EP

SEO, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment

All

N

Purchase

L3970

NU EP

SEO, addition to mobile arm support elevating proximal arm

All

N

Purchase

L3972

NU EP

SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control

All

N

Purchase

L3974

NU EP

SEO, addition to mobile arm support, supinator

All

N

Purchase

L3980

NU EP

Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment

All

N

Purchase

L3982

NU EP

Upper extremity fracture orthosis, radius/ulnar prefabricated, includes fitting and adjustment

All

N

Purchase

L3984

NU EP

Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment

All

N

Purchase

L3985

NU EP

Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated

All

N

Purchase

L3986

NU EP

Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example ? Colles? fracture), custom fabricated

All

N

Purchase

L3995

NU EP

Addition to upper extremity orthosis sock, fracture or equal, each

All

N

Purchase

L3999

EP

Upper limb orthosis, NOS

U21

N/A

Manually Priced

L3999

NU EP

***(The manufacturer?s invoice must be attached to all claims.) Upper limb orthosis, NOS

All

Y

Manually Priced

Manually Priced

L4000

NU EP

Replace girdle for spinal orthosis (CTLSO or SO)

All

Y

Purchase

L4002

NU EP

Replace strap, any orthosis, includes all components, any length, any type

All

N

Manually Priced

L4010

NU EP

Replace trilateral socket brim

All

N

Purchase

L4020

NU EP

Replace quadrilateral socket brim, molded to patient model

All

N

Purchase

L4030

NU EP

Replace quadrilateral socket brim, custom fitted

All

N

Purchase

L4040

NU EP

Replace molded thigh lacer, for custom fabricated orthosis only

All

N

Purchase

L4045

NU EP

Replace nonmolded thigh lacer, for custom fabricated orthosis only

All

N

Purchase

L4050

NU EP

Replace molded calf lacer, for custom fabricated orthosis only

All

N

Purchase

L4055

NU EP

Replace nonmolded calf lacer, for custom fabricated orthosis only

All

N

Purchase

L4060

NU EP

Replace high roll cuff

All

N

Purchase

L4070

NU EP

Replace proximal and distal upright for KAFO

All

N

Purchase

L4080

NU EP

Replace metal bands KAFO, proximal thigh

All

N

Purchase

L4090

EP

***(Custom night A frame-KAFO, torsion control, bilateral night ?A? frame) Replace metal bands KAFO-AFO, calf or distal thigh

U21

N/A

Purchase

L4090

NU EP

Replace metal bands KAFO-AFO, calf or distal thigh

All

N

Purchase

L4100

NU EP

Replace leather cuff KAFO, proximal thigh

All

N

Purchase

L4110

NU EP

Replace leather cuff KAFO-AFO, calf or distal thigh

All

N

Purchase

L4130

NU EP

Replace pretibial shell

All

N

Purchase

L4205

NU EP

Repair of orthotic device, labor component, per 15 minutes

All

Y

Purchase

L4210

NU EP

Repair of orthotic device, repair or replace minor parts

All

Y

Purchase

L4350

NU EP

Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment

All

N

Purchase

L4360

NU EP

Walking boot, pneumatic with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

All

N

Purchase

L4370

NU EP

Pneumatic full leg splint, prefabricated, includes fitting and adjustment

All

N

Purchase

L4380

NU EP

Pneumatic knee splint, prefabricated, includes fitting and adjustment

All

N

Purchase

L4392

NU

Replacement soft interface material, static AFO

21+

N

Purchase

L4394

NU

Replace soft interface material, foot drop splint

21+

N

Purchase

L4396

NU

Static ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, pressure reduction, may be used for minimal ambulation, prefabricated, includes fitting and adjustment

21+

N

Purchase

L4398

NU

Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment

21+

N

Purchase

L5999

NU EP

***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Lower extremity prosthesis, not otherwise specified

All

Y

Manually Priced

Manually Priced

L7499

NU EP

***(Unlisted Prosthetic Devices or Orthotic Appliances; the manufacturer?s invoice must be attached to all claims.) Upper extremity prosthesis, not otherwise specified

All

Y

Manually Priced

Manually Priced

L7510

NU EP

UB

Repair of prosthetic device, hourly rate

All

Y

Purchase

L7520

NU EP

Repair prosthetic device, labor component, per 15 minutes

All

Y

Purchase

L8499

NU EP

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

All

Y

Manually Priced

016.06.08 Ark. Code R. 004

3/6/2008