medical coverage policy - aaos coverage policy effective date: 01/01/2012 ... the version of this...

Orthotics

Medical Coverage Policy

Effective Date: 01/01/2012 Revision Date: 01/01/2012 Review Date: 04/28/2011 Policy Number: CLPD-0330-013

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Change Summary: Updated Provider Claims Codes

When printed, the version of this document becomes uncontrolled because Humana's documents are updated

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Disclaimer Description Coverage Determination Background

Medical Alternatives Provider Claims Codes Medical Terms References

Disclaimer

State and federal law, as well as contract language, including definitions and specific inclusions/ exclusions, take precedence over clinical policy and must be considered first in determining eligibility for coverage. Coverage may also differ for our Medicare and/or Medicaid members based on any applicable Centers for Medicare & Medicaid Services (CMS) coverage statements including National Coverage Determinations (NCD), Local Medical Review Policies (LMRP), and/or Local Coverage Determinations. See the CMS web site at http://www.cms.hhs.gov/. The member's health plan benefits, in effect on the date services are rendered, must be used. Clinical policy is not intended to preempt the judgment of the reviewing Medical Director or dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in rendering the most appropriate care. Identification of selected brand names of devices, tests, and procedures in a Medical Coverage Policy are for reference only and is not an endorsement of any one device, test or procedure over another. Clinical technology is constantly evolving, and we reserve the right to review and update this policy periodically. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any shape or form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Humana Inc.

Description Orthotics are devices that are utilized to support, align, prevent, or correct deformities or to improve the function of movable parts of the body. Orthotics includes braces (devices that support a weak joint or joints), splints (rigid devices used to immobilize an injury), casts (devices used for immobilization of body parts for fractures), supports and other devices. There are two classifications of orthotics: over-the-counter and custom-made. Custom made or custom fitted involves substantial work such as cutting, bending, molding or sewing. For custom molded orthoses, an impression of the specific body part is made and is used to make a model. The orthosis is molded from that model. Over-the-counter orthotics are available without a prescription and are not custom-fitted for the individual. These are generally not covered under the Plan. Orthopedic shoes are shoes used to prevent or correct disorders of the bones, joints, muscles, ligaments, and cartilage of the legs and feet.

http://apps.humana.com/tad/tad_new/home.aspx

http://www.cms.hhs.gov/

Orthotics Effective Date: 01/01/2012 Revision Date: 01/01/2012

Review Date: 04/28/2011 Policy Number: CLPD-0330-013

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See the DISCLAIMER. All Humana member health plan contracts are NOT the same. All legislation/regulations on

this subject may not be included. This document is for informational purposes only.

Coverage Determination

Any state mandates for orthotics would take precedence over this clinical policy. Humana members may be eligible under the Plan for orthotics, which would include braces, splints, and supports that are prescribed by a physician, if they are custom-fitted or custom-made by the physician or brace shop for the specific needs of the patient and rigid or semi-rigid in structure. The following also applies for shoes:

Specially constructed shoes that are an integral part of a leg brace (the shoe cannot be removed from the brace without making the shoe unusable); OR

Cast boots or shoes requested by the surgeon following a surgical procedure or treatment of a fracture; OR

One pair of custom made or custom fitted arch supports or shoes per calendar year ONLY for members with hammer toe or with sensory or vascular abnormalities of the feet due to diabetes mellitus.

Examples of orthotics include, but may not be limited to:

Air splints.

Cervical collars post-surgery

Denis-Browne or torsion bar braces.

Figure-eight splints for clavicle fractures.

Finger splints for volar plate or tendon avulsions.

Knee immobilizers for internal derangements and ligament sprains.

Lumbar braces with metal stays, custom-fitted.

Serial casting and plaster splinting.

Wrist splints for carpal tunnel syndrome.

Substitute casts, splints, trusses, crutches, and non-dental braces, when required by growth or a change in medical condition and their replacement when irreparable.

V-Loc unloader back brace (must be utilized for activities of daily living, not just for sporting activities).

Note: This criteria for orthotics is not consistent with the Medicare National Coverage Policy, and therefore may not be applicable to Medicare members.



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Refer to the CMS web site at http://www.cms.hhs.gov for additional information.

Coverage Limitations

Humana members may NOT be eligible under the Plan for the following types of supports (list may not be all inclusive) as they are generally excluded by contract or not considered medically necessary:

Any over-the-counter devices such as arch supports, wrist supports, knee supports and heel cups because they are not custom fitted or custom made

Braces used only for activities other than normal daily living, this includes braces used for sports

Fabric supports

Heel wedges, lifts or shoe inserts

Lumbar sacral supports, industrial back braces

Mechanical stretch devices, which includes static progressive (SP) stretch (Dynasplint , low-load prolonged-duration stretch (LLPS) (Joint Active Systems , and patient-actuated serial stretch (PASS) devices (Extensionaters and Flexionaters). Please refer to the Continuous Passive Motion and Mechanical Stretching Devices Medical Coverage Policy for additional coverage information on these devices

Repair and replacement of orthotics

SpineCor System Dynamic Corrective Brace

http://www.cms.hhs.gov/

http://dctm.humana.com/Mentor/Web/v.aspx?chronicleID=0900092980aafad0&dl=1

http://dctm.humana.com/Mentor/Web/v.aspx?chronicleID=0900092980aafad0&dl=1

http://dctm.humana.com/Mentor/Web/v.aspx?chronicleID=0900092980aacb93&dl=1

http://dctm.humana.com/Mentor/Web/v.aspx?chronicleID=0900092980aacb93&dl=1



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Background You can learn more about injuries and/or disorders that may constitute the use of braces, supports or splints from the following sites:

American Academy of Orthopedic Surgeons – http://www.aaos.org

American Academy of Pediatrics - http://www.aap.org

American College of Foot and Ankle Surgeons – http://www.acfas.org

National Diabetes Information Clearinghouse – http://www.diabetes.niddk.nih.gov

National Institute of Neurological Disorders and Stroke -http://www.ninds.gov

National Library of Medicine - http://www.nlm.nih.gov.

Medical Alternatives

To make the best health decision for your individual needs, consult your physician.

Provider Claims Codes

All provider claims codes surrounding this topic may not be included in the following table:

CPT© Codes

Description Comments

97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes

97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes

http://www.aaos.org/

http://www.aap.org/

http://www.acfas.org/

http://www.diabetes.niddk.nih.gov/

http://www.ninds.gov/

http://www.nlm.nih.gov/



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HCPCS© Codes

Description Comments

Diabetic Shoes and Shoe Inserts

A5500 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

Must have diagnosis of

diabetes

A5501 For diabetics only, fitting (including follow-up) custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe


diabetes

A5503 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


diabetes

A5504 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe


diabetes

A5505 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe


diabetes

A5506 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe


diabetes

A5507 For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe


diabetes

A5508 For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom-molded shoe, per shoe.


diabetes

A5510 For diabetics only, direct formed, compression molded to patient’s foot without external heat source, multiple-density insert(s) prefabricated, per shoe


diabetes



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A5512

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 or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each


diabetes

A5513

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 ¼ inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), includes arch filler and other shaping material, custom fabricated, each


diabetes.

Helmets

L0112 Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated

Please refer to the Cranial Orthotics

Medical Coverage Policy.

L0113 Cranial cervical orthotic, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment

Not Covered



S1040 Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)



Harness – Cervical, Pelvic Belts, and Extremity Belt

E0942 Cervical head harness/halter

E0944 Pelvic belt/harness/boot

E0945 Extremity belt/harness (fabric support) Not Covered

http://apps.humana.com/tad/tad_new/issuedetail.asp?issue=530








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Mechanical Stretch Devices

E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material

Not Covered

Please refer to the Continuous

Passive Motion and Mechanical

Stretching Devices Medical Coverage

Policy

E1801 Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories

Not Covered




Policy

E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material

Not Covered




Policy

E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material

Not Covered




Policy

http://www.mondofacto.com/facts/dictionary?query=casts


















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E1806 Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories

Not Covered




Policy

E1810 Dynamic adjustable knee extension/flexion device, includes soft interface material

Not Covered




Policy

E1811 Static progressive stretch knee device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories

Not Covered




Policy

E1812 Dynamic knee, extension/flexion device with active resistance control

Not Covered




Policy



















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E1815 Dynamic adjustable ankle extension/flexion, includes soft interface material

Not Covered




Policy

E1816 Static progressive stretch ankle device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories

Not Covered




Policy

E1818 Static progressive stretch forearm pronation/supination device, with or without range of motion adjustment, includes all components and accessories

Not Covered




Policy

E1820 Replacement soft interface material, dynamic adjustable extension/flexion device

Not Covered




Policy



















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E1821 Replacement soft interface material/cuffs for bi-directional static progressive stretch device

Not Covered




Policy

E1825 Dynamic adjustable finger extension/flexion device, included soft interface material

Not Covered




Policy

E1830 Dynamic adjustable toe extension/flexion device, includes soft interface material

Not Covered




Policy

E1831 Static progressive stretch toe device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories

Not Covered




Policy



















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E1840 Dynamic adjustable shoulder flexion/abduction/rotation device, includes soft interface material

Not Covered




Policy

E1841 Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories

Not Covered




Policy

Cervical Collars

L0120 Cervical, flexible, nonadjustable (foam collar)

L0130 Cervical, flexible, thermoplastic collar, molded to patient

L0140 Cervical, semi-rigid, adjustable (plastic collar)

L0150 Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)

L0160 Cervical, semi-rigid, wire frame occipital/mandibular support

L0170 Cervical collar, molded to patient model

L0172 Cervical, collar, semi-rigid thermoplastic foam, two piece

L0174 Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension

L0180 Cervical, multiple post collar, occipital/mandibular supports, adjustable











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L0190 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types)

L0200 Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension

Thoracic Rib Belts

A4466 Garment, belt, sleeve or other covering, elastic or similar stretchable material, any type, each

Not Covered

L0220 Thoracic, rib belt, custom fabricated

Thoracic-Lumbar-Sacral Orthosis

L0430 Spinal orthosis, anterior-posterior-lateral control, with interface material, custom fitted (Dewall posture protector only)

L0450

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

L0452

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

L0454

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



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L0456

TLSO, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the 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

L0458

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 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

L0460

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, includes straps and closures, prefabricated, includes fitting and adjustment

L0462

TLSO, triplanar control, modular segmented spinal system, three 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, includes straps and closures, prefabricated, includes fitting and adjustment



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L0464

TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from 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, includes straps and closures, prefabricated, includes fitting and adjustment

L0466

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

L0468

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

L0470

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, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment



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L0472

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

L0480

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 pubix 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

L0482

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.

L0484

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.



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L0486

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

L0488

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

L0490

TLSO, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment

L0491

TLSO, sagittal-coronal 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 xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment



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L0492

TLSO, sagittal-coronal control, modular segmented spinal system, three 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 xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment

Sacroiliac Orthosis

L0621

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

Not Covered

L0622

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

Not Covered

L0623

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

Not Covered

L0624

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

Lumbar Orthosis/Lumbar Sacral Orthosis

L0625

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

Not Covered



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adjustment

L0626

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

Not Covered

L0627

Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, 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

L0628

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

Not Covered

L0629

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

L0630

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

Not Covered

L0631

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, prefabricated, includes fitting and adjustment



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L0632

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

L0633

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 intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

Not Covered

L0634

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 intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated

L0635

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 intervertebral discs, includes straps, closures, may includes padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0636

Lumbar sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, 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 intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated



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L0637

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 intervertebral discs, includes straps, closures, may includes padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0638

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 intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated

L0639

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 is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, includes fitting and adjustment

L0640

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 is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated

L0972 LSO, corset front Not Covered

L0976 LSO, full corset Not Covered



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Cervical-Thoracic-Lumbar-Sacral Orthosis

L0700 CTLSO, anterior-posterior-lateral control, molded to patient model (Minerva type)

L0710 CTLSO, anterior-posterior-lateral control, molded to patient model, with interface material (Minerva type)

L1000 CTLSO (Milwaukee), inclusive of furnishing initial orthosis, including model

L1001 Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustment

Halo Procedure and Supplies

L0810 Halo procedure, cervical halo incorporated into jacket vest

L0820 Halo procedure, cervical halo incorporated into plaster body jacket

L0830 Halo procedure, cervical halo incorporated into Milwaukee type orthosis

L0859 Addition to halo procedure, magnetic resonance image compatible system, rings and pins, any material

L0861 Addition to halo procedure, replacement liner/interface material

Straps, Stockings, Supports and Body Gloves

L0980 Peroneal straps, pair Not Covered

L0982 Stocking supporter grips, set of four (4) Not Covered

L0984 Protective body sock, each Not Covered

Supplies for Cervical-Thoracic-Lumbar-Sacral and Thoracic-Lumbar-Sacral Orthosis

L0970 TLSO, corset front Not Covered



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L0974 TLSO, full corset Not Covered

L1010 Addition to CTLSO or scoliosis orthosis, axilla sling

L1020 Addition to CTLSO or scoliosis orthosis, kyphosis pad

L1025 Addition to CTLSO or scoliosis orthosis, kyphosis pad, floating

L1030 Addition to CTLSO or scoliosis orthosis, lumbar bolster pad

L1040 Addition to CTLSO or scoliosis orthosis, lumbar or lumbar rib pad

L1050 Addition to CTLSO or scoliosis orthosis, sternal pad

L1060 Addition to CTLSO or scoliosis orthosis, thoracic pad

L1070 Addition to CTLSO or scoliosis orthosis, trapezius sling

L1080 Addition to CTLSO or scoliosis orthosis, outrigger

L1085 Addition to CTLSO or scoliosis orthosis, outrigger, bilateral with vertical extensions

L1090 Addition to CTLSO or scoliosis orthosis, lumbar sling

L1100 Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather

L1110 Addition to CTLSO or scoliosis orthosis, ring flange, plastic or leather, molded to patient model

L1120 Addition to CTLSO, scoliosis orthosis, cover for upright, each

L1200 TLSO, inclusive of furnishing initial orthosis only

L1210 Addition to TLSO, (low profile), lateral thoracic extension

L1220 Addition to TLSO, (low profile), anterior thoracic extension

L1230 Addition to TLSO, (low profile), Milwaukee type superstructure

L1240 Addition to TLSO, (low profile), lumbar derotation pad

L1250 Addition to TLSO, (low profile), anterior ASIS pad

L1260 Addition to TLSO, (low profile), anterior thoracic derotation pad

L1270 Addition to TLSO, (low profile), abdominal pad



Page: 23 of 56






L1280 Addition to TLSO, (low profile), rib gusset (elastic), each

L1290 Addition to TLSO, (low profile), lateral trochanteric pad

Scoliosis Braces

L1005 Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment

Not Covered

L1300 Other scoliosis procedure, body jacket molded to patient model

L1310 Other scoliosis procedure, postoperative body jacket

Thoracic-Hip-Knee-Ankle Orthosis

L1500 THKAO, mobility frame (Newington, Parapodium types)

Deleted Code

Effective 01/01/2012

L1510 THKAO, standing frame, with or without tray and accessories

Deleted Code


L1520 THKAO, swivel walker

Deleted Code


Hip Orthosis

L1600 Hip orthotic (HO), abduction control of hip joints, flexible, Frejka type with cover, prefabricated, includes fitting and adjustment

Not Covered

L1610 Hip orthotic (HO), abduction control of hip joints, flexible, (Frejka cover only), prefabricated, includes fitting and adjustment

Not Covered

L1620 Hip orthosis (HO), abduction control of hip joints, flexible, (Pavlik harness), prefabricated, includes fitting and adjustment

Not Covered

L1630 HO, abduction control of hip joints, semi-flexible (Von Rosen type), custom fabricated



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L1640 HO, abduction control of hip joints, static pelvic band or spreader bar, thigh cuffs, custom fabricated

L1650 HO, abduction control of hip joints, static, adjustable (Ilfled type), prefabricated, includes fitting and adjustment

Not Covered

L1652 Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type

Not Covered

L1660 HO, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment

Not Covered

L1680 HO, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (Rancho hip action type), custom fabricated

L1685 HO, abduction control of hip joint, postoperative hip abduction type, custom fabricated

L1686 HO, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustments

Combination Orthosis

L1690 Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment

L1700 Legg Perthes orthosis, (Toronto type), custom fabricated

L1710 Legg Perthes orthosis, (Newington type), custom fabricated

L1720 Legg Perthes orthosis, trilateral, (Tachdijan type), custom fabricated

L1730 Legg Perthes orthosis, (Scottish Rite type), custom fabricated

L1755 Legg Perthes orthosis, (Patten bottom type), custom fabricated

Knee Orthosis

L1810 KO, elastic with joints, prefabricated, includes fitting and adjustment

Not Covered



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L1820 KO, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment

Not Covered

L1830 KO, immobilizer, canvas longitudinal, prefabricated, includes fitting and adjustment

Not Covered

L1831 Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment

Not Covered

L1832 KO, adjustable knee joints, positional orthosis, rigid support, prefabricated, includes fitting and adjustment

L1834 KO, without knee joint, rigid, custom fabricated

L1836 Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, includes fitting and adjustment

Not Covered

L1840 KO, derotation, medial-lateral, anterior cruciate ligament, custom fabricated

L1843

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

L1844

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

L1845

KO, 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

L1846

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

L1847 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, includes fitting and adjustment

Not Covered



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L1850 KO, Swedish type, prefabricated, includes fitting and adjustment

Not Covered

L1860 KO, modification of supracondylar prosthetic socket, custom fabricated (SK)

Ankle Foot Orthosis

L1900 AFO, spring wire, dorsiflexion assist calf band, custom fabricated

L1902 AFO, ankle gauntlet, prefabricated, includes fitting and adjustment

Not Covered

L1904 AFO, molded ankle gauntlet, custom fabricated

L1906 AFO, multiligamentus ankle support, prefabricated, includes fitting and adjustment

Not Covered

L1907 AFO, supramalleolar with straps, with or without interface/pads, custom fabricated

L1910 AFO, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment

Not Covered

L1920 AFO, single upright with static or adjustable stop (Phelps or Perlstein type), custom fabricated

L1930 Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment

Not Covered

L1932 AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment

L1940 Ankle foot orthosis, plastic or other material, custom-fabricated

L1945 AFO, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated

L1950 AFO, spiral, (Institute of Rehabilitative Medicine type), plastic, custom fabricated

L1951 AFO, spiral, (Institute of Rehabilitative Medicine type), plastic or other material, prefabricated, included fitting and adjustment



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L1960 AFO, posterior solid ankle, plastic, custom fabricated

L1970 AFO, plastic, with ankle joint, custom fabricated

L1971 AFO, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment

L1980 AFO, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar "BK" orthosis), custom fabricated

L1990 AFO, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar "BK" orthosis), custom fabricated

L2106 AFO, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated

L2108 AFO, fracture orthosis, tibial fracture cast orthosis, custom fabricated

L2112 AFO, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment (fabric support)

L2114 AFO, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment

L2116 AFO, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment

L4350 Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, includes fitting and adjustment

Not Covered

L4360 Walking boot, pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

L4386 Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, includes fitting and adjustment

L4396

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

Not Covered



Page: 28 of 56






L4631

Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated

Knee-Ankle-Foot Orthosis

L2000 KAFO, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), custom fabricated

L2005

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

L2010 KAFO, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar "AK" orthosis), without knee joint, custom fabricated

L2020 KAFO, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar "AK" orthosis), custom fabricated

L2030 KAFO, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar "AK" orthosis), without knee joint, custom fabricated

L2034 Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, medial lateral rotation control, with or without free ankle, custom fabricated

L2035 KAFO, full plastic, static, (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment

L2036 KAFO, full plastic, double upright, free knee, with or without free motion ankle, custom fabricated

L2037 KAFO, full plastic, single upright, free knee, with or without free motion ankle, custom fabricated

L2038 KAFO, full plastic, without knee joint, multiaxis ankle, (Lively orthosis or equal), custom fabricated



Page: 29 of 56






L2126 KAFO, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated

L2128 KAFO, fracture orthosis, femoral fracture cast orthosis, custom fabricated

L2132 KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment

L2134 KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, included fitting and adjustment

L2136 KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment

Hip-Knee-Ankle-Foot Orthosis

L2040 HKAFO, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated

L2050 HKAFO, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated

L2060 HKAFO, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/belt, custom fabricated

L2070 HKAFO, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated

L2080 HKAFO, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated

L2090 HKAFO, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated

Additions to Fracture Orthosis

L2180 Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints

L2182 Addition to lower extremity fracture orthosis, drop lock knee joint

L2184 Addition to lower extremity fracture orthosis, limited motion knee joint



Page: 30 of 56






L2186 Addition to lower extremity fracture orthosis, adjustable motion knee joint, Lerman type

L2188 Addition to lower extremity fracture orthosis, quadrilateral brim

L2190 Addition to lower extremity fracture orthosis, waist belt

L2192 Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt

Additions to Lower Extremity Orthosis – Shoe-Ankle-Shin-Knee

L2200 Addition to lower extremity, limited ankle motion, each joint

L2210 Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint

L2220 Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint

L2230 Addition to lower extremity, split flat caliper stirrups and plate attachment

L2232 Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only

L2240 Addition to lower extremity, round caliper and plate attachment

L2250 Addition to lower extremity, foot plate, molded to patient model, stirrup attachment

L2260 Addition to lower extremity, reinforced solid stirrup (Scott-Craig type)

L2265 Addition to lower extremity, long tongue stirrup

L2270 Addition to lower extremity, varus/valgus correction ("T") strap, padded/lined or malleolus pad

L2275 Addition to lower extremity, varus/vulgus correction, plastic modification, padded/lined

L2280 Addition to lower extremity, molded inner boot

L2300 Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable



Page: 31 of 56






L2310 Addition to lower extremity, abduction bar, straight

L2320 Addition to lower extremity, nonmolded lacer, for custom fabricated orthosis only

L2330 Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only

L2335 Addition to lower extremity, anterior swing band

L2340 Addition to lower extremity, pretibial shell, molded to patient model

L2350 Addition to lower extremity, prosthetic type, (BK) socket, molded to patient model, (used for "PTB," "AFO" orthoses)

L2360 Addition to lower extremity, extended steel shank

L2370 Addition to lower extremity, Patten bottom

L2375 Addition to lower extremity, torsion control, ankle joint and half solid stirrup

L2380 Addition to lower extremity, torsion control, straight knee joint, each joint

L2385 Addition to lower extremity, straight knee joint, heavy duty, each joint

L2387 Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint

L2390 Addition to lower extremity, offset knee joint, each joint

L2395 Addition to lower extremity, offset knee joint, heavy duty, each joint

L2397 Addition to lower extremity orthosis, suspension sleeve

Additions to Knee Joint Orthosis

L2405 Addition to knee joint, lock; drop, stance or swing phase, each joint

L2415 Addition to knee lock with integrated release mechanism (ball, cable, or equal), any material, each joint



Page: 32 of 56






L2425 Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint

L2430 Addition to knee joint, ratchet lock for active and progressive knee extension, each joint

L2492 Addition to knee joint, lift loop for drop lock ring

Additions to Lower Extremity Orthosis – Thigh/Weight Bearing

L2500 Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring

L2510 Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model

L2520 Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted

L2525 Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim molded to patient model

L2526 Addition to lower extremity, thigh/weight bearing, ischial containment/narrow M-L brim, custom fitted

L2530 Addition to lower extremity, thigh/weight bearing, lacer, nonmolded

L2540 Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model

L2550 Addition to lower extremity, thigh/weight bearing, high roll cuff

Addition to Lower Extremity Orthosis – Pelvic/Hip

L2570 Addition to lower extremity, pelvic control, hip joint, Clevis type, two position joint, each

L2580 Addition to lower extremity, pelvic control, pelvic sling

L2600 Addition to lower extremity, pelvic control hip joint, Clevis type, or thrust bearing, free, each

L2610 Addition to lower extremity, pelvic control, hip joint, Clevis or thrust bearing, lock, each



Page: 33 of 56






L2620 Addition to lower extremity, pelvic control, hip joint, heavy-duty, each

L2622 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each

L2624 Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each

L2627 Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables

L2628 Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables

L2630 Addition to lower extremity, pelvic control, band and belt, unilateral

L2640 Addition to lower extremity, pelvic control band and belt, bilateral

L2650 Addition to lower extremity, pelvic and thoracic control, gluteal pad, each

L2660 Addition to lower extremity, thoracic control, thoracic band

L2670 Addition to lower extremity, thoracic control, paraspinal uprights

L2680 Addition to lower extremity, thoracic control, lateral support uprights

General Additions

L2750 Addition to lower extremity orthosis, plating chrome or nickel, per bar

L2755 Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only

L2760 Addition to lower extremity orthosis extension, per extension, per bar (for lineal adjustment for growth)

L2768 Orthotic side bar disconnect device, per bar

L2780 Addition to lower extremity orthosis, noncorrosive finish, per bar

L2785 Addition to lower extremity orthosis, drop lock retainer, each



Page: 34 of 56






L2795 Addition to lower extremity orthosis, knee control, full kneecap

L2800 Addition to lower extremity orthosis, knee control, kneecap, medial or lateral pull, for use with custom fabricated orthosis only

L2810 Addition to lower extremity orthosis, knee control, condylar pad

L2820 Addition to lower extremity orthosis, soft interface for molded plastic, below knee section

L2830 Addition to lower extremity orthosis, soft interface for molded plastic, above knee section

L2840 Addition to lower extremity orthosis, tibial length sock, fracture or equal, each

L2850 Addition to extremity orthosis, femoral length sock, fracture or equal, each

L2861 Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each

Shoe Inserts

L3000 Foot insert, removable, molded to patient model, "UCB" type, Berkeley shell, each

Not Covered

L3001 Foot insert, removable, molded to patient model, Spenco, each Not Covered

L3002 Foot insert, removable, molded to patient model, Plastazote or equal, each

Not Covered

L3003 Foot insert, removable, molded to patient model, silicone gel, each

Not Covered

L3010 Foot insert, removable, molded to patient model, longitudinal arch support, each


hammer toe. For diagnosis of

diabetes, see codes A5500-

A5513.



Page: 35 of 56






L3020 Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each

Not Covered

L3030 Foot insert, removable, formed to patient foot, each Not Covered

L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each

Not Covered

L3040 Foot, arch support, removable, premolded, longitudinal, each (OTC)

Not Covered

L3050 Foot, arch support, removable, premolded, metatarsal, each (OTC)

Not Covered

L3060 Foot, arch support, removable, premolded, longitudinal/metatarsal, each (OTC)

Not Covered

L3070 Foot, arch support, nonremovable, attached to shoe, longitudinal, each




A5513.

L3080 Foot, arch support, nonremovable, attached to shoe, metatarsal, each




A5513.

L3090 Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each




A5513.



Page: 36 of 56






Foot Splints, Abduction and Rotation Bars

L3100 Hallus-Valgus night dynamic splint Not Covered

L3140 Foot, abduction rotation bar, including shoes

L3150 Foot, abduction rotation bar, without shoes

L3160 Foot, adjustable shoe-styled positioning device Not Covered

L3170 Foot, plastic heel stabilizer Not Covered

Orthopedic Shoes – Infant-Child-Junior

L3201 Orthopedic shoe, oxford with supinator or pronator, infant Not Covered

L3202 Orthopedic shoe, oxford with supinator or pronator, child Not Covered

L3203 Orthopedic shoe, oxford with supinator or pronator, junior Not Covered

L3204 Orthopedic shoe, hightop with supinator or pronator, infant Not Covered

L3206 Orthopedic shoe, hightop with supinator, or pronator, child Not Covered

L3207 Orthopedic shoe, hightop with supinator or pronator, junior Not Covered

L3208 Surgical boot, each, infant

L3209 Surgical boot, each, child

L3211 Surgical boot, each, junior

L3212 Benesch boot, pair, infant Not Covered

L3213 Benesch boot, pair, child Not Covered

L3214 Benesch boot, pair, junior Not Covered



Page: 37 of 56






Orthopedic Shoes – Women and Men

L3215 Orthopedic footwear, woman's shoes, oxford




A5513.

L3216

Orthopedic footwear, woman's shoes, depth inlay




A5513.

L3217 Orthopedic footwear, woman's shoes, hightop, depth inlay A5500-A5513.




A5513.

L3219 Orthopedic foot wear, man's shoes, oxford




A5513



Page: 38 of 56






L3221 Orthopedic footwear, man's shoes, depth inlay




A5513

L3222 Orthopedic footwear, man's shoes, hightop, depth inlay




A5513

L3224 Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis)

L3225 Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)

L3230 Orthopedic footwear, custom shoes, depth inlay




A5513

L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each




A5513



Page: 39 of 56






L3251 Foot, shoe molded to patient model, silicone shoe, each




A5513

L3252 Foot, shoe molded to patient model, Plastazote (or similar), custom fabricated, each




A5513

L3253 Foot, molded shoe Plastazote (or similar), custom fitted, each




A5513

L3254 Nonstandard size or width




A5513

L3255 Nonstandard size or length




A5513



Page: 40 of 56






L3257 Orthopedic footwear, additional charge for split size




A5513

L3260 Surgical boot/shoe, each

L3265 Plastazote sandal, each




A5513.

Heels, Wedges and Lifts

L3300 Lift, elevation, heel, tapered to metatarsals, per inch Not Covered.

L3310 Lift, elevation, heel and sole, neoprene, per inch Not Covered

L3320 Lift elevation, heel and sole, cork, per inch Not Covered

L3330 Lift, elevation, metal extension (skate) Not Covered

L3332 Lift, elevation, inside shoe, tapered, up to one-half inch Not Covered

L3334 Lift, elevation, heel, per inch Not Covered

L3340 Heel wedge, SACH Not Covered

L3350 Heel wedge Not Covered

L3360 Sole wedge, outside sole Not Covered

L3370 Sole wedge, between sole Not Covered

L3380 Clubfoot wedge Not Covered

L3390 Outflare wedge Not Covered

L3400 Metatarsal bar wedge, rocker Not Covered



Page: 41 of 56






L3410 Metatarsal bar wedge, between sole Not Covered

L3420 Full sole and heel wedge, between sole Not Covered

L3430 Heel, counter, plastic reinforced Not Covered

L3440 Heel, counter, leather reinforced Not Covered

L3450 Heel, SACH cushion type Not Covered

L3455 Heel, new leather, standard Not Covered

L3460 Heel, new rubber, standard Not Covered

L3465 Heel, Thomas with wedge Not Covered

L3470 Heel, Thomas extended to ball Not Covered

L3480 Heel, pad and depression for spur Not Covered

L3485 Heel, pad, removable for spur Not Covered

Orthopedic Shoe Additions

L3500 Orthopedic shoe addition, insole, leather




A5513

L3510 Orthopedic shoe addition, insole, rubber




A5513



Page: 42 of 56






L3520 Orthopedic shoe addition, insole, felt covered with leather




A5513

L3530 Orthopedic shoe addition, sole, half




A5513

L3540 Orthopedic shoe addition, sole, full




A5513

L3550 Orthopedic shoe addition, toe tap, standard




A5513

L3560 Orthopedic shoe addition, toe tap, horseshoe




A5513



Page: 43 of 56






L3570 Orthopedic shoe addition, special extension to instep (leather with eyelets)




A5513

L3580 Orthopedic shoe addition, convert instep to Velcro closure




A5513

L3590 Orthopedic shoe addition, convert firm shoe counter to soft counter




A5513

L3595 Orthopedic shoe addition, March bar




A5513

L3600 Transfer of an orthosis from one shoe to another, caliper plate, existing

L3610 Transfer of an orthosis from one shoe to another, caliper plate, new

L3620 Transfer of an orthosis from one shoe to another, solid stirrup, existing



Page: 44 of 56






L3630 Transfer of an orthosis from one shoe to another, solid stirrup, new

L3640 Transfer of an orthosis from one shoe to another, Dennis Browne splint (Riveton), both shoes

L3649 Orthopedic shoe, modification, addition or transfer, not otherwise specified




A5513

Shoulder Orthosis

L3650 SO, figure of eight design abduction re-strainer, prefabricated, includes fitting and adjustment

L3660 SO, figure of eight design abduction restrainer, canvas and webbing, prefabricated, includes fitting and adjustment

Not Covered

L3670 SO, acromio/clavicular (canvas and webbing type), prefabricated, includes fitting and adjustment (fabric support)

Not Covered

L3671 Shoulder orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3674

Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface straps, custom fabricated, includes fitting and adjustment

L3675 SO, vest type abduction restrainer, canvas webbing type, or equal, prefabricated, includes fitting and adjustment (fabric support)

Not Covered

L3677 Shoulder orthosis, hard plastic, shoulder stabilizer, prefabricated, includes fitting and adjustment



Page: 45 of 56






Elbow Orthosis

L3702 Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3710 EO, elastic with metal joints, prefabricated, includes fitting and adjustment

Not Covered

L3720 EO, double upright with forearm/arm cuffs, free motion, custom fabricated

L3730 EO, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated

L3740 EO, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated

L3760 Elbow orthosis, with adjustable position locking joint(s), prefabricated, includes fitting and adjustments, any type

L3762 Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, includes fitting and adjustment

Not Covered

Elbow-Wrist-Hand-Finger Orthosis

L3763 Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3764 Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3765 Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3766

Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment



Page: 46 of 56






L3806

Wrist and finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment

L3807 WHFO, without joint(s), prefabricated, includes fitting and adjustments, any type

L3808 Wrist and finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment

L3891 Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each

L3900 WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated

L3901 WHFO, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated

L3904 WHFO, external powered, electric, custom fabricated

L3905 Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3906 WHO, wrist gauntlet, molded to patient model, custom fabricated

L3908 WHO, wrist extension control cock-up, nonmolded, prefabricated, includes fitting and adjustment

Not Covered

L3912 HFO, flexión glove with elastic finger control, prefabricated, includes fitting and adjustment (fabric support)

Not Covered

L3913 Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3915 Wrist hand orthosis (WHO), includes one or more nontorsion joint(s), elastic band, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment



Page: 47 of 56






L3917 Hand orthosis (HO), metacarpal fracture orthosis, prefabricated, includes fitting and adjustment

L3919 Hand orthosis (HO), without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3921 Hand finger orthosis (HFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3923 Hand finger orthosis (HFO), without joint(s), prefabricated, includes fitting and adjustments

Not Covered

L3925

FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), nontorsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustment

Not Covered

L3927

FO, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, includes fitting and adjustment

Not Covered

L3929 HFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment

Not Covered

L3931 WHFO, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment

Not Covered

L3933 Finger orthosis (FO), without joints, may include soft interface, custom fabricated, includes fitting and adjustment

L3935 Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment

L3956 Addition of joint to upper extremity orthosis, any material; per joint



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Shoulder-Elbow-Wrist-Hand Orthosis

L3960 SEWHO, abduction positioning, airplane design, prefabricated, includes fitting and adjustment

L3961 Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3962 SEWHO, abduction positioning, Erbs palsey design, prefabricated, includes fitting and adjustment

L3964 SEO, mobile arm support attached to wheelchair balanced, adjustable, prefabricated, includes fitting and adjustment

Deleted Code


L3965 SEO, mobile arm support attached to wheelchair, balance, adjustable Rancho type, prefabricated, includes fitting and adjustment

Deleted Code


L3966 SEO, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment

Deleted Code


L3967

Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, without joint, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3968 SEO, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment

Deleted Code


L3969

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

Deleted Code




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L3970 SEO, addition to mobile arm support, elevating proximal arm

Deleted Code


L3971

Shoulder elbow wrist hand orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3972 SEO, addition to mobile arm support, offset or lateral rocker arm with elastic balance control

Deleted Code


L3973

Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3974 SEO, addition to mobile support, supinator

Deleted Code


L3975 Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3976

Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment

L3977

Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment



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L3978

Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment

Upper Extremity Fracture Orthosis

L3980 Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment

L3982 Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment

L3984 Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment

L3995 Addition to upper extremity orthosis, sock, fracture or equal, each

L3999 Upper limb orthosis, not otherwise specified

Replacement Parts

L4000 Replace girdle for spinal orthosis (CTLSO or SO) Not Covered

L4002 Replacement strap, any orthosis, includes all components, any length, any type

Not Covered

L4010 Replace trilateral socket brim Not Covered

L4020 Replace quadrilateral socket brim, molded to patient model Not Covered

L4030 Replace quadrilateral socket brim, custom fitted Not Covered

L4040 Replace molded thigh lacer, for custom fabricated orthosis only Not Covered

L4045 Replace nonmolded thigh lacer, for custom fabricated orthosis only

Not Covered

L4050 Replace molded calf lacer, for custom fabricated orthosis only Not Covered

L4055 Replace nonmolded calf lacer, for custom fabricated orthosis only

Not Covered



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L4060 Replace high roll cuff Not Covered

L4070 Replace proximal and distal upright for KAFO Not Covered

L4080 Replace metal bands KAFO, proximal thigh Not Covered

L4090 Replace metal bands KAFO-AFO, calf or distal thigh Not Covered

L4100 Replace leather cuff KAFO, proximal thigh Not Covered

L4110 Replace leather cuff KAFO-AFO, calf or distal thigh Not Covered

L4130 Replace pretibial shell Not Covered

L4205 Repair of orthotic device, labor component, per 15 minutes Not Covered

L4210 Repair of orthotic device, repair or replace minor parts Not Covered

Slings and Splints

A4565 Slings (fabric support) Not Covered

A4566 Shoulder sling or vest design, abduction restrainer, with or without swathe control, prefabricated, includes fitting and adjustment

Not Covered

A4570 Splint Not Covered

L4370 Pneumatic full leg splint (e.g., aircast), prefabricated, includes fitting and adjustment

L4380 Pneumatic knee splint (e.g., aircast), prefabricated, includes fitting and adjustment

Deleted Code


L4392 Replace soft interface material, static AFO

L4394 Replace soft interface material, foot drop splint

L4398 Foot drop splint, recumbent positioning device, prefabricated, includes fitting and adjustment

L9900 Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS “L” code

S8450 Splint, prefabricated, digit (specify digit by use of modifier) Not Covered



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S8451 Splint, prefabricated, wrist or ankle Not Covered

S8452 Splint, prefabricated, elbow Not Covered

Medical Terms

Align - To arrange in a straight line. Arch Support - A rigid support placed inside a shoe so that its molded form fits the arch of the foot and relieves strain on the muscles of the foot while walking, standing, etc. Avulsion - A forcible tearing away or separation of a bodily structure or part. Cartilage - Tough, elastic, fibrous, connective tissue found in various parts of the body. Carpal Tunnel Syndrome - A common disorder of the wrist and hand characterized by pain, tingling, and muscular weakness, caused by pressure on the median nerve in the wrist area and often associated with trauma, rheumatoid arthritis, or edema of pregnancy. Cervical – Of or relating to a neck. Cervical Collar - A firm brace worn to support the neck. Clavicle - Also called the collarbone. It articulates with the shoulder on one end and the sternum on the other. Deformity - A bodily malformation, distortion, or disfigurement. Derangement - To disturb the order or arrangement of. Diabetes Mellitus - A disorder of carbohydrate metabolism, usually occurring in genetically predisposed individuals, characterized by inadequate production or utilization of insulin and resulting in excessive amounts of glucose in the blood and urine, excessive thirst, weight loss, and in some cases progressive destruction of small blood vessels leading to such complications as infections and gangrene of the limbs or blindness. Fracture - The breaking of a bone, cartilage or the like.



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Hammertoe - A clawlike deformity of a toe, usually the second or third, in which there is a permanent flexion of the second and third joints. Immobilize - To prevent the use, activity, or movement of. Integral - Consisting or composed of parts that together constitute a whole. Joint - The movable or fixed place or part where two bones or elements of a skeleton join. Ligaments - Bands of fibrous tissue connecting bones and cartilage, serving to support and strengthen joints. Lumbar - Of, near, or relating to the part of the body between the lowest ribs and the hipbones. Phalanx - Any one of the bones of the fingers or toes. Sacral - Pertaining to the sacrum, the part of the spinal column that is directly connected with or forms a part of the pelvis and that in humans consists of five fused vertebrae. Serial - Of, pertaining to, consisting of, or occurring in a series rather than simultaneously. Substantial - Of or pertaining to the essence of a thing; essential, material, or important. Tendon - A cord or band of dense, tough, inelastic, white, fibrous tissue, serving to connect a muscle with a bone or part. Torsion Bar Braces (Denis Brown splint) - Splint utilized on the feet to correct abnormal rotation of the foot (e.g. clubfoot). Vascular - To be characterized by or containing vessels that carry or circulate fluids, such as blood or lymph fluid, throughout the body of an animal. Volar Plate - Fibrocartilaginous structure firmly attached to the base of the phalanx.



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References

American Academy of Orthopedic Surgeons (AAOS) Website. AAOS now. Splints as good as casts in some wrist fractures. July 2010. Available at: http://www.aaos.org. Accessed April 14, 2011. American Academy of Orthopedic Surgeons (AAOS) Website. Your orthopedic connection. Arthritis of the knee. October 2007. Available at: http://www.aaos.org. Accessed April 14, 2011. American Academy of Orthopedic Surgeons (AAOS) Website. Your orthopedic connection. Hammer toe. November 2000. Available at: http://www.aaos.org. Accessed April 14, 2011. American Academy of Orthopedic Surgeons (AAOS) Website. Your orthopedic connection. Orthotics. July 2002. Available at: http://www.aaos.org. Accessed April 14, 2011. American Academy of Orthopedic Surgeons (AAOS) Website. Your orthopedic connection. Treatment for scoliosis. March 2011. Available at: http://www.aaos.org. Accessed April 14, 2011. American Academy of Pediatrics (AAP) Website. Healthy children: scoliosis. August 13, 2010. Available at: http://www.aap.org. Acessed April 15, 2011. American College of Foot and Ankle Surgeons (ACFAS) Website. Pediatric flatfoot. March 31, 2010. Available at: http://www.acfas.org. Accessed April 15, 2011. Hayes, Winifred S. Directory Report. Cranial orthotic devices. March 25, 2011. Available at: http://www.hayesinc.com. Accessed April 14, 2011. MD Consult Website. Ballow LR, Wang B. Modalities of therapy in rheumatic disease. In: Kelley’s Textbook of Rheumatology. St. Louis, MO; Saunders: 2008. Available at: http://www.mdconsult.com. Accessed April 15, 2011. MD Consult Website. Borom AH, Clanton TO. Sports shoes and orthoses. In: DeLee and Drez’s Orthopedic Sports Medicine. St. Louis, MO; Saunders: 2009. Available at: http://www.mdconsult.com. Accessed April 15, 2011. MD Consult Website. Freeman BL. Scoliosis and kyphosis. In: Campbell’s Operative Orthopedics. St. Louis, MO; Saunders: 2007. Available at:






http://www.aap.org/

http://www.acfas.org/

http://www.hayesinc.com/

http://www.mdconsult.com/




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http://www.mdconsult.com. Accessed April 15, 2011. MD Consult Website. Wilkins AN, Phillips EM. In: Essentials of Physical Medicine and Rehabilitation. St. Louis, MO; Saunders: 2008. Available at: http://www.mdconsult.com. Accessed April 15, 2011. Milliman Care Guidelines® 14th Edition. Cranial orthotic devices. Available at: http://chi.careguidelines.com/login-careweb.htm. Accessed March 14, 2011. Milliman Care Guidelines® 14th Edition. Foot orthotics, custom. Available at: http://chi.careguidelines.com/login-careweb.htm. Accessed March 14, 2011. Milliman Care Guidelines® 14th Edition. Hallux valgus/bunions – referral management. Available at: http://chi.careguidelines.com/login-careweb.htm. Accessed March 14, 2011. Milliman Care Guidelines® 14th Edition. Lower extremity soft tissue dysfunction rehabilitation. Available at: http://chi.careguidelines.com/login-careweb.htm. Accessed March 14, 2011. National Diabetes Information Clearinghouse (NDIC) Website. Diabetes overview. November 2008. Available at: http://www.diabetes.niddk.nih.gov. Accessed April 18, 2011. National Guideline Clearinghouse (NGC) Website. American College of Foot and Ankle Surgeons. The diagnosis and treatment of heel pain: a clinical practice guideline. May 2010. Available at: http://www.guideline.gov. Accessed April 14, 2011. National Institute of Neurological Disorders and Stroke (NINDS) Website. Low back pain fact sheet. February 18, 2011. Available at: http://www.ninds.nih.gov. Accessed April 18, 2011. National Institute of Neurological Disorders and Stroke (NINDS) Website. Spina bifida fact sheet. February 18, 2011. Available at: http://www.ninds.nih.gov. Accessed April 18, 2011. National Library of Medicine Website. Medline Plus. Foot Injuries and Disorders. April 2, 2011. Available at: http://www.nlm.nih.gov. Accessed April



http://chi.careguidelines.com/login-careweb.htm




http://www.diabetes.niddk.nih.gov/

http://www.guideline.gov/

http://www.ninds.nih.gov/

http://www.ninds.nih.gov/

http://www.nlm.nih.gov/



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15, 2011. UpToDate® Website. Ankle sprain. January 2011. Available at: http://www.uptodate.com/home/index.html. Accessed April 13, 2011. UpToDate® Website. Hallux valgus deformity (bunion). January 2011. Available at: http://www.uptodate.com/home/index.html. Accessed April 13, 2011. UpToDate® Website. Nonpharmacologic therapy of osteoarthritis. January 2011. Available at: http://www.uptodate.com/home/index.html. Accessed April 13, 2011. UpToDate® Website. Orthopedic issues in myelomeningocele (spina bifida). January 2011. Available at: http://www.uptodate.com/home/index.html. Accessed April 13, 2011. UpToDate® Website. Overview of hyperkyphosis in older persons. January 2011. Available at: http://www.uptodate.com/home/index.html. Accessed April 13, 2011. UpToDate® Website. Overview of running injuries of the lower extremity. January 2011. Available at: http://www.uptodate.com/home/index.html. Accessed April 13, 2011. UpToDate® Website. Patellofemoral pain syndrome. January 2011. Available at: http://www.uptodate.com/home/index.html. Accessed April 13, 2011. UpToDate® Website. Plantar fasciitis and other causes of heel and sole pain. January 2011. Available at: http://www.uptodate.com/home/index.html. Accessed April 13, 2011. UpToDate® Website. Treatment and prognosis of adolescent idiopathic scoliosis. January 2011. Available at: http://www.uptodate.com/home/index.html. Accessed April 13, 2011.

http://www.uptodate.com/home/index.html









medical coverage policy - aaos coverage policy effective date: 01/01/2012 ... the version of this...

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