RT/LT MODIFIER REQUIREMENT WILL BE IMPLEMENTED October 1 ... · GA Medicaid Orthotic & Prosthetic...

GA Medicaid Orthotic & Prosthetic (O&P) Services Fee ScheduleEffective Date: October 1, 2017

New or Revision Date

Functional Level Required CODE DESCRIPTION

Maximum Allowed

Pricing Modifier

RT/LT Modifiers

(Left/Right) Required

MAX Units

Billing period

PA REQUIRED Certification Required

Under 21 (or specified age) Only

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 49.53 LT-1

RT-1 2 1 yearYes CPed, CO

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 148.56 LT-1

RT-1 2 1 yearYes CO

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 22.03 LT-1


A5504 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH WEDGE(S), PER SHOE 22.03 LT-1


A5505 FOR DIABETICS ONLY, MODIFICATION (INCLUDING FITTING) OF OFF-THE-SHELF DEPTH-INLAY SHOE OR CUSTOM-MOLDED SHOE WITH METATARSAL BAR, PER SHOE 22.03 LT-1


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 22.03 LT-1


10/15

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 1/4 INCH MATERIAL OF SHORE A 35 DUROMETER OR 3/16 INCH MATERIAL OF SHORE A 40 DUROMETER (OR HIGHER), PREFABRICATED, EACH (1 PER SIX MONTHS)

20.20LT-2 RT-2 4 1 year

Yes CPed, CO

10/15

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 3/16 INCH MATERIAL OF SHORE A 35 DUROMETER OR HIGHER), INCLUDES ARCH FILLER AND OTHER SHAPING MATERIAL, CUSTOM FABRICATED, EACH (1 PER SIX MONTHS

30.15LT-2 RT-2 4 1 year

Yes CO

A8000 HELMET, PROTECTIVE, SOFT, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES 153.35 2 1 year No ABC CO/CP ABC clinical < 21 yrsA8001 HELMET, PROTECTIVE, HARD, PREFABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES 153.35 2 1 year No ABC CO/CP ABC clinical < 21 yrsA8002 HELMET, PROTECTIVE, SOFT, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES 800.00 2 1 year Yes ABC CO/CP < 21 yrsA8003 HELMET, PROTECTIVE, HARD, CUSTOM FABRICATED, INCLUDES ALL COMPONENTS AND ACCESSORIES 800.00 2 1 year Yes ABC CO/CP < 21 yrs

L0112 CRANIAL CERVICAL ORTHOSIS, CONGENITAL TORTICOLLIS TYPE, WITH OR WITHOUT SOFT INTERFACE MATERIAL, ADJUSTABLE RANGE OF MOTION JOINT, CUSTOM FABRICATED 945.27

1 1 yearYes ABC CO

< 21 yrsL0120 CERVICAL, FLEXIBLE, NON-ADJUSTABLE, PREFABRICATED, OFF-THE-SHELF (FOAM COLLAR) 18.90 1 2 months No FitterL0130 CERVICAL, FLEXIBLE, THERMOPLASTIC COLLAR, MOLDED TO PATIENT 136.63 1 1 year Yes COL0140 CERVICAL, SEMI-RIGID, ADJUSTABLE (PLASTIC COLLAR) 47.14 1 4 months No FitterL0150 78.62 1 1 year No FitterL0160 CERVICAL, SEMI-RIGID, WIRE FRAME OCCIPITAL/MANDIBULAR SUPPORT, PREFABRICATED, OFF-THE-SHELF 111.94 1 1 year No FitterL0170 CERVICAL, COLLAR, MOLDED TO PATIENT MODEL 473.70 1 1 year Yes COL0172 CERVICAL, COLLAR, SEMI-RIGID THERMOPLASTIC FOAM, TWO-PIECE, PREFABRICATED, OFF-THE-SHELF 96.05 1 1 year No Fitter

L0174 CERVICAL, COLLAR, SEMI-RIGID, THERMOPLASTIC FOAM, TWO PIECE WITH THORACIC EXTENSION, PREFABRICATED, OFF-THE-SHELF 172.54

1 1 yearNo NCPA (NARD)

L0180 CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE 234.66 1 1 year No NCPA (NARD)

L0190 CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE CERVICAL BARS (SOMI, GUILFORD, TAYLOR TYPES)

353.241 1 year

No NCPA (NARD)

L0200 CERVICAL, MULTIPLE POST COLLAR, OCCIPITAL/MANDIBULAR SUPPORTS, ADJUSTABLE CERVICAL BARS, AND THORACIC EXTENSION 324.35

1 1 yearNo NCPA (NARD)

L0220 THORACIC, RIB BELT, CUSTOM FABRICATED 76.93 1 1 year No Fitter

L0430 SPINAL ORTHOSIS, ANTERIOR-POSTERIOR-LATERAL CONTROL, WITH INTERFACE MATERIAL, CUSTOM FITTED (DEWALL POSTURE PROTECTOR ONLY) 939.43

1 3 yearsYes CO

L0450TLSO, 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, OFF-THE-SHELF

126.991 2 years

No NCPA (NARD)

10/15

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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

234.23

1Case-By-Case

Yes CO

L0455

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, OFF-THE-SHELF

263.04

1 2 years

Yes CO

10/15

L0456TLSO, 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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

671.72

1Case-By-Case

Yes CO

L0457

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, OFF-THE-SHELF

754.39

1 2 years

Yes CO

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 TRANVERSE PLANES, LATERAL STRENGTH IS PROVIDED BY OVERLAPPING PLASTIC AND STABILIZING CLOSURES, INCLUDES STRAPS AND CLOSURES, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

602.33

1 2 years

Yes CO

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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

677.97

1 2 years

Yes CO

L0462TLSO, 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

843.28

1 2 years

Yes CO

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

1003.91

1 2 years

Yes CO

L0466TLSO, 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, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

258.14

1 3 years

Yes CO

L0467 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, PREFABRICATED, OFF-THE-SHELF

289.91

1 2 years

Yes CO

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, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

323.65

1 3 years

Yes CO

L0469

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, PREFABRICATED, OFF-THE-SHELF

363.47

1 2 years

Yes CO

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

460.79

1 2 years

Yes CO

RT/LT MODIFIER REQUIREMENT WILL BE IMPLEMENTED October 1, 2015 Reminder* The RT/LT modifiers must be used when billing codes that require the use of these modifiers. Claims billed without required modifiers will be denied.

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

289.23

1 2 years

Yes CO

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 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

894.38

1 3 years

Yes CO

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

1025.28

1 3 years

Yes CO

L0484TLSO, 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

1195.46

1 3 years

Yes CO

L0486TLSO, 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

1184.24

1 3 years

Yes CO

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

677.97

1 2 years

Yes CO

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 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

191.05

1 2 years

Yes CO

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

518.68

1 2 years

Yes CO

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

336.15

1 2 years

Yes CO

L0621 SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF

60.221 1 year

No Fitter

L0622 SACROILIAC ORTHOSIS, FLEXIBLE, PROVIDES PELVIC-SACRAL SUPPORT, REDUCES MOTION ABOUT THE SACROILIAC JOINT, INCLUDES STRAPS, CLOSURES, MAY INCLUDE PENDULOUS ABDOMEN DESIGN, CUSTOM FABRICATED 163.30

1 3 yearsNo NCPA (NARD)

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, OFF-THE-SHELF

37.22

1 1 year

No Fitter

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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

52.65

1 1 years

No Fitter

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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

277.62

1 2 years

Yes NCPA (NARD)

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, OFF-THE-SHELF

56.65

1 1 year

No Fitter

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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

109.37

1 2 years

No Fitter

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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

693.32

1 3 years

Yes CO

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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

193.66

1 2 years

No CO, NCPA (NARD)

L0635LUMBAR-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 INCLUDE PADDING, ANTERIOR PANEL, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

718.18

1 3 years

Yes CO

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

1059.70

1 3 years

Yes CO

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 INCLUDE PADDING, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

919.44

1 2 years

Yes CO

10/15

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

890.76

1Case-By-Case

Yes CO

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 XYPHOID, 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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

919.44

1 2 years

Yes CO

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 XYPHOID, 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

706.72

1 3 years

Yes CO

L0643

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, OFF-THE-SHELF

122.82

1 2 years

No Fitter

L0648

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, OFF-THE-SHELF

778.66

1 2 years

Yes CO

L0649

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, OFF-THE-SHELF

217.50

1 2 years

No NCPA (NARD)

L0650

LUMBAR-SACRAL ORTHOSIS, SAGITTAL-CORONAL CONTROL, WITH RIGID ANTERIOR AND 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, SHOULDER STRAPS, PENDULOUS ABDOMEN DESIGN, PREFABRICATED, OFF-THE-SHELF

1032.59

1 2 years

Yes CO

L0651

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 XYPHOID, 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, OFF-THE-SHELF

1032.59

1 2 years

Yes CO

L0700 CERVICAL-THORACIC-LUMBAR-SACRAL-ORTHOSES (CTLSO), ANTERIOR-POSTERIOR-LATERAL CONTROL, MOLDED TO PATIENT MODEL, (MINERVA TYPE) 1454.10

1 2 yearsYes CO

L0710 CTLSO, ANTERIOR-POSTERIOR-LATERAL-CONTROL, MOLDED TO PATIENT MODEL, WITH INTERFACE MATERIAL, (MINERVA TYPE) 1587.26

1 2 yearsYes CO

L0810 HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO JACKET VEST 1686.22 1 2 years Yes COL0820 HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO PLASTER BODY JACKET 1364.08 1 2 years Yes COL0830 HALO PROCEDURE, CERVICAL HALO INCORPORATED INTO MILWAUKEE TYPE ORTHOSIS 1969.58 1 2 years Yes CO

L0859 ADDITION TO HALO PROCEDURE, MAGNETIC RESONANCE IMAGE COMPATIBLE SYSTEMS, RINGS AND PINS, ANY MATERIAL 765.171 1 year

Yes CO

L0861 ADDITION TO HALO PROCEDURE, REPLACEMENT LINER/INTERFACE MATERIAL 145.58 1 1 year Yes COL0970 THORACIC-LUMBAR-SACRAL ORTHOTIC (TLSO), CORSET FRONT 71.78 1 1 year No NCPA (NARD)L0972 LUMBAR-SACRAL ORTHOTIC (LSO), CORSET FRONT 73.38 1 1 year No NCPA (NARD)L0974 THORACIC-LUMBAR-SACRAL ORTHOTIC (TLSO), FULL CORSET 149.94 1 1 year No FitterL0976 LUMBAR-SACRAL ORTHOTIC (LSO), FULL CORSET 133.90 1 1 year No FitterL0978 AXILLARY CRUTCH EXTENSION 120.90 2 1 year No NCPA (NARD)L0980 PERONEAL STRAPS, PREFABRICATED, OFF-THE-SHELF, PAIR 10.97 1 1 year No FitterL0982 STOCKING SUPPORTER GRIPS, PREFABRICATED, OFF-THE-SHELF, SET OF FOUR (4) 11.95 1 1 year No FitterL0984 PROTECTIVE BODY SOCK, PREFABRICATED, OFF-THE-SHELF, EACH 38.14 3 6 months No Fitter

L1000 CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS, INCLUDING MODEL 1275.19

1 1 yearYes ABCO only

< 21 yrsL1005 TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, INCLUDES FITTING AND ADJUSTMENT 2161.65 1 1 year Yes ABCO onlyL1010 ADDITION TO CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) OR SCOLIOSIS ORTHOSIS, AXILLA SLING 51.35 2 1 year Yes ABCO only < 21 yrsL1020 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD 70.16 2 1 year Yes ABCO only < 21 yrsL1025 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD, FLOATING 79.74 1 1 year Yes ABCO only < 21 yrsL1030 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR BOLSTER PAD 53.28 1 1 year Yes ABCO only < 21 yrsL1040 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR OR LUMBAR RIB PAD 64.13 1 1 year Yes ABCO only < 21 yrsL1050 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, STERNAL PAD 55.53 1 1 year Yes ABCO only < 21 yrsL1060 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, THORACIC PAD 62.63 1 1 year Yes ABCO only < 21 yrsL1070 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, TRAPEZIUS SLING 64.02 2 1 year Yes ABCO only < 21 yrsL1080 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER 44.37 2 1 year Yes ABCO only < 21 yrsL1085 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER, BILATERAL WITH VERTICAL EXTENSIONS 123.26 1 1 year Yes ABCO only < 21 yrsL1090 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR SLING 57.58 1 1 year Yes ABCO only < 21 yrsL1100 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER 101.64 2 1 year Yes ABCO only < 21 yrsL1110 ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER, MOLDED TO PATIENT MODEL 172.14 2 1 year Yes ABCO only < 21 yrsL1120 ADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, COVER FOR UPRIGHT, EACH 27.42 3 1 year Yes ABCO only < 21 yrs

07/16L1200 THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS ONLY 1091.56

1Case-By-Case Yes ABCO only

< 21 yrs

10/15L1210 ADDITION TO TLSO, (LOW PROFILE), LATERAL THORACIC EXTENSION 164.35

2Case-By-Case Yes ABCO only

< 21 yrsL1220 ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC EXTENSION 139.15 1 3 years Yes ABCO only < 21 yrsL1230 ADDITION TO TLSO, (LOW PROFILE), MILWAUKEE TYPE SUPERSTRUCTURE 357.05 1 3 years Yes ABCO only < 21 yrsL1240 ADDITION TO TLSO, (LOW PROFILE), LUMBAR DEROTATION PAD 61.45 1 1 year Yes ABCO only < 21 yrsL1250 ADDITION TO TLSO, (LOW PROFILE), ANTERIOR ASIS PAD 60.50 2 1 year Yes ABCO only < 21 yrsL1260 ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC DEROTATION PAD 62.17 1 1 year Yes ABCO only < 21 yrsL1270 ADDITION TO TLSO, (LOW PROFILE), ABDOMINAL PAD 62.09 3 1 year Yes ABCO only < 21 yrsL1280 ADDITION TO TLSO, (LOW PROFILE), RIB GUSSET (ELASTIC), EACH 55.35 2 1 year Yes ABCO only < 21 yrsL1290 ADDITION TO TLSO, (LOW PROFILE), LATERAL TROCHANTERIC PAD 62.76 2 1 year Yes ABCO only < 21 yrsL1300 OTHER SCOLIOSIS PROCEDURE, BODY JACKET MOLDED TO PATIENT MODEL 1049.20 1 1 year Yes ABCO only < 21 yrs

L1310OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET

1079.621

1 year (surgery required)

Yes ABCO only< 21 yrs

04/15 L1499 SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED BR ----- 1 ----- Yes ABCO only

04/16L1600

HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, FREJKA TYPE WITH COVER, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INIDIVIDUAL WITH EXPERTISE 80.90 1 1-2 years No Fitter < 21 yrs

04/16L1610

HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (FREJKA COVER ONLY), PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

27.581 1-2 years

No Fitter< 21 yrs

04/16L1620

HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, FLEXIBLE, (PAVLIK HARNESS), PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

90.811 1-2 years

No Fitter< 21 yrs

04/16 L1630 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, SEMI-FLEXIBLE (VON ROSEN TYPE), CUSTOM-FABRICATED 108.35 1 1-2 years No NCPA (NARD) < 21 yrs

04/16L1640 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, PELVIC BAND OR SPREADER BAR, THIGH CUFFS, CUSTOM-

FABRICATED 289.821 1-2 years

No NCPA (NARD)< 21 yrs

04/16L1650 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, STATIC, ADJUSTABLE, (ILFLED TYPE), PREFABRICATED, INCLUDES

FITTING AND ADJUSTMENT 153.691 1-2 years


04/16L1652 HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BAR, ADULT SIZE, PREFABRICATED,

INCLUDES FITTING AND ADJUSTMENT, ANY TYPE 240.751 3 years

Yes CO< 21 yrs

04/16L1660 HIP ORTHOSIS, BILATERAL THIGH CUFFS WITH ADJUSTABLE ABDUCTOR SPREADER BAR, ADULT SIZE, PREFABRICATED,

INCLUDES FITTING AND ADJUSTMENT, ANY TYPE 107.491 3 years


04/16L1680 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINTS, DYNAMIC, PELVIC CONTROL, ADJUSTABLE HIP MOTION CONTROL,

THIGH CUFFS (RANCHO HIP ACTION TYPE), CUSTOM FABRICATED883.73

1 1-2 yearsYes CO

< 21 yrs04/16 L1685 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, CUSTOM FABRICATED 932.48 1 1-2 years Yes CO < 21 yrs

04/16L1686 HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, PREFABRICATED, INCLUDES

FITTING AND ADJUSTMENT 625.581 1-2 years

Yes CO

04/16L1690 COMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDUCTION AND INTERNAL ROTATION

CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 1306.021 1-2 years

Yes CO

L1700 LEGG PERTHES ORTHOSIS, (TORONTO TYPE), CUSTOM-FABRICATED 1086.52 1 2 years Yes CO < 21 yrsL1710 LEGG PERTHES ORTHOSIS, (NEWINGTON TYPE), CUSTOM FABRICATED 1277.14 1 2 years Yes CO < 21 yrsL1720 LEGG PERTHES ORTHOSIS, TRILATERAL, (TACHDIJAN TYPE), CUSTOM-FABRICATED 943.42 2 2 years Yes CO < 21 yrsL1730 LEGG PERTHES ORTHOSIS, (SCOTTISH RITE TYPE), CUSTOM-FABRICATED 711.80 1 2 years Yes CO < 21 yrsL1755 LEGG PERTHES ORTHOSIS, (PATTEN BOTTOM TYPE), CUSTOM-FABRICATED 1036.02 2 2 years Yes CO < 21 yrs

L1810 KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 81.77

LT-1 RT-1 2 2 years No Fitter

L1812 KNEE ORTHOSIS, ELASTIC WITH JOINTS, PREFABRICATED, OFF-THE-SHELF 91.83LT-1 RT-1 2 2 years No

Fitter

L1820 KNEE ORTHOSIS, ELASTIC WITH CONDYLAR PADS AND JOINTS, WITH OR WITHOUT PATELLAR CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 81.44 LT-1

RT-1 2 2 yearsNo Fitter

10/15L1830 KNEE ORTHOSIS, IMMOBILIZER, CANVAS LONGITUDINAL, PREFABRICATED, OFF-THE-SHELF 68.13 LT-1

RT-1 2Case-By-Case No Fitter

L1831 KNEE ORTHOSIS, LOCKING KNEE JOINT(S), POSITIONAL ORTHOSIS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 198.77 LT-1 RT-1 2 2 years

No Fitter

L1832KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

509.15 LT-1 RT-1 2 2 years

Yes CO

L1833 KNEE ORTHOSIS, ADJUSTABLE KNEE JOINTS (UNICENTRIC OR POLYCENTRIC), POSITIONAL ORTHOSIS, RIGID SUPPORT, PREFABRICATED, OFF-THE SHELF 571.82

LT-1 RT-1 2 2 years Yes CO

L1834 KNEE ORTHOSIS, WITHOUT KNEE JOINT, RIGID, CUSTOM-FABRICATED 599.00 LT-1 RT-1 2 3 years

Yes CO

L1836 KNEE ORTHOSIS, RIGID, WITHOUT JOINT(S), INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF 90.11 LT-1 RT-1 2 3 years

No NCPA (NARD)

L1840 KNEE ORTHOSIS, DEROTATION, MEDIAL-LATERAL, ANTERIOR CRUCIATE LIGAMENT, CUSTOM FABRICATED 629.66 LT-1 RT-1 2 3 years

Yes CO

L1843

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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

605.99LT-1 RT-1 2 3 years

Yes CO

L1844KNEE 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

1050.04 LT-1 RT-1 2 3 years

Yes CO

L1845

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 ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

632.60LT-1 RT-1 2 3 years

Yes CO

L1846KNEE 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

792.86 LT-1 RT-1 2 3 years

Yes CO

L1847KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR SUPPORT CHAMBER(S), PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

388.46 LT-1 RT-1 2 3 years

Yes CO

L1848 KNEE ORTHOSIS, DOUBLE UPRIGHT WITH ADJUSTABLE JOINT, WITH INFLATABLE AIR SUPPORT CHAMBER(S), PREFABRICATED, OFF-THE-SHELF 463.27


L1850 KNEE ORTHOSIS, SWEDISH TYPE, PREFABRICATED, OFF-THE-SHELF 180.79LT-1 RT-1 2 2 years Yes CO

L1860KNEE ORTHOSIS, MODIFICATION OF SUPRACONDYLAR PROSTHETIC SOCKET, CUSTOM-FABRICATED (SK) 701.22


L1900 ANKLE FOOT ORTHOSIS, SPRING WIRE, DORSIFLEXION ASSIST CALF BAND, CUSTOM-FABRICATED 189.97 LT-1 RT-1 2 1 year

Yes CO

01/16L1902 ANKLE ORTHOSIS, ANKLE GAUNTLET OR SIMILAR, WITH OR WITHOUT JOINTS, PREFABRICATED, OFF-THE-SHELF 51.59 LT-1

RT-1 2 1 yearNo Fitter

01/16L1904 ANKLE ORTHOSIS, ANKLE GAUNTLET OR SIMILAR, WITH OR WITHOUT JOINTS, CUSTOM FABRICATED 295.37 LT-1

RT-1 2 1 yearYes CO

L1906 ANKLE FOOT ORTHOSIS, MULTILIGAMENTUS ANKLE SUPPORT, PREFABRICATED, OFF-THE-SHELF 86.31 LT-1 RT-1 2 1 year

Yes CO

10/15L1907 ANKLE ORTHOSIS, SUPRAMALLEOLAR WITH STRAPS, WITH OR WITHOUT INTERFACE/PADS, CUSTOM FABRICATED 380.03 LT-1

RT-1 2Case-By-Case Yes CO

L1910 ANKLE FOOT ORTHOSIS, POSTERIOR, SINGLE BAR, CLASP ATTACHMENT TO SHOE COUNTER, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 167.97 LT-1

RT-1 2 1 yearYes CO

L1920 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT WITH STATIC OR ADJUSTABLE STOP (PHELPS OR PERLSTEIN TYPE), CUSTOM-FABRICATED 219.58 LT-1

RT-1 2 1 yearYes CO

L1930 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 148.58 LT-1 RT-1 2 1 year

No NCPA (NARD)

L1932 AFO, RIGID ANTERIOR TIBIAL SECTION, TOTAL CARBON FIBER OR EQUAL MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 602.67 LT-1

RT-1 2 1 yearYes CO

L1940 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL, CUSTOM-FABRICATED 335.78 LT-1 RT-1 2 1 year

Yes CO

10/15L1945 ANKLE FOOT ORTHOSIS, PLASTIC, RIGID ANTERIOR TIBIAL SECTION (FLOOR REACTION), CUSTOM-FABRICATED 616.64 LT-1


L1950 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC, CUSTOM-FABRICATED 467.84 LT-1 RT-1 2 1 year

Yes CO

L1951 ANKLE FOOT ORTHOSIS, SPIRAL, (INSTITUTE OF REHABILITATIVE MEDICINE TYPE), PLASTIC OR OTHER MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 567.20 LT-1

RT-1 2 1 yearYes CO

10/15L1960 ANKLE FOOT ORTHOSIS, POSTERIOR SOLID ANKLE, PLASTIC, CUSTOM-FABRICATED 348.15 LT-1


10/15L1970 ANKLE FOOT ORTHOSIS, PLASTIC WITH ANKLE JOINT, CUSTOM-FABRICATED 514.93 LT-1


L1971 ANKLE FOOT ORTHOSIS, PLASTIC OR OTHER MATERIAL WITH ANKLE JOINT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 316.57 LT-1

RT-1 2 1 yearYes CO

L1980 ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (SINGLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATED 230.52 LT-1

RT-1 2 1 yearYes CO

L1990 ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT FREE PLANTAR DORSIFLEXION, SOLID STIRRUP, CALF BAND/CUFF (DOUBLE BAR 'BK' ORTHOSIS), CUSTOM-FABRICATED 296.18 LT-1

RT-1 2 1 yearYes CO

07/16L2000 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE KNEE, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS

(SINGLE BAR 'AK' ORTHOSIS), CUSTOM-FABRICATED 637.07 LT-1 RT-1 2

Case-By-Case Yes CO

07/16L2005 KNEE ANKLE FOOT ORTHOSIS, ANY MATERIAL, SINGLE OR DOUBLE UPRIGHT, STANCE CONTROL, AUTOMATIC LOCK AND

SWING PHASE RELEASE, ANY TYPE ACTIVATION, INCLUDES ANKLE JOINT, ANY TYPE, CUSTOM FABRICATED 2767.52 LT-1 RT-1 2

Case-By-Case Yes CO

07/16L2010 KNEE ANKLE FOOT ORTHOSIS, SINGLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (SINGLE

BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM-FABRICATED580.75 LT-1

RT-1 2Case-By-Case

Yes CO

07/16L2020 KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS (DOUBLE

BAR 'AK' ORTHOSIS), CUSTOM-FABRICATED 733.40 LT-1 RT-1 2

Case-By-Case Yes CO

07/16L2030 KNEE ANKLE FOOT ORTHOSIS, DOUBLE UPRIGHT, FREE ANKLE, SOLID STIRRUP, THIGH AND CALF BANDS/CUFFS, (DOUBLE

BAR 'AK' ORTHOSIS), WITHOUT KNEE JOINT, CUSTOM FABRICATED 636.29 LT-1 RT-1 2

Case-By-Case Yes CO

07/16L2034 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, MEDIAL LATERAL

ROTATION CONTROL, WITH OR WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED 1386.76 LT-1 RT-1 2

Case-By-Case Yes CO

07/16L2035 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, STATIC (PEDIATRIC SIZE), WITHOUT FREE MOTION ANKLE, PREFABRICATED,

INCLUDES FITTING AND ADJUSTMENT 117.00 LT-1 RT-1 2

Case-By-Case Yes CO

< 21 yrs

10/15L2036 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, DOUBLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR

WITHOUT FREE MOTION ANKLE, CUSTOM FABRICATED 1165.33 LT-1 RT-1 2

Case-By-Case Yes CO

10/15L2037 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, SINGLE UPRIGHT, WITH OR WITHOUT FREE MOTION KNEE, WITH OR WITHOUT

FREE MOTION ANKLE, CUSTOM FABRICATED 1073.92 LT-1 RT-1 2

Case-By-Case Yes CO

07/16L2038 KNEE ANKLE FOOT ORTHOSIS, FULL PLASTIC, WITH OR WITHOUT FREE MOTION KNEE, MULTI-AXIS ANKLE, CUSTOM

FABRICATED 898.02 LT-1 RT-1 2

Case-By-Case Yes CO

10/15L2040 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL ROTATION STRAPS, PELVIC BAND/BELT, CUSTOM

FABRICATED 114.701

Case-By-Case Yes CO

< 21 yrs

07/16L2050 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, HIP JOINT, PELVIC BAND/BELT,

CUSTOM-FABRICATED 305.481

Case-By-Case Yes CO

< 21 yrs

07/16L2060 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, BILATERAL TORSION CABLES, BALL BEARING HIP JOINT, PELVIC

BAND/ BELT, CUSTOM-FABRICATED 392.061

Case-By-Case Yes CO

< 21 yrs

07/16L2070 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL ROTATION STRAPS, PELVIC BAND/BELT, CUSTOM

FABRICATED 112.621

Case-By-Case Yes CO

< 21 yrs

07/16L2080 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, HIP JOINT, PELVIC BAND/BELT,

CUSTOM-FABRICATED 240.181

Case-By-Case Yes CO

< 21 yrs

07/16L2090 HIP KNEE ANKLE FOOT ORTHOSIS, TORSION CONTROL, UNILATERAL TORSION CABLE, BALL BEARING HIP JOINT, PELVIC

BAND/ BELT, CUSTOM-FABRICATED 296.061

Case-By-Case Yes CO

< 21 yrs

L2106 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED 427.06 LT-1

RT-1 2 2 yearsYes CO

L2108 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED 671.10 LT-1 RT-1 2 2 years

Yes CO

L2112 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 318.65 LT-1


L2114 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 364.57 LT-1


L2116 ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, TIBIAL FRACTURE ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 480.34 LT-1


L2126 KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, THERMOPLASTIC TYPE CASTING MATERIAL, CUSTOM-FABRICATED 854.62 LT-1


L2128 KNEE ANKLE FOOT ORTHOSIS, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, CUSTOM-FABRICATED 1077.02 LT-1 RT-1 2 2 years

Yes CO

L2132 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SOFT, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 506.67 LT-1


L2134 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, SEMI-RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 607.48 LT-1


L2136 KAFO, FRACTURE ORTHOSIS, FEMORAL FRACTURE CAST ORTHOSIS, RIGID, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 742.79 LT-1


L2180 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, PLASTIC SHOE INSERT WITH ANKLE JOINTS 73.55 LT-1 RT-1 2 2 years

Yes CO

L2182ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, DROP LOCK KNEE JOINT

57.57 LT-2 RT-2 4 2 years

Yes CO

L2184ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, LIMITED MOTION KNEE JOINT

103.74 LT-2 RT-2 4 2 years

Yes CO

L2186 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, ADJUSTABLE MOTION KNEE JOINT, LERMAN TYPE 114.95 LT-2 RT-2 4 2 years

Yes CO

L2188ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, QUADRILATERAL BRIM 250.82

LT-1 RT-1 2 2 years

Yes CO

L2190 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, WAIST BELT 65.14 2 2 years Yes CO

L2192 ADDITION TO LOWER EXTREMITY FRACTURE ORTHOSIS, HIP JOINT, PELVIC BAND, THIGH FLANGE, AND PELVIC BELT 223.95 LT-1 RT-1 2 2 years

Yes CO

10/15L2200

ADDITION TO LOWER EXTREMITY, LIMITED ANKLE MOTION, EACH JOINT29.86 LT-2


10/15L2210 ADDITION TO LOWER EXTREMITY, DORSIFLEXION ASSIST (PLANTAR FLEXION RESIST), EACH JOINT 48.46 LT-2


L2220 ADDITION TO LOWER EXTREMITY, DORSIFLEXION AND PLANTAR FLEXION ASSIST/RESIST, EACH JOINT 55.64 LT-2 RT-2 4 1 year

Yes CO

L2230ADDITION TO LOWER EXTREMITY, SPLIT FLAT CALIPER STIRRUPS AND PLATE ATTACHMENT

48.19 LT-1 RT-1 2 1 year

Yes CO

L2232 ADDITION TO LOWER EXTREMITY ORTHOSIS, ROCKER BOTTOM FOR TOTAL CONTACT ANKLE FOOT ORTHOSIS, FOR CUSTOM FABRICATED ORTHOSIS ONLY 65.25 LT-1


L2240ADDITION TO LOWER EXTREMITY, ROUND CALIPER AND PLATE ATTACHMENT

52.53 LT-1 RT-1 2 2 years

Yes CO

L2250 ADDITION TO LOWER EXTREMITY, FOOT PLATE, MOLDED TO PATIENT MODEL, STIRRUP ATTACHMENT 223.18 LT-1 RT-1 2 2 years

Yes CO

L2260ADDITION TO LOWER EXTREMITY, REINFORCED SOLID STIRRUP (SCOTT-CRAIG TYPE)

125.91 LT-1 RT-1 2 2 years

Yes CO

L2265ADDITION TO LOWER EXTREMITY, LONG TONGUE STIRRUP

73.97 LT-1 RT-1 2 2 years

Yes CO

10/15L2270 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION ('T') STRAP, PADDED/LINED OR MALLEOLUS PAD 33.73 LT-1


10/15L2275 ADDITION TO LOWER EXTREMITY, VARUS/VALGUS CORRECTION, PLASTIC MODIFICATION, PADDED/LINED 82.07 LT-1


10/15L2280 ADDITION TO LOWER EXTREMITY, MOLDED INNER BOOT 304.91 LT-1


L2300 ADDITION TO LOWER EXTREMITY, ABDUCTION BAR (BILATERAL HIP INVOLVEMENT), JOINTED, ADJUSTABLE 172.11 1 1 year Yes COL2310 ADDITION TO LOWER EXTREMITY, ABDUCTION BAR-STRAIGHT 77.27 1 2 years Yes CO

L2320 ADDITION TO LOWER EXTREMITY, NON-MOLDED LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY 129.23 LT-1 RT-1 2 1 year

Yes CO

L2330 ADDITION TO LOWER EXTREMITY, LACER MOLDED TO PATIENT MODEL, FOR CUSTOM FABRICATED ORTHOSIS ONLY 246.63 LT-1 RT-1 2 1 year

Yes CO

L2335ADDITION TO LOWER EXTREMITY, ANTERIOR SWING BAND

145.09 LT-1 RT-1 2 3 years

Yes CO

10/15L2340

ADDITION TO LOWER EXTREMITY, PRE-TIBIAL SHELL, MOLDED TO PATIENT MODEL342.37 LT-1


L2350 ADDITION TO LOWER EXTREMITY, PROSTHETIC TYPE, (BK) SOCKET, MOLDED TO PATIENT MODEL, (USED FOR 'PTB' 'AFO' ORTHOSES) 559.66 LT-1

RT-1 2 1 yearYes CO

L2360ADDITION TO LOWER EXTREMITY, EXTENDED STEEL SHANK

32.50 LT-1 RT-1 2 2 years

Yes CO

L2370ADDITION TO LOWER EXTREMITY, PATTEN BOTTOM

161.24 LT-1 RT-1 2 3 years

Yes CO

L2375ADDITION TO LOWER EXTREMITY, TORSION CONTROL, ANKLE JOINT AND HALF SOLID STIRRUP

70.97 LT-1 RT-1 2 1 year

Yes CO

L2380ADDITION TO LOWER EXTREMITY, TORSION CONTROL, STRAIGHT KNEE JOINT, EACH JOINT

77.33 LT-1 RT-1 2 1 year

Yes CO

10/15L2385

ADDITION TO LOWER EXTREMITY, STRAIGHT KNEE JOINT, HEAVY DUTY, EACH JOINT84.13 LT-2


L2387 ADDITION TO LOWER EXTREMITY, POLYCENTRIC KNEE JOINT, FOR CUSTOM FABRICATED KNEE ANKLE FOOT ORTHOSIS, EACH JOINT 114.18 LT-2


10/15L2390

ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, EACH JOINT68.75 LT-2


L2395ADDITION TO LOWER EXTREMITY, OFFSET KNEE JOINT, HEAVY DUTY, EACH JOINT

104.98 LT-2 RT-2 4 1 year

Yes CO

L2397ADDITION TO LOWER EXTREMITY ORTHOSIS, SUSPENSION SLEEVE

73.62 LT-2 RT-2 4 1 year

Yes CO

10/15L2405

ADDITION TO KNEE JOINT, DROP LOCK, EACH58.89 LT-2


L2415 ADDITION TO KNEE LOCK WITH INTEGRATED RELEASE MECHANISM ( BAIL, CABLE, OR EQUAL), ANY MATERIAL, EACH JOINT 82.04 LT-2 RT-2 4 3 years

Yes CO

L2425ADDITION TO KNEE JOINT, DISC OR DIAL LOCK FOR ADJUSTABLE KNEE FLEXION, EACH JOINT

96.80 LT-2 RT-2 4 3 years

Yes CO

L2430 ADDITION TO KNEE JOINT, RATCHET LOCK FOR ACTIVE AND PROGRESSIVE KNEE EXTENSION, EACH JOINT 96.80 LT-2 RT-2 4 3 years

Yes CO

L2492ADDITION TO KNEE JOINT, LIFT LOOP FOR DROP LOCK RING

64.05 LT-2 RT-2 4 3 years

Yes CO

L2500 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, GLUTEAL/ ISCHIAL WEIGHT BEARING, RING 198.15 LT-1 RT-1 2 3 years

Yes CO

L2510 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, MOLDED TO PATIENT MODEL 530.53 LT-1 RT-1 2 3 years

Yes CO

L2520 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, QUADRI- LATERAL BRIM, CUSTOM FITTED 289.35 LT-1 RT-1 2 3 years

Yes CO

L2525 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM MOLDED TO PATIENT MODEL 992.71 LT-1


L2526 ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, ISCHIAL CONTAINMENT/NARROW M-L BRIM, CUSTOM FITTED 535.07 LT-1 RT-1 2 3 years

Yes CO

L2530ADDITION TO LOWER EXTREMITY, THIGH-WEIGHT BEARING, LACER, NON-MOLDED

147.58 LT-1 RT-1 2 3 years

Yes CO

L2540ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, LACER, MOLDED TO PATIENT MODEL

265.55 LT-1 RT-1 2 3 years

Yes CO

L2550ADDITION TO LOWER EXTREMITY, THIGH/WEIGHT BEARING, HIGH ROLL CUFF

180.39 LT-1 RT-1 2 3 years

Yes CO

L2580 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PELVIC SLING 378.13 2 3 years Yes CO

10/15L2600 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS TYPE, OR THRUST BEARING, FREE, EACH 128.99

2Case-By-Case Yes CO

L2610 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, CLEVIS OR THRUST BEARING, LOCK, EACH 152.54 2 3 years Yes CO

10/15L2620

ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, HEAVY DUTY, EACH167.94


L2622 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, ADJUSTABLE FLEXION, EACH 192.62 2 3 years Yes CO

L2624 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, HIP JOINT, ADJUSTABLE FLEXION, EXTENSION, ABDUCTION CONTROL, EACH

216.852 3 years

Yes CO

L2627 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, PLASTIC, MOLDED TO PATIENT MODEL, RECIPROCATING HIP JOINT AND CABLES 1078.81

1 3 yearsYes CO

10/15L2628 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, METAL FRAME, RECIPROCATING HIP JOINT AND CABLES 1267.26


L2630 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT, UNILATERAL 155.53 1 3 years Yes CO

10/15L2640 ADDITION TO LOWER EXTREMITY, PELVIC CONTROL, BAND AND BELT, BILATERAL 211.08


L2650 ADDITION TO LOWER EXTREMITY, PELVIC AND THORACIC CONTROL, GLUTEAL PAD, EACH 75.38 2 3 years Yes COL2660 ADDITION TO LOWER EXTREMITY, THORACIC CONTROL, THORACIC BAND 117.06 1 3 years Yes COL2670 ADDITION TO LOWER EXTREMITY, THORACIC CONTROL, PARASPINAL UPRIGHTS 107.14 1 3 years Yes CO

10/15L2680

ADDITION TO LOWER EXTREMITY, THORACIC CONTROL, LATERAL SUPPORT UPRIGHTS98.29

1 3 yearsCase-By-Case

CO

L2750ADDITION TO LOWER EXTREMITY ORTHOSIS, PLATING CHROME OR NICKEL, PER BAR

52.50 LT-1 RT-1 2 3 years

Yes CO

L2755 ADDITION TO LOWER EXTREMITY ORTHOSIS, HIGH STRENGTH, LIGHTWEIGHT MATERIAL, ALL HYBRID LAMINATION/PREPREG COMPOSITE, PER SEGMENT, FOR CUSTOM FABRICATED ORTHOSIS ONLY 88.26 LT-2


L2760 ADDITION TO LOWER EXTREMITY ORTHOSIS, EXTENSION, PER EXTENSION, PER BAR (FOR LINEAL ADJUSTMENT FOR GROWTH)

38.16 LT-2 RT-2 4 2 years

Yes CO

L2768 ORTHOTIC SIDE BAR DISCONNECT DEVICE, PER BAR 88.02LT-2 RT-2 4 3 years Yes CO

10/15L2780

ADDITION TO LOWER EXTREMITY ORTHOSIS, NON-CORROSIVE FINISH, PER BAR45.14 LT-4


L2785ADDITION TO LOWER EXTREMITY ORTHOSIS, DROP LOCK RETAINER, EACH

26.54 LT-2 RT-2 4 3 years

Yes CO

10/15L2795

ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, FULL KNEECAP53.37 LT-1

RT-1 2Case-By-Case

Yes CO

L2800 ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, KNEE CAP, MEDIAL OR LATERAL PULL, FOR USE WITH CUSTOM FABRICATED ORTHOSIS ONLY

66.99 LT-1 RT-1 2 1 year

Yes CO

10/15L2810

ADDITION TO LOWER EXTREMITY ORTHOSIS, KNEE CONTROL, CONDYLAR PAD49.06 LT-2

RT-2 4Case-By-Case

Yes CO

10/15L2820 ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, BELOW KNEE SECTION 54.54

LT-1 RT-1 2 6 months Yes CO

10/15L2830

ADDITION TO LOWER EXTREMITY ORTHOSIS, SOFT INTERFACE FOR MOLDED PLASTIC, ABOVE KNEE SECTION 61.34LT-1 RT-1 2

Case-By-Case

Yes CO

10/15 02/15 L2840 ADDITION TO LOWER EXTREMITY ORTHOSIS, TIBIAL LENGTH SOCK, FRACTURE OR EQUAL, EACH 34.22

LT-4 RT-4 8

Case-By-Case Yes CO

10/15 02/15 L2850 ADDITION TO LOWER EXTREMITY ORTHOSIS, FEMORAL LENGTH SOCK, FRACTURE OR EQUAL, EACH 38.89

LT-4 RT-4 8

Case-By-Case Yes CO

L2999 LOWER EXTREMITY ORTHOSES, NOT OTHERWISE SPECIFIED BR ----- 1 ----- Yes CO/CP

L3000FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, 'UCB' TYPE, BERKELEY SHELL, EACH

212.16 LT-1 RT-1 2 6 months

Yes CO, COA/CPA

10/15L3010 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL ARCH SUPPORT, EACH 117.67 LT-1

RT-1 2Case-By-Case Yes CO, COA/CPA

10/15L3020 FOOT, INSERT, REMOVABLE, MOLDED TO PATIENT MODEL, LONGITUDINAL/ METATARSAL SUPPORT, EACH 134.00 LT-1

RT-1 2Case-By-Case Yes CO, COA/CPA

L3030 FOOT, INSERT, REMOVABLE, FORMED TO PATIENT FOOT, EACH 51.54 LT-1 RT-1 2 6 months

Yes CO, COA/CPA

L3040 FOOT, ARCH SUPPORT, REMOVABLE, PREMOLDED, LONGITUDINAL, EACH 31.78 LT-1 RT-1 2 6 months

Yes Cped, CO, COA/CPA

10/15L3140 FOOT, ABDUCTION ROTATION BAR, INCLUDING SHOES 60.13

1Case-By-Case Yes NCPA (NARD), COA/CPA

< 21 yrs

10/15L3203 ORTHOPEDIC SHOE, OXFORD WITH SUPINATOR OR PRONATOR, JUNIOR 58.50 LT-1

RT-1 2Case-By-Case Yes CPed, CO, COA/CPA

< 21 yrs

10/15L3204 ORTHOPEDIC SHOE, HIGHTOP WITH SUPINATOR OR PRONATOR, INFANT 29.00 LT-1


< 21 yrs

10/15L3215 ORTHOPEDIC FOOTWEAR, LADIES SHOE, OXFORD, EACH 86.41 LT-1


07/16L3219 ORTHOPEDIC FOOTWEAR, MENS SHOE, OXFORD, EACH 90.00 LT-1


L3224 ORTHOPEDIC FOOTWEAR, WOMAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) 36.94 LT-1 RT-1 2 1 year

Yes CPed, CO, COA/CPA

L3225 ORTHOPEDIC FOOTWEAR, MAN'S SHOE, OXFORD, USED AS AN INTEGRAL PART OF A BRACE (ORTHOSIS) 42.49 LT-1 RT-1 2 1 year


L3250 ORTHOPEDIC FOOTWEAR, CUSTOM MOLDED SHOE, REMOVABLE INNER MOLD, PROSTHETIC SHOE, EACH 226.91 LT-1 RT-1 2 1 year

Yes CO/ CP, COA/CPA

L3310 LIFT, ELEVATION, HEEL AND SOLE, NEOPRENE, PER INCH 54.97 LT-2 RT-2 4 1 year

Yes Cped, CO, COA/CPA

L3332 LIFT, ELEVATION, INSIDE SHOE, TAPERED, UP TO ONE-HALF INCH 49.82 LT-2 RT-2 4 1 year


L3334 LIFT, ELEVATION, HEEL, PER INCH 25.77 LT-2 RT-2 4 1 year


L3400 METATARSAL BAR WEDGE, ROCKER 27.50 LT-2 RT-2 4 1 year


L3410 METATARSAL BAR WEDGE, BETWEEN SOLE 62.71 LT-2 RT-2 4 1 year


L3580 ORTHOPEDIC SHOE ADDITION, CONVERT INSTEP TO VELCRO CLOSURE 43.80 LT-1 RT-1 2 1 year


L3600 TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, EXISTING 51.54 LT-1 RT-1 2 1 year


L3610TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, CALIPER PLATE, NEW

67.86 LT-1 RT-1 2 1 year


L3620TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, EXISTING

51.54 LT-1 RT-1 2 1 year


L3630TRANSFER OF AN ORTHOSIS FROM ONE SHOE TO ANOTHER, SOLID STIRRUP, NEW

67.86 LT-1 RT-1 2 1 year


L3650 SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF 36.79 1 3 years No Fitter

L3660 SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, CANVAS AND WEBBING, PREFABRICATED, OFF-THE-SHELF 63.18

1 3 yearsNo Fitter

L3670 SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE), PREFABRICATED, OFF-THE-SHELF 88.06 1 3 years No NCPA (NARD)

L3671 SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 553.83

1 3 yearsYes CO

L3675 SHOULDER ORTHOSIS, VEST TYPE ABDUCTION RESTRAINER, CANVAS WEBBING TYPE OR EQUAL, PREFABRICATED, OFF-THE-SHELF 107.87


L3702 ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 177.48 LT-1


L3710ELBOW ORTHOSIS, ELASTIC WITH METAL JOINTS, PREFABRICATED, OFF-THE-SHELF

89.11 LT-1 RT-1 2 3 years

No NCPA (NARD)

L3720 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, FREE MOTION, CUSTOM-FABRICATED 444.60 LT-1 RT-1 2 3 years

Yes CO

L3730 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ FLEXION ASSIST, CUSTOM-FABRICATED 585.27 LT-1 RT-1 2 3 years

Yes CO

10/15L3740 ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE POSITION LOCK WITH ACTIVE CONTROL,

CUSTOM-FABRICATED 657.74 LT-1 RT-1 2

Case-By-Case Yes CO

L3760 ELBOW ORTHOSIS, WITH ADJUSTABLE POSITION LOCKING JOINT(S), PREFABRICATED, INCLUDES FITTING AND ADJUSTMENTS, ANY TYPE 307.38 LT-1


L3762 ELBOW ORTHOSIS, RIGID, WITHOUT JOINTS, INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF 66.10 LT-1 RT-1 2 5 years

No Fitter

L3763 ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 788.14 LT-1


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 499.82 LT-1


L3765 ELBOW WRIST HAND FINGER ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 788.14 LT-1


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 834.58 LT-1


10/15L3807 WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED,

ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 153.69 LT-1 RT-1 2

Case-By-Case Yes CO

L3808 WRIST HAND FINGER ORTHOSIS, RIGID WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE MATERIAL; STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 210.85 LT-1


L3809 WRIST HAND FINGER ORTHOSIS, WITHOUT JOINT(S), PREFABRICATED, OFF-THE-SHELF, ANY TYPE 172.62LT-1 RT-1 2 1 year Yes Fitter

L3900 WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/ FLEXION, FINGER FLEXION/EXTENSION, WRIST OR FINGER DRIVEN, CUSTOM-FABRICATED 960.19 LT-1


L3901 WRIST HAND FINGER ORTHOSIS, DYNAMIC FLEXOR HINGE, RECIPROCAL WRIST EXTENSION/ FLEXION, FINGER FLEXION/EXTENSION, CABLE DRIVEN, CUSTOM-FABRICATED 1076.63 LT-1


L3904 WRIST HAND FINGER ORTHOSIS, EXTERNAL POWERED, ELECTRIC, CUSTOM-FABRICATED 2191.73 LT-1 RT-1 2 3 years

Yes CO

L3905 WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 609.54 LT-1


10/15L3906 WRIST HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES

FITTING AND ADJUSTMENT 259.30 LT-1 RT-1 2 3 years Yes CO

01/14L3908 WRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED, PREFABRICATED, OFF-THE-SHELF 36.82 LT-1

RT-1 2 1 yearNo Fitter

L3909 WRIST HAND ORTHOSIS, WRIST EXTENSION CONTROL COCK-UP, NON MOLDED, PREFABRICATED, OFF-THE-SHELF 172.62 LT-1 RT-1 2 1 year

No Fitter

L3912 HAND FINGER ORTHOSIS (HFO), FLEXION GLOVE WITH ELASTIC FINGER CONTROL, PREFABRICATED, OFF-THE-SHELF 59.08 LT-1 RT-1 2 1 year

No NCPA (NARD)

L3913 HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 166.47 LT-1

RT-1 2 3 yearsNo CO

L3915 WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

335.56 LT-1 RT-1 2 3 years

Yes NCPA (NARD)

L3916 WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, OFF-THE-SHELF 366.94

LT-1 RT-1 2 3 years Yes NCPA (NARD)

L3917 HAND ORTHOSIS, METACARPAL FRACTURE ORTHOSIS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 64.93


L3918 HAND ORTHOSIS, METACARPAL FRACTURE ORTHOSIS, PREFABRICATED, OFF-THE-SHELF 72.92LT-1 RT-1 2 1 year Yes CO

L3919 HAND ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 166.47


L3921 HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 197.42 LT-1

RT-1 2 3 yearsNo CO

L3923HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

23.92 LT-1 RT-1 2 1 year

No NCPA (NARD)

L3924 HAND FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, OFF-THE-SHELF 60.05LT-1 RT-1 2 1 year No NCPA (NARD)

L3925 FINGER ORTHOSIS, PROXIMAL INTERPHALANGEAL (PIP)/DISTAL INTERPHALANGEAL (DIP), NON TORSION JOINT/SPRING, EXTENSION/FLEXION, MAY INCLUDE SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF 33.35 LT-2

RT-2 4 1 year No NCPA (NARD)

L3929 HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

53.14 LT-1 RT-1 2 1 year No NCPA (NARD)

L3930 HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS, PREFABRICATED, OFF-THE-SHELF 58.11

LT-1 RT-1 2 1 year No NCPA (NARD)

L3931 WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINT(S), TURNBUCKLES, ELASTIC BANDS/SPRINGS, MAY INCLUDE SOFT INTERFACE MATERIAL, STRAPS, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT

128.55 LT-1 RT-1 2 1 year

No NCPA (NARD)

L3933 FINGER ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 131.15


L3935 FINGER ORTHOSIS, NONTORSION JOINT, MAY INCLUDE SOFT INTERFACE, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 135.80

3 3 yearsNo CO

L3960 SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, AIRPLANE DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 506.65

1 5 yearsYes CO

L3961 SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 1032.70

1 5 yearsYes CO

L3962 SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, ERBS PALSEY DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 527.54

1 5 yearsYes CO

L3967SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT

1219.261 5 years

Yes CO

L3971SHOULDER 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

1157.341 5 years

Yes CO

L3973SHOULDER 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

1219.261 5 years

Yes CO

L3975 SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT 1032.70

1 5 yearsYes CO

L3976SHOULDER 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

1032.701 5 years

Yes CO

L3977SHOULDER 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

1157.341 5 years

Yes CO

L3978SHOULDER 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

1219.261 5 years

Yes CO

L3980 UPPER EXTREMITY FRACTURE ORTHOSIS, HUMERAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 190.01 2 5 years Yes COL3982 UPPER EXTREMITY FRACTURE ORTHOSIS, RADIUS/ULNAR, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 234.76 2 5 years Yes COL3984 UPPER EXTREMITY FRACTURE ORTHOSIS, WRIST, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 250.58 2 5 years Yes CO

10/15 02/15 L3995 ADDITION TO UPPER EXTREMITY ORTHOSIS, SOCK, FRACTURE OR EQUAL, EACH 21.03 LT-4

RT-4 8 Case-By-Case Yes CO

07/17 L3999 UPPER LIMB ORTHOSIS, NOT OTHERWISE SPECIFIED 500.00 LT -1 RT -1 2 1 year Yes CO

L4000 REPLACE GIRDLE FOR SPINAL ORTHOSIS (CTLSO OR SO) 819.38 1 1 year No CO

L4010 REPLACE TRILATERAL SOCKET BRIM 461.10 LT-1 RT-1 2 1 year

No CO

L4020 REPLACE QUADRILATERAL SOCKET BRIM, MOLDED TO PATIENT MODEL 575.95 LT-1 RT-1 2 1 year

No CO

L4040 REPLACE MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY 256.39 LT-1 RT-1 2 1 year

No CO

L4045 REPLACE NON-MOLDED THIGH LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY 206.03 LT-1 RT-1 2 1 year

No CO

L4050 REPLACE MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY 259.31 LT-1 RT-1 2 1 year

No CO

L4055 REPLACE NON-MOLDED CALF LACER, FOR CUSTOM FABRICATED ORTHOSIS ONLY 167.91 LT-1 RT-1 2 1 year

No CO

L4060 REPLACE HIGH ROLL CUFF 199.61 LT-1 RT-1 2 1 year

No CO

L4070 REPLACE PROXIMAL AND DISTAL UPRIGHT FOR KAFO 190.45 LT-1 RT-1 2 1 year

No CO

L4080 REPLACE METAL BANDS KAFO, PROXIMAL THIGH 67.14 LT-1 RT-1 2 1 year

No CO

L4090 REPLACE METAL BANDS KAFO-AFO, CALF OR DISTAL THIGH 59.42 LT-1 RT-1 2 1 year

No CO

L4100 REPLACE LEATHER CUFF KAFO, PROXIMAL THIGH 67.02 LT-1 RT-1 2 1 year

No CO

L4110 REPLACE LEATHER CUFF KAFO-AFO, CALF OR DISTAL THIGH 53.26 LT-1 RT-1 2 1 year

No CO

L4130 REPLACE PRETIBIAL SHELL 366.59 LT-1 RT-1 2 1 year

No CO

L4205 REPAIR OF ORTHOTIC DEVICE, LABOR COMPONENT, PER 15 MINUTES 14.07 8 6 months No CO, COA/CPAL4210 REPAIR OF ORTHOTIC DEVICE, REPAIR OR REPLACE MINOR PARTS 55.00 2 6 months No CO, COA/CPA

L4350 ANKLE CONTROL ORTHOSIS, STIRRUP STYLE, RIGID, INCLUDES ANY TYPE INTERFACE (E.G., PNEUMATIC, GEL), PREFABRICATED, OFF-THE-SHELF 66.05 LT-1

RT-1 2 2 yearsNo Fitter

L4360WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

184.78 LT-1 RT-1 2 2 years

No Fitter

L4361 WALKING BOOT, PNEUMATIC AND/OR VACUUM, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF 207.52


L4370 PNEUMATIC FULL LEG SPLINT, PREFABRICATED, OFF-THE-SHELF 118.58 LT-1 RT-1 2 1 year

No Fitter

L4386WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

107.09 LT-1 RT-1 2 2 years

No Fitter

L4387 WALKING BOOT, NON-PNEUMATIC, WITH OR WITHOUT JOINTS, WITH OR WITHOUT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF 120.26


L4392 REPLACEMENT, SOFT INTERFACE MATERIAL, STATIC AFO 15.90LT-1 RT-1 2 1 year No Fitter

L4394 REPLACE SOFT INTERFACE MATERIAL, FOOT DROP SPLINT 11.63LT-1 RT-1 2 1 year No Fitter

L4396STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE 113.35

LT-1 RT-1 2 1 year No Fitter

L4397 STATIC OR DYNAMIC ANKLE FOOT ORTHOSIS, INCLUDING SOFT INTERFACE MATERIAL, ADJUSTABLE FOR FIT, FOR POSITIONING, MAY BE USED FOR MINIMAL AMBULATION, PREFABRICATED, OFF-THE-SHELF 127.31

LT-1 RT-1 2 1 year No Fitter

L4398 FOOT DROP SPLINT, RECUMBENT POSITIONING DEVICE, PREFABRICATED, OFF-THE-SHELF 52.16 LT-1 RT-1 2 1 year

No Fitter

01/14L4631

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

1357.20 LT-1 RT-1 2 1 year

CO

L5000 PARTIAL FOOT, SHOE INSERT WITH LONGITUDINAL ARCH, TOE FILLER 354.14 LT-1 RT-1 2 3 years

Yes CP

L5010 PARTIAL FOOT, MOLDED SOCKET, ANKLE HEIGHT, WITH TOE FILLER 855.30 LT-1 RT-1 2 3 years

Yes CP

L5020 PARTIAL FOOT, MOLDED SOCKET, TIBIAL TUBERCLE HEIGHT, WITH TOE FILLER 1452.53 LT-1 RT-1 2 3 years

Yes CP

L5050 ANKLE, SYMES, MOLDED SOCKET, SACH FOOT 1606.76 LT-1 RT-1 2 3 years

Yes CP

L5060 ANKLE, SYMES, METAL FRAME, MOLDED LEATHER SOCKET, ARTICULATED ANKLE/FOOT 1848.23 LT-1 RT-1 2 3 years

Yes CP

L5100 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT 1610.30 LT-1 RT-1 2 3 years

Yes CP

L5105 BELOW KNEE, PLASTIC SOCKET, JOINTS AND THIGH LACER, SACH FOOT 2324.64 LT-1 RT-1 2 3 years

Yes CP

L5150 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT 2349.89 LT-1 RT-1 2 3 years

Yes CP

L5160 KNEE DISARTICULATION (OR THROUGH KNEE), MOLDED SOCKET, BENT KNEE CONFIGURATION, EXTERNAL KNEE JOINTS, SHIN, SACH FOOT 2555.93 LT-1

RT-1 2 3 yearsYes CP

L5200 ABOVE KNEE, MOLDED SOCKET, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT 2447.66 LT-1 RT-1 2 3 years

Yes CP

L5210 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH FOOT BLOCKS, NO ANKLE JOINTS, EACH 1623.78 LT-1 RT-1 2 3 years

Yes CP

L5220 ABOVE KNEE, SHORT PROSTHESIS, NO KNEE JOINT ('STUBBIES'), WITH ARTICULATED ANKLE/FOOT, DYNAMICALLY ALIGNED, EACH 1845.71 LT-1


L5230 ABOVE KNEE, FOR PROXIMAL FEMORAL FOCAL DEFICIENCY, CONSTANT FRICTION KNEE, SHIN, SACH FOOT 2545.61 LT-1 RT-1 2 3 years

Yes CP

L5250 HIP DISARTICULATION, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT 3471.98 LT-1


L5270 HIP DISARTICULATION, TILT TABLE TYPE; MOLDED SOCKET, LOCKING HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT 3456.58 LT-1


L5280 HEMIPELVECTOMY, CANADIAN TYPE; MOLDED SOCKET, HIP JOINT, SINGLE AXIS CONSTANT FRICTION KNEE, SHIN, SACH FOOT 3430.10 LT-1


L5301 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM 1840.67 LT-1 RT-1 2 3 years

Yes CP

L5321 ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE AXIS KNEE 2668.10 LT-1 RT-1 2 3 years

Yes CP

L5331 HIP DISARTICULATION, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT 3399.70 LT-1


L5341 HEMIPELVECTOMY, CANADIAN TYPE, MOLDED SOCKET, ENDOSKELETAL SYSTEM, HIP JOINT, SINGLE AXIS KNEE, SACH FOOT 3539.10 LT-1


L5400 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT, SUSPENSION, AND ONE CAST CHANGE, BELOW KNEE 911.29 LT-1

RT-1 2 5 years Yes CP

L5410 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION, BELOW KNEE, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT 279.58 LT-1


L5420 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING, ALIGNMENT AND SUSPENSION AND ONE CAST CHANGE 'AK' OR KNEE DISARTICULATION 1116.76 LT-1


L5430 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCL. FITTING, ALIGNMENT AND SUPENSION, 'AK' OR KNEE DISARTICULATION, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT 336.73 LT-1


L5450 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARING RIGID DRESSING, BELOW KNEE 273.94 LT-1 RT-1 2 5 years

Yes CP

L5460 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF NON-WEIGHT BEARING RIGID DRESSING, ABOVE KNEE 364.97 LT-1 RT-1 2 5 years

Yes CP

L5500 INITIAL, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED 859.42 LT-1

RT-1 2 3-5 yearsYes CP

L5505 INITIAL, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, DIRECT FORMED 1188.61 LT-1


L5510 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL 974.22 LT-1


L5520 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED 962.29 LT-1


L5530 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL 1155.80 LT-1


L5535 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, NO COVER, SACH FOOT, PREFABRICATED, ADJUSTABLE OPEN END SOCKET 1134.77 LT-1


L5540 PREPARATORY, BELOW KNEE 'PTB' TYPE SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL 1211.16 LT-1


L5560 PREPARATORY, ABOVE KNEE- KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PLASTER SOCKET, MOLDED TO MODEL

1300.58 LT-1 RT-1 2 3-5 years

Yes CP

L5570 PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, DIRECT FORMED 1352.14 LT-1


L5580 PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO MODEL 1578.52 LT-1


L5585 PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION, ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON, NO COVER, SACH FOOT, PREFABRICATED ADJUSTABLE OPEN END SOCKET 1942.63 LT-1


L5590 PREPARATORY, ABOVE KNEE - KNEE DISARTICULATION ISCHIAL LEVEL SOCKET, NON-ALIGNABLE SYSTEM, PYLON NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO MODEL 1608.62 LT-1

RT-1 2 3-5 years Yes CP

L5595 PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, THERMOPLASTIC OR EQUAL, MOLDED TO PATIENT MODEL 2841.86 LT-1


L5600 PREPARATORY, HIP DISARTICULATION-HEMIPELVECTOMY, PYLON, NO COVER, SACH FOOT, LAMINATED SOCKET, MOLDED TO PATIENT MODEL 3054.86 LT-1


K3/K4 ONLY L5610 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, HYDRACADENCE SYSTEM 1385.42 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5611 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE - KNEE DISARTICULATION, 4 BAR LINKAGE, WITH FRICTION SWING PHASE CONTROL 1078.14 LT-1


K3/K4 ONLY L5613 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE, WITH HYDRAULIC SWING PHASE CONTROL 1685.62 LT-1


K3/K4 ONLY L5614 ADDITION TO LOWER EXTREMITY, EXOSKELETAL SYSTEM, ABOVE KNEE-KNEE DISARTICULATION, 4 BAR LINKAGE, WITH PNEUMATIC SWING PHASE CONTROL 1141.90 LT-1


L5616 ADDITION TO LOWER EXTREMITY, ENDOSKELETAL SYSTEM, ABOVE KNEE, UNIVERSAL MULTIPLEX SYSTEM, FRICTION SWING PHASE CONTROL 910.90 LT-1


L5617 ADDITION TO LOWER EXTREMITY, QUICK CHANGE SELF-ALIGNING UNIT, ABOVE KNEE OR BELOW KNEE, EACH 378.62 LT-1 RT-1 2 3 years

Yes CP

L5618 ADDITION TO LOWER EXTREMITY, TEST SOCKET, SYMES 200.30 LT-2 RT-2 4 3 years

Yes CP

10/15L5620 ADDITION TO LOWER EXTREMITY, TEST SOCKET, BELOW KNEE 186.04 LT-2

RT-2 4Case-By-Case Yes CP

L5622 ADDITION TO LOWER EXTREMITY, TEST SOCKET, KNEE DISARTICULATION 242.58 LT-2 RT-2 4 3 years

Yes CP

10/15L5624 ADDITION TO LOWER EXTREMITY, TEST SOCKET, ABOVE KNEE 243.28 LT-2


L5626 ADDITION TO LOWER EXTREMITY, TEST SOCKET, HIP DISARTICULATION 319.05 LT-2 RT-2 4 3 years

Yes CP

L5628 ADDITION TO LOWER EXTREMITY, TEST SOCKET, HEMIPELVECTOMY 341.14 LT-1 RT-1 2 3 years

Yes CP

10/15L5629 ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKET 212.66 LT-1


L5630 ADDITION TO LOWER EXTREMITY, SYMES TYPE, EXPANDABLE WALL SOCKET 300.31 LT-1 RT-1 2 2 years

Yes CP

10/15L5631 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, ACRYLIC SOCKET 294.02 LT-1


L5632 ADDITION TO LOWER EXTREMITY, SYMES TYPE, 'PTB' BRIM DESIGN SOCKET 164.10 LT-1 RT-1 2 2 years

Yes CP

L5634 ADDITION TO LOWER EXTREMITY, SYMES TYPE, POSTERIOR OPENING (CANADIAN) SOCKET 203.55 LT-1 RT-1 2 2 years

Yes CP

L5636 ADDITION TO LOWER EXTREMITY, SYMES TYPE, MEDIAL OPENING SOCKET 170.50 LT-1 RT-1 2 2 years

Yes CP

10/15L5637 ADDITION TO LOWER EXTREMITY, BELOW KNEE, TOTAL CONTACT 193.31 LT-1


L5638 ADDITION TO LOWER EXTREMITY, BELOW KNEE, LEATHER SOCKET 336.74 LT-1 RT-1 2 2 years

Yes CP

L5639 ADDITION TO LOWER EXTREMITY, BELOW KNEE, WOOD SOCKET 750.25 LT-1 RT-1 2 2 years

Yes CP

L5640 ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, LEATHER SOCKET 427.89 LT-1 RT-1 2 2 years

Yes CP

L5642 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, LEATHER SOCKET 414.59 LT-1 RT-1 2 2 years

Yes CP

L5643 ADDITION TO LOWER EXTREMITY, HIP DISARTICULATION, FLEXIBLE INNER SOCKET, EXTERNAL FRAME 1041.51 LT-1 RT-1 2 2 years

Yes CP

L5644 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, WOOD SOCKET 395.23 LT-1 RT-1 2 2 years

Yes CP

10/15L5645 ADDITION TO LOWER EXTREMITY, BELOW KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME 533.92 LT-1


L5646ADDITION TO LOWER EXTREMITY, BELOW KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET

366.64 LT-1 RT-1 2 2 years

Yes CP

10/15L5647 ADDITION TO LOWER EXTREMITY, BELOW KNEE SUCTION SOCKET 532.29 LT-1


L5648ADDITION TO LOWER EXTREMITY, ABOVE KNEE, AIR, FLUID, GEL OR EQUAL, CUSHION SOCKET

440.56 LT-1 RT-1 2 2 years

Yes CP

10/15L5649 ADDITION TO LOWER EXTREMITY, ISCHIAL CONTAINMENT/NARROW M-L SOCKET 1596.39 LT-1


10/15L5650 ADDITIONS TO LOWER EXTREMITY, TOTAL CONTACT, ABOVE KNEE OR KNEE DISARTICULATION SOCKET 326.67 LT-1


10/15L5651 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, FLEXIBLE INNER SOCKET, EXTERNAL FRAME 803.61 LT-1


10/15L5652 ADDITION TO LOWER EXTREMITY, SUCTION SUSPENSION, ABOVE KNEE OR KNEE DISARTICULATION SOCKET 291.74 LT-1


L5653 ADDITION TO LOWER EXTREMITY, KNEE DISARTICULATION, EXPANDABLE WALL SOCKET 389.45 LT-1 RT-1 2 2 years

Yes CP

L5654 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, SYMES, (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) 221.92 LT-1 RT-1 2 1 year

Yes CP

L5655 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, BELOW KNEE (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) 188.06 LT-1 RT-1 2 1 year

Yes CP

L5656 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, KNEE DISARTICULATION (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) 252.30 LT-1

RT-1 2 1 yearYes CP

L5658 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, ABOVE KNEE (KEMBLO, PELITE, ALIPLAST, PLASTAZOTE OR EQUAL) 243.30 LT-1 RT-1 2 1 year

Yes CP

L5661 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER SYMES 407.22 LT-1 RT-1 2 1 year

Yes CP

L5665 ADDITION TO LOWER EXTREMITY, SOCKET INSERT, MULTI-DUROMETER, BELOW KNEE 342.62 LT-1 RT-1 2 1 year

Yes CP

L5666 ADDITION TO LOWER EXTREMITY, BELOW KNEE, CUFF SUSPENSION 46.84 LT-1 RT-1 2 1 year

Yes CP

L5668 ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED DISTAL CUSHION 75.55 LT-1 RT-1 2 1 year

Yes CP

L5670 ADDITION TO LOWER EXTREMITY, BELOW KNEE, MOLDED SUPRACONDYLAR SUSPENSION ('PTS' OR SIMILAR) 181.11 LT-1 RT-1 2 1 year

Yes CP

10/15L5671 ADDITION TO LOWER EXTREMITY, BELOW KNEE / ABOVE KNEE SUSPENSION LOCKING MECHANISM (SHUTTLE, LANYARD OR

EQUAL), EXCLUDES SOCKET INSERT 384.78 LT-1 RT-1 2

Case-By-Case Yes CP

L5672 ADDITION TO LOWER EXTREMITY, BELOW KNEE, REMOVABLE MEDIAL BRIM SUSPENSION 199.54 LT-1 RT-1 2 1 year

Yes CP

10/15L5673 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR

PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM 475.81 LT-2 RT-2 4

Case-By-Case Yes CP

L5676 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, SINGLE AXIS, PAIR 242.49 LT-1 RT-1 2 1 year

Yes CP

L5677 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, KNEE JOINTS, POLYCENTRIC, PAIR 329.94 LT-1 RT-1 2 1 year

Yes CP

L5678 ADDITIONS TO LOWER EXTREMITY, BELOW KNEE, JOINT COVERS, PAIR 26.57 LT-1 RT-1 2 1 year

Yes CP

10/15L5679 ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED FROM EXISTING MOLD OR

PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM 396.50 LT-2 RT-2 4

Case-By-Case Yes CP

L5680 ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, NONMOLDED 221.78 LT-1 RT-1 2 1 year

Yes CP

10/15L5681

ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L5673 OR L5679)

890.13 LT-1 RT-1 2

Case-By-Case

Yes CP

L5682 ADDITION TO LOWER EXTREMITY, BELOW KNEE, THIGH LACER, GLUTEAL/ISCHIAL, MOLDED 418.49 LT-1 RT-1 2 1 year

Yes CP

01/17L5683

ADDITION TO LOWER EXTREMITY, BELOW KNEE/ABOVE KNEE, CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L5673 OR L5679)

890.13 LT-1 RT-1 2 initial only

Yes CP

L5684 ADDITION TO LOWER EXTREMITY, BELOW KNEE, FORK STRAP 32.21 LT-1 RT-1 2 1 year

Yes CP

10/15L5685 ADDITION TO LOWER EXTREMITY PROSTHESIS, BELOW KNEE, SUSPENSION/SEALING SLEEVE, WITH OR WITHOUT VALVE,

ANY MATERIAL, EACH 86.67 LT-2 RT-2 4

Case-By-Case Yes CP

L5686 ADDITION TO LOWER EXTREMITY, BELOW KNEE, BACK CHECK (EXTENSION CONTROL) 34.18 LT-1 RT-1 2 1 year

Yes CP

L5688 ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, WEBBING 40.87 LT-1 RT-1 2 6 months

Yes CP

L5690 ADDITION TO LOWER EXTREMITY, BELOW KNEE, WAIST BELT, PADDED AND LINED 65.48 LT-1 RT-1 2 6 months

Yes CP

L5692 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, LIGHT 88.91 LT-1 RT-1 2 6 months

Yes CP

L5694 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL BELT, PADDED AND LINED 121.39 LT-1 RT-1 2 6 months

Yes CP

10/15L5695 ADDITION TO LOWER EXTREMITY, ABOVE KNEE, PELVIC CONTROL, SLEEVE SUSPENSION, NEOPRENE OR EQUAL, EACH 112.07 LT-1


L5696 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC JOINT 123.81 LT-1 RT-1 2 3 years

Yes CP

L5697 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, PELVIC BAND 53.72 LT-1 RT-1 2 6 months

Yes CP

L5698 ADDITION TO LOWER EXTREMITY, ABOVE KNEE OR KNEE DISARTICULATION, SILESIAN BANDAGE 87.58 LT-1 RT-1 2 6 months

Yes CP

L5699 ALL LOWER EXTREMITY PROSTHESES, SHOULDER HARNESS 158.24 LT-1 RT-1 2 6 months

Yes CP

10/15L5700 REPLACEMENT, SOCKET, BELOW KNEE, MOLDED TO PATIENT MODEL 1917.27 LT-1


10/15L5701 REPLACEMENT, SOCKET, ABOVE KNEE/KNEE DISARTICULATION, INCLUDING ATTACHMENT PLATE, MOLDED TO PATIENT

MODEL 2302.50 LT-1 RT-1 2

Case-By-Case Yes CP

L5702 REPLACEMENT, SOCKET, HIP DISARTICULATION, INCLUDING HIP JOINT, MOLDED TO PATIENT MODEL 2913.02 LT-1 RT-1 2 2 years

Yes CP

L5703 ANKLE, SYMES, MOLDED TO PATIENT MODEL, SOCKET WITHOUT SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY 1507.51 LT-1


L5704 CUSTOM SHAPED PROTECTIVE COVER, BELOW KNEE 358.67 LT-1 RT-1 2 1 year

Yes CP

L5705 CUSTOM SHAPED PROTECTIVE COVER, ABOVE KNEE 640.89 LT-1 RT-1 2 1 year

Yes CP

L5706 CUSTOM SHAPED PROTECTIVE COVER, KNEE DISARTICULATION 628.25 LT-1 RT-1 2 1 year

Yes CP

L5707 CUSTOM SHAPED PROTECTIVE COVER, HIP DISARTICULATION 828.25 LT-1 RT-1 2 1 year

Yes CP

L5710 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK 250.26 LT-1 RT-1 2 1 year

Yes CP

L5711 ADDITIONS EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL 349.76 LT-1 RT-1 2 1 year

Yes CP

L5712 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) 293.07 LT-1

RT-1 2 1 yearYes CP

L5714 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, VARIABLE FRICTION SWING PHASE CONTROL 301.03 LT-1 RT-1 2 1 year

Yes CP

L5716 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE LOCK 487.71 LT-1 RT-1 2 1 year

Yes CP

L5718 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING AND STANCE PHASE CONTROL 609.58 LT-1 RT-1 2 1 year

Yes CP

K3/K4 ONLY L5722 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL 644.01 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5724 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL 1010.04 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5726 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, EXTERNAL JOINTS FLUID SWING PHASE CONTROL 1164.06 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5728 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL 1592.26 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5780 ADDITION, EXOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/HYDRA PNEUMATIC SWING PHASE CONTROL 766.13 LT-1 RT-1 2 3 years

Yes CP

L5781 ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM 2707.58 LT-1


L5782 ADDITION TO LOWER LIMB PROSTHESIS, VACUUM PUMP, RESIDUAL LIMB VOLUME MANAGEMENT AND MOISTURE EVACUATION SYSTEM, HEAVY DUTY 2854.41 LT-1


L5785 ADDITION, EXOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) 430.66 LT-1 RT-1 2 3 years

Yes CP

L5790 ADDITION, EXOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) 481.14 LT-1 RT-1 2 3 years

Yes CP

L5795 ADDITION, EXOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) 957.97 LT-1 RT-1 2 3 years

Yes CP

L5810 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK 325.79 LT-1 RT-1 2 3 years

Yes CP

L5811 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, MANUAL LOCK, ULTRA-LIGHT MATERIAL 488.03 LT-1 RT-1 2 3 years

Yes CP

L5812 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FRICTION SWING AND STANCE PHASE CONTROL (SAFETY KNEE) 378.27 LT-1


K3/K4 ONLY L5814 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, HYDRAULIC SWING PHASE CONTROL, MECHANICAL STANCE PHASE LOCK 2513.17 LT-1


L5816 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, MECHANICAL STANCE PHASE LOCK 572.50 LT-1 RT-1 2 3 years

Yes CP

L5818 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, POLYCENTRIC, FRICTION SWING, AND STANCE PHASE CONTROL 642.62 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5822 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC SWING, FRICTION STANCE PHASE CONTROL 1139.51 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5824 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING PHASE CONTROL 1026.20 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5826 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, HYDRAULIC SWING PHASE CONTROL, WITH MINIATURE HIGH ACTIVITY FRAME 2113.25 LT-1


< 21 yrs

K3/K4 ONLY L5828 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL 1889.67 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5830 ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, PNEUMATIC/ SWING PHASE CONTROL 1269.76 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5840 ADDITION, ENDOSKELETAL KNEE/SHIN SYSTEM, 4-BAR LINKAGE OR MULTIAXIAL, PNEUMATIC SWING PHASE CONTROL 2347.78 LT-1 RT-1 2 3 years

Yes CP

L5845 ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUSTABLE 1212.90 LT-1 RT-1 2 3 years

Yes CP

L5848 ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING FEATURE, WITH OR WITHOUT ADJUSTABILITY 727.65 LT-1


L5850 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, KNEE EXTENSION ASSIST 85.60 LT-1 RT-1 2 3 years

Yes CP

L5855ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, MECHANICAL HIP EXTENSION ASSIST 230.02

LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5856 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE 16,244.68

LT-1 RT-1 2 5 years YES ABCP Only

K3/K4 ONLY L5857 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE 5,764.20


K3/K4 ONLY L5858 ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE 12,576.54


10/15L5910 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ALIGNABLE SYSTEM 242.35 LT-1


10/15L5920 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE OR HIP DISARTICULATION, ALIGNABLE SYSTEM 355.05 LT-1


L5925 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, KNEE DISARTICULATION OR HIP DISARTICULATION, MANUAL LOCK 299.79 LT-1 RT-1 2 3 years

Yes CP

K4 ONLY L5930 ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME 2277.68 LT-1 RT-1 2 3 years

Yes CP

10/15L5940 ADDITION, ENDOSKELETAL SYSTEM, BELOW KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) 335.66 LT-1


10/15L5950 ADDITION, ENDOSKELETAL SYSTEM, ABOVE KNEE, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) 524.83 LT-1


L5960 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, ULTRA-LIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) 645.10 LT-1 RT-1 2 3 years

Yes CP

L5966 ADDITION, ENDOSKELETAL SYSTEM, HIP DISARTICULATION, FLEXIBLE PROTECTIVE OUTER SURFACE COVERING SYSTEM 798.55 LT-1 RT-1 2 3 years

Yes CP

L5968 ADDITION TO LOWER LIMB PROSTHESIS, MULTIAXIAL ANKLE WITH SWING PHASE ACTIVE DORSIFLEXION FEATURE 2459.07 LT-1 RT-1 2 5 years

Yes CP

L5970 ALL LOWER EXTREMITY PROSTHESES, FOOT, EXTERNAL KEEL, SACH FOOT 135.90 LT-1 RT-1 2 3 years

Yes CP

L5971 ALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY 135.90 LT-1 RT-1 2 3 years

Yes CP

L5972 ALL LOWER EXTREMITY PROSTHESES, FOOT, FLEXIBLE KEEL 253.85 LT-1 RT-1 2 3 years

Yes CP

L5974 ALL LOWER EXTREMITY PROSTHESES, FOOT, SINGLE AXIS ANKLE/FOOT 155.94 LT-1 RT-1 2 3 years

Yes CP

L5975 ALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS ANKLE AND FLEXIBLE KEEL FOOT 313.72 LT-1 RT-1 2 3 years

Yes CP

L5976 ALL LOWER EXTREMITY PROSTHESES, ENERGY STORING FOOT (SEATTLE CARBON COPY II OR EQUAL) 374.74 LT-1 RT-1 2 3 years

Yes CP

K2-K4 ONLY L5978 ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL ANKLE/FOOT 195.28 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5979 ALL LOWER EXTREMITY PROSTHESIS, MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT, ONE PIECE SYSTEM 1526.86 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5980 ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM 2481.06 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5981 ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQUAL 2004.35 LT-1 RT-1 2 3 years

Yes CP

L5982 ALL EXOSKELETAL LOWER EXTREMITY PROSTHESES, AXIAL ROTATION UNIT 386.85 LT-1 RT-1 2 3 years

Yes CP

L5984 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT, WITH OR WITHOUT ADJUSTABILITY 381.21 LT-1 RT-1 2 3 years

Yes CP

L5985 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES, DYNAMIC PROSTHETIC PYLON 191.08 LT-1 RT-1 2 3 years

Yes CP

L5986 ALL LOWER EXTREMITY PROSTHESES, MULTI-AXIAL ROTATION UNIT ('MCP' OR EQUAL) 424.04 LT-1 RT-1 2 3 years

Yes CP

K3/K4 ONLY L5987ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON

4867.99 LT-1 RT-1 2 3 years

Yes CP

L5988 ADDITION TO LOWER LIMB PROSTHESIS, VERTICAL SHOCK REDUCING PYLON FEATURE 1351.83 LT-1 RT-1 2 3 years

Yes CP

L6000 PARTIAL HAND, THUMB REMAINING 889.11 LT-1 RT-1 2 3 years

Yes CP

L6010 PARTIAL HAND, LITTLE AND/OR RING FINGER REMAINING 989.43 LT-1 RT-1 2 3 years

Yes CP

L6020 PARTIAL HAND, NO FINGER REMAINING 922.49 LT-1 RT-1 2 3 years

Yes CP

1/15L6026

TRANSCARPAL/METACARPAL OR PARITAL HAND DISARTICULATION PROSTHESIS, EXTERNAL POWER, SELF-SUSPENDED, INNER SOCKET WITH REMOVABLE FOREARM SECTION, ELECTRODES AND CABLES, TWO BATTERIES, CHARGER, MYOELECTRIC CONTROL OF TERMINAL

3813.13 LT-1 RT-1 2 3 years

Yes CP

L6050 WRIST DISARTICULATION, MOLDED SOCKET, FLEXIBLE ELBOW HINGES, TRICEPS PAD 1271.15 LT-1 RT-1 2 3-5 years

Yes CP

L6055 WRIST DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, FLEXIBLE ELBOW HINGES, TRICEPS PAD 1771.66 LT-1 RT-1 2 3-5 years

Yes CP

L6100 BELOW ELBOW, MOLDED SOCKET, FLEXIBLE ELBOW HINGE, TRICEPS PAD 1287.87 LT-1 RT-1 2 3-5 years

Yes CP

L6110 BELOW ELBOW, MOLDED SOCKET, (MUENSTER OR NORTHWESTERN SUSPENSION TYPES) 1366.01 LT-1 RT-1 2 3-5 years

Yes CP

L6120 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STEP-UP HINGES, HALF CUFF 1591.89 LT-1 RT-1 2 3-5 years

Yes CP

L6130 BELOW ELBOW, MOLDED DOUBLE WALL SPLIT SOCKET, STUMP ACTIVATED LOCKING HINGE, HALF CUFF 1732.27 LT-1 RT-1 2 3-5 years

Yes CP

L6200 ELBOW DISARTICULATION, MOLDED SOCKET, OUTSIDE LOCKING HINGE, FOREARM 1825.53 LT-1 RT-1 2 3-5 years

Yes CP

L6205 ELBOW DISARTICULATION, MOLDED SOCKET WITH EXPANDABLE INTERFACE, OUTSIDE LOCKING HINGES, FOREARM 2436.80 LT-1 RT-1 2 3-5 years

Yes CP

L6250 ABOVE ELBOW, MOLDED DOUBLE WALL SOCKET, INTERNAL LOCKING ELBOW, FOREARM 1912.74 LT-1 RT-1 2 3-5 years

Yes CP

L6300 SHOULDER DISARTICULATION, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION, INTERNAL LOCKING ELBOW, FOREARM 2493.05 LT-1


L6310 SHOULDER DISARTICULATION, PASSIVE RESTORATION (COMPLETE PROSTHESIS) 2152.63 LT-1 RT-1 2 3-5 years

Yes CP

L6320 SHOULDER DISARTICULATION, PASSIVE RESTORATION (SHOULDER CAP ONLY) 1175.94 LT-1 RT-1 2 3-5 years

Yes CP

L6350 INTERSCAPULAR THORACIC, MOLDED SOCKET, SHOULDER BULKHEAD, HUMERAL SECTION, INTERNAL LOCKING ELBOW, FOREARM 2621.06 LT-1


L6360 INTERSCAPULAR THORACIC, PASSIVE RESTORATION (COMPLETE PROSTHESIS) 2357.23 LT-1 RT-1 2 3-5 years

Yes CP

L6370 INTERSCAPULAR THORACIC, PASSIVE RESTORATION (SHOULDER CAP ONLY) 1410.50 LT-1 RT-1 2 3-5 years

Yes CP

L6380 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING, INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, WRIST DISARTICULATION OR BELOW ELBOW 817.34 LT-1


L6382 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, ELBOW DISARTICULATION OR ABOVE ELBOW

1229.67 LT-1 RT-1 2 5 years

Yes CP

L6384IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF INITIAL RIGID DRESSING INCLUDING FITTING ALIGNMENT AND SUSPENSION OF COMPONENTS, AND ONE CAST CHANGE, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC

1701.10 LT-1 RT-1 2 5 years

Yes CP

L6386 IMMEDIATE POST SURGICAL OR EARLY FITTING, EACH ADDITIONAL CAST CHANGE AND REALIGNMENT 268.73 LT-1 RT-1 2 5 years Yes CP

L6388 IMMEDIATE POST SURGICAL OR EARLY FITTING, APPLICATION OF RIGID DRESSING ONLY 294.18 LT-1 RT-1 2 5 years Yes CP

L6400 BELOW ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING 1552.72 LT-1 RT-1 2 3 years Yes CP

L6450 ELBOW DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING 2074.40 LT-1 RT-1 2 3 years Yes CP

L6500 ABOVE ELBOW, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING 2270.25 LT-1 RT-1 2 3 years Yes CP

L6550 SHOULDER DISARTICULATION, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING 2608.68 LT-1 RT-1 2 3 years Yes CP

L6570 INTERSCAPULAR THORACIC, MOLDED SOCKET, ENDOSKELETAL SYSTEM, INCLUDING SOFT PROSTHETIC TISSUE SHAPING 2928.84 LT-1 RT-1 2 3 years Yes CP

L6580PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL PLASTIC SOCKET, FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDEN CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL

1118.17 LT-1 RT-1 2 3 years

Yes CP

L6582PREPARATORY, WRIST DISARTICULATION OR BELOW ELBOW, SINGLE WALL SOCKET, FRICTION WRIST, FLEXIBLE ELBOW HINGES, FIGURE OF EIGHT HARNESS, HUMERAL CUFF, BOWDEN CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED

1012.76 LT-1 RT-1 2 3 years

Yes CP

L6584PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL PLASTIC SOCKET, FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL

1588.26 LT-1 RT-1 2 3 years

Yes CP

L6586 PREPARATORY, ELBOW DISARTICULATION OR ABOVE ELBOW, SINGLE WALL SOCKET, FRICTION WRIST, LOCKING ELBOW, FIGURE OF EIGHT HARNESS, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED

1486.36 LT-1 RT-1 2 3 years

Yes CP

L6588PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALL PLASTIC SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, MOLDED TO PATIENT MODEL

1953.05 LT-1 RT-1 2 3 years

Yes CP

L6590PREPARATORY, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC, SINGLE WALL SOCKET, SHOULDER JOINT, LOCKING ELBOW, FRICTION WRIST, CHEST STRAP, FAIR LEAD CABLE CONTROL, USMC OR EQUAL PYLON, NO COVER, DIRECT FORMED

1855.10 LT-1 RT-1 2 3 years

Yes CP

L6600 UPPER EXTREMITY ADDITIONS, POLYCENTRIC HINGE, PAIR 125.52 LT-1 RT-1 2 3 years Yes CP

L6605 UPPER EXTREMITY ADDITIONS, SINGLE PIVOT HINGE, PAIR 120.90 LT-1 RT-1 2 3 years Yes CP

L6610 UPPER EXTREMITY ADDITIONS, FLEXIBLE METAL HINGE, PAIR 116.09 LT-1 RT-1 2 3 years Yes CP

L6611 ADDITION TO UPPER EXTREMITY PROSTHESIS, EXTERNAL POWERED, ADDITIONAL SWITCH, ANY TYPE 278.61 LT-1 RT-1 2 3 years Yes CP

L6615 UPPER EXTREMITY ADDITION, DISCONNECT LOCKING WRIST UNIT 128.25 LT-1 RT-1 2 3 years Yes CP

L6616UPPER EXTREMITY ADDITION, ADDITIONAL DISCONNECT INSERT FOR LOCKING WRIST UNIT, EACH

47.52 LT-1 RT-1 2 3 years Yes CP

L6620 UPPER EXTREMITY ADDITION, FLEXION/EXTENSION WRIST UNIT, WITH OR WITHOUT FRICTION 205.18 LT-1 RT-1 2 3 years Yes CP

L6621 UPPER EXTREMITY PROSTHESIS ADDITION, FLEXION/EXTENSION WRIST WITH OR WITHOUT FRICTION, FOR USE WITH EXTERNAL POWERED TERMINAL DEVICE 1547.79 LT-1


L6623 UPPER EXTREMITY ADDITION, SPRING ASSISTED ROTATIONAL WRIST UNIT WITH LATCH RELEASE 558.25 LT-1 RT-1 2 3 years

Yes CP

L6624 UPPER EXTREMITY ADDITION, FLEXION/EXTENSION AND ROTATION WRIST UNIT 2548.50 LT-1 RT-1 2 3 years

Yes CP

L6625 UPPER EXTREMITY ADDITION, ROTATION WRIST UNIT WITH CABLE LOCK 406.66 LT-1 RT-1 2 3 years

Yes CP

L6628 UPPER EXTREMITY ADDITION, QUICK DISCONNECT HOOK ADAPTER, OTTO BOCK OR EQUAL 320.56 LT-1 RT-1 2 3 years

Yes CP

L6629 UPPER EXTREMITY ADDITION, QUICK DISCONNECT LAMINATION COLLAR WITH COUPLING PIECE, OTTO BOCK OR EQUAL 97.90 LT-1 RT-1 2 3 years

Yes CP

L6630 UPPER EXTREMITY ADDITION, STAINLESS STEEL, ANY WRIST 144.22 LT-1 RT-1 2 3 years

Yes CP

L6632 UPPER EXTREMITY ADDITION, LATEX SUSPENSION SLEEVE, EACH 50.09 LT-1 RT-1 2 3 years

Yes CP

L6635 UPPER EXTREMITY ADDITION, LIFT ASSIST FOR ELBOW 117.86 LT-1 RT-1 2 3 years

Yes CP

L6637 UPPER EXTREMITY ADDITION, NUDGE CONTROL ELBOW LOCK 251.40 LT-1 RT-1 2 3 years

Yes CP

L6638 UPPER EXTREMITY ADDITION TO PROSTHESIS, ELECTRIC LOCKING FEATURE, ONLY FOR USE WITH MANUALLY POWERED ELBOW 1692.24 LT-1


L6639 UPPER EXTREMITY ADDITION, HEAVY DUTY FEATURE, ANY ELBOW 1032.08 LT-1 RT-1 2 3 years

Yes CP

L6640 UPPER EXTREMITY ADDITIONS, SHOULDER ABDUCTION JOINT, PAIR 223.33 LT-1 RT-1 2 3 years

Yes CP

L6641 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, PULLEY TYPE 107.35 LT-1 RT-1 2 3 years

Yes CP

L6642 UPPER EXTREMITY ADDITION, EXCURSION AMPLIFIER, LEVER TYPE 145.50 LT-1 RT-1 2 3 years

Yes CP

L6645 UPPER EXTREMITY ADDITION, SHOULDER FLEXION-ABDUCTION JOINT, EACH 268.58 LT-1 RT-1 2 3 years

Yes CP

L6646 UPPER EXTREMITY ADDITION, SHOULDER JOINT, MULTIPOSITIONAL LOCKING, FLEXION, ADJUSTABLE ABDUCTION FRICTION CONTROL, FOR USE WITH BODY POWERED OR EXTERNAL POWERED SYSTEM 2134.30 LT-1


L6647 UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, BODY POWERED ACTUATOR 351.36 LT-1 RT-1 2 3 years

Yes CP

L6648UPPER EXTREMITY ADDITION, SHOULDER LOCK MECHANISM, EXTERNAL POWERED ACTUATOR

2201.22 LT-1 RT-1 2 3 years

Yes CP

L6650 UPPER EXTREMITY ADDITION, SHOULDER UNIVERSAL JOINT, EACH 278.86 LT-1 RT-1 2 3 years

Yes CP

L6655 UPPER EXTREMITY ADDITION, STANDARD CONTROL CABLE, EXTRA 54.81 LT-1 RT-1 2 3 years

Yes CP

L6660 UPPER EXTREMITY ADDITION, HEAVY DUTY CONTROL CABLE 61.42 LT-1 RT-1 2 3 years

Yes CP

L6665 UPPER EXTREMITY ADDITION, TEFLON, OR EQUAL, CABLE LINING 30.82 LT-1 RT-1 2 1 year

Yes CP

L6670 UPPER EXTREMITY ADDITION, HOOK TO HAND, CABLE ADAPTER 34.07 LT-1 RT-1 2 3 years

Yes CP

L6672 UPPER EXTREMITY ADDITION, HARNESS, CHEST OR SHOULDER, SADDLE TYPE 135.22 LT-1 RT-1 2 3 years

Yes CP

L6675UPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), SINGLE CABLE DESIGN

80.36 LT-1 RT-1 2 3 years

Yes CP

L6676 UPPER EXTREMITY ADDITION, HARNESS, (E.G. FIGURE OF EIGHT TYPE), DUAL CABLE DESIGN 92.90 LT-1 RT-1 2 3 years

Yes CP

L6677 UPPER EXTREMITY ADDITION, HARNESS, TRIPLE CONTROL, SIMULTANEOUS OPERATION OF TERMINAL DEVICE AND ELBOW 200.76 LT-1 RT-1 2 3 years

Yes CP

L6680 UPPER EXTREMITY ADDITION, TEST SOCKET, WRIST DISARTICULATION OR BELOW ELBOW 155.26 LT-1 RT-1 2 3 years

Yes CP

L6682 UPPER EXTREMITY ADDITION, TEST SOCKET, ELBOW DISARTICULATION OR ABOVE ELBOW 171.65 LT-1 RT-1 2 3 years

Yes CP

L6684 UPPER EXTREMITY ADDITION, TEST SOCKET, SHOULDER DISARTICULATION OR INTERSCAPULAR THORACIC 233.25 LT-1 RT-1 2 3 years

Yes CP

L6686 UPPER EXTREMITY ADDITION, SUCTION SOCKET 526.73 LT-1 RT-1 2 3 years

Yes CP

L6687 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, BELOW ELBOW OR WRIST DISARTICULATION 385.98 LT-1 RT-1 2 3 years

Yes CP

L6688 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, ABOVE ELBOW OR ELBOW DISARTICULATION 383.66 LT-1 RT-1 2 3 years

Yes CP

L6689 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, SHOULDER DISARTICULATION 459.66 LT-1 RT-1 2 3 years

Yes CP

L6690 UPPER EXTREMITY ADDITION, FRAME TYPE SOCKET, INTERSCAPULAR-THORACIC 500.90 LT-1 RT-1 2 3 years

Yes CP

L6691 UPPER EXTREMITY ADDITION, REMOVABLE INSERT, EACH 231.85 LT-1 RT-1 2 1 year

Yes CP

L6692 UPPER EXTREMITY ADDITION, SILICONE GEL INSERT OR EQUAL, EACH 374.22 LT-1 RT-1 2 1 year

Yes CP

L6693 UPPER EXTREMITY ADDITION, LOCKING ELBOW, FOREARM COUNTERBALANCE 1921.13 LT-1 RT-1 2 3 years

Yes CP

L6694ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM

475.81 LT-1 RT-1 2 1 year

Yes CP

L6695ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED FROM EXISTING MOLD OR PREFABRICATED, SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM

396.50 LT-1 RT-1 2 1 year

Yes CP

L6696ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED SOCKET INSERT FOR CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L6694 OR L6695)

890.13 LT-1 RT-1 2 1 year

Yes CP

L6697ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, CUSTOM FABRICATED SOCKET INSERT FOR OTHER THAN CONGENITAL OR ATYPICAL TRAUMATIC AMPUTEE, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH OR WITHOUT LOCKING MECHANISM, INITIAL ONLY (FOR OTHER THAN INITIAL, USE CODE L6694 OR L6695)

890.13 LT-1 RT-1 2 1 year

Yes CP

L6698 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/ABOVE ELBOW, LOCK MECHANISM, EXCLUDES SOCKET INSERT 384.78 LT-1

RT-1 2 1 yearYes CP

L6703 TERMINAL DEVICE, PASSIVE HAND/MITT, ANY MATERIAL, ANY SIZE 243.27 LT-1 RT-1 2 3 years

Yes CP

L6704 TERMINAL DEVICE, SPORT/RECREATIONAL/WORK ATTACHMENT, ANY MATERIAL, ANY SIZE 391.89 LT-1 RT-1 2 3 years

Yes CP

L6706 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED 233.49 LT-1 RT-1 2 3 years

Yes CP

L6707 TERMINAL DEVICE, HOOK, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE, LINED OR UNLINED 860.58 LT-1 RT-1 2 3 years

Yes CP

L6708 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY OPENING, ANY MATERIAL, ANY SIZE 562.59 LT-1 RT-1 2 3 years

Yes CP

L6709 TERMINAL DEVICE, HAND, MECHANICAL, VOLUNTARY CLOSING, ANY MATERIAL, ANY SIZE 810.71 LT-1 RT-1 2 3 years

Yes CP

L6805 ADDITION TO TERMINAL DEVICE, MODIFIER WRIST UNIT 227.67 LT-1 RT-1 2 3 years

Yes CP

L6810 ADDITION TO TERMINAL DEVICE, PRECISION PINCH DEVICE 129.05 LT-1 RT-1 2 3 years

Yes CP

L6881 AUTOMATIC GRASP FEATURE, ADDITION TO UPPER LIMB ELECTRIC PROSTHETIC TERMINAL DEVICE 2766.49 LT-1 RT-1 2 5 years

Yes CP

L6882 MICROPROCESSOR CONTROL FEATURE, ADDITION TO UPPER LIMB PROSTHETIC TERMINAL DEVICE 2098.53 LT-1 RT-1 2 5 years

Yes CP

L6883 REPLACEMENT SOCKET, BELOW ELBOW/WRIST DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER 1061.88 LT-1


L6884 REPLACEMENT SOCKET, ABOVE ELBOW/ELBOW DISARTICULATION, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER 1576.05 LT-1


L6885 REPLACEMENT SOCKET, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, MOLDED TO PATIENT MODEL, FOR USE WITH OR WITHOUT EXTERNAL POWER 2357.23 LT-1


L6890 ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY MATERIAL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT 113.82 LT-1

RT-1 2 1 yearYes CP

L6895 ADDITION TO UPPER EXTREMITY PROSTHESIS, GLOVE FOR TERMINAL DEVICE, ANY MATERIAL, CUSTOM FABRICATED 418.70 LT-1 RT-1 2 1 year

Yes CP

L6900 HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, THUMB OR ONE FINGER REMAINING 1194.86 LT-1


L6905 HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, MULTIPLE FINGERS REMAINING 1188.06 LT-1


L6910 HAND RESTORATION (CASTS, SHADING AND MEASUREMENTS INCLUDED), PARTIAL HAND, WITH GLOVE, NO FINGERS REMAINING 1015.92 LT-1


L6915 HAND RESTORATION (SHADING, AND MEASUREMENTS INCLUDED), REPLACEMENT GLOVE FOR ABOVE 512.21 LT-1 RT-1 2 3 years

Yes CP

L6920 WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL, SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE 4465.81 LT-1

RT-1 2 3-5 yearsYes ABCP only

L6925WRIST DISARTICULATION, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

6011.74 LT-1 RT-1 2 3-5 years

Yes ABCP only

L6930 BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE 4493.50 LT-1


L6935 BELOW ELBOW, EXTERNAL POWER, SELF-SUSPENDED INNER SOCKET, REMOVABLE FOREARM SHELL, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE 6105.04 LT-1


L6940ELBOW DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

5871.05 LT-1 RT-1 2 3-5 years

Yes ABCP only

L6945 HUMERAL SHELL, OUTSIDE LOCKING HINGES, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

7173.73 LT-1 RT-1 2 3-5 years

Yes ABCP only

L6950ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

6673.70 LT-1 RT-1 2 3-5 years

Yes ABCP only

L6955ABOVE ELBOW, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE HUMERAL SHELL, INTERNAL LOCKING ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

7992.16 LT-1 RT-1 2 3-5 years

Yes ABCP only

L6960SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

9053.12 LT-1 RT-1 2 3-5 years

Yes ABCP only

L6965SHOULDER DISARTICULATION, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

9655.48 LT-1 RT-1 2 3-5 years

Yes ABCP only

L6970INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL SWITCH, CABLES, TWO BATTERIES AND ONE CHARGER, SWITCH CONTROL OF TERMINAL DEVICE

10, 061.18 LT-1


L6975INTERSCAPULAR-THORACIC, EXTERNAL POWER, MOLDED INNER SOCKET, REMOVABLE SHOULDER SHELL, SHOULDER BULKHEAD, HUMERAL SECTION, MECHANICAL ELBOW, FOREARM, OTTO BOCK OR EQUAL ELECTRODES, CABLES, TWO BATTERIES AND ONE CHARGER, MYOELECTRONIC CONTROL OF TERMINAL DEVICE

11003.69 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7007 ELECTRIC HAND, SWITCH OR MYOELECTRIC CONTROLLED, ADULT 2302.63 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7008 ELECTRIC HAND, SWITCH OR MYOELECTRIC, CONTROLLED, PEDIATRIC 3624.10 LT-1 RT-1 2 3-5 years

Yes ABCP only< 21 yrs

L7009 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, ADULT 2349.42 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7040 PREHENSILE ACTUATOR, SWITCH CONTROLLED 1886.49 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7045 ELECTRIC HOOK, SWITCH OR MYOELECTRIC CONTROLLED, PEDIATRIC 1081.59 LT-1 RT-1 2 3-5 years

Yes ABCP only< 21 yrs

L7170 ELECTRONIC ELBOW, HOSMER OR EQUAL, SWITCH CONTROLLED 4980.02 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7180 ELECTRONIC ELBOW, MICROPROCESSOR SEQUENTIAL CONTROL OF ELBOW AND TERMINAL DEVICE 21859.60 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7181 ELECTRONIC ELBOW, MICROPROCESSOR SIMULTANEOUS CONTROL OF ELBOW AND TERMINAL DEVICE 27113.90 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7185 ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED 4917.85 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7186 ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, SWITCH CONTROLLED 5919.11 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7190 ELECTRONIC ELBOW, ADOLESCENT, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED 5165.42 LT-1 RT-1 2 3-5 years

Yes ABCP only

L7191ELECTRONIC ELBOW, CHILD, VARIETY VILLAGE OR EQUAL, MYOELECTRONICALLY CONTROLLED

6185.12 LT-1 RT-1 2 3-5 years

Yes ABCP only

1/15L7259 ELECTRONIC WRIST ROTATOR, ANY TYPE 2437.82 LT-1


L7360 SIX VOLT BATTERY, EACH 159.67 1 6 months Yes ABCP onlyL7362 BATTERY CHARGER, SIX VOLT, EACH 167.66 1 2 years Yes ABCP onlyL7364 TWELVE VOLT BATTERY, EACH 266.65 1 6 months Yes ABCP onlyL7366 BATTERY CHARGER, TWELVE VOLT, EACH 359.18 1 2 years Yes ABCP onlyL7367 LITHIUM ION BATTERY, REPLACEMENT 263.45 2 1 year Yes ABCP onlyL7368 LITHIUM ION BATTERY CHARGER, REPLACEMENT ONLY 341.52 1 1 year Yes ABCP only

L7400 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) 207.41 LT-1

RT-1 2 1 yearYes ABCP

L7401 ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL) 232.18 LT-1


L7402 ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER OR EQUAL)

250.73 LT-1 RT-1 2 1 year

Yes ABCP

L7403 ADDITION TO UPPER EXTREMITY PROSTHESIS, BELOW ELBOW/WRIST DISARTICULATION, ACRYLIC MATERIAL 249.22 LT-1 RT-1 2 1 year

Yes ABCP

L7404 ADDITION TO UPPER EXTREMITY PROSTHESIS, ABOVE ELBOW DISARTICULATION, ACRYLIC MATERIAL 376.10 LT-1 RT-1 2 1 year

Yes ABCP

L7405 ADDITION TO UPPER EXTREMITY PROSTHESIS, SHOULDER DISARTICULATION/INTERSCAPULAR THORACIC, ACRYLIC MATERIAL 491.89 LT-1


1/15 L7510 REPAIR OF PROSTHETIC DEVICE, REPAIR OR REPLACE MINOR PARTS 55.39 3 6 months No CPL7520 REPAIR PROSTHETIC DEVICE, LABOR COMPONENT, PER 15 MINUTES 18.26 8 6 months No CP

L8000 BREAST PROSTHESIS, MASTECTOMY BRA, WITHOUT INTEGRATED BREAST PROSTHESIS FORM, ANY SIZE, ANY TYPE 29.442 1 year

No ABC Certified mastectomy fitter/CO/CP

L8001 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, UNILATERAL, ANY SIZE, ANY TYPE 84.87

2 1 yearNo ABC Certified mastectomy

fitter/CO/CP

L8002 BREAST PROSTHESIS, MASTECTOMY BRA, WITH INTEGRATED BREAST PROSTHESIS FORM, BILATERAL, ANY SIZE, ANY TYPE 111.652 1 year


L8010 BREAST PROSTHESIS, MASTECTOMY SLEEVE 40.822 6 months


L8015 EXTERNAL BREAST PROSTHESIS GARMENT, WITH MASTECTOMY FORM, POST MASTECTOMY 40.562 1 year


L8020 BREAST PROSTHESIS, MASTECTOMY FORM 152.56 LT-1 RT-1 2 2 years


L8030 BREAST PROSTHESIS, SILICONE OR EQUAL, WITHOUT INTEGRAL ADHESIVE 220.67 LT-1 RT-1 2 2 years


L8035CUSTOM BREAST PROSTHESIS, POST MASTECTOMY, MOLDED TO PATIENT MODEL

2479.16 LT-1 RT-1 2 2 years

YesABC Certified mastectomy fitter UNDER SUPERVISION OF CO/CP

L8300 TRUSS, SINGLE WITH STANDARD PAD 65.17 1 1 year No FitterL8310 TRUSS, DOUBLE WITH STANDARD PADS 100.21 1 1 year No Fitter L8320 TRUSS, ADDITION TO STANDARD PAD, WATER PAD 43.78 2 1 year No FitterL8330 TRUSS, ADDITION TO STANDARD PAD, SCROTAL PAD 43.39 2 1 year No Fitter

L8400 PROSTHETIC SHEATH, BELOW KNEE, EACH 12.68 LT-6 RT-6 12 6 months

No Fitter

L8410 PROSTHETIC SHEATH, ABOVE KNEE, EACH 14.42 LT-6 RT-6 12 6 months

No Fitter

L8415 PROSTHETIC SHEATH, UPPER LIMB, EACH 14.34 LT-6 RT-6 12 6 months

No Fitter

L8417 PROSTHETIC SHEATH/SOCK, INCLUDING A GEL CUSHION LAYER, BELOW KNEE OR ABOVE KNEE, EACH 50.88 LT-6 RT-6 12 6 months

No Fitter

10/15L8420 PROSTHETIC SOCK, MULTIPLE PLY, BELOW KNEE, EACH 16.17 LT-6


10/15L8430 PROSTHETIC SOCK, MULTIPLE PLY, ABOVE KNEE, EACH 18.44 LT-6


L8435 PROSTHETIC SOCK, MULTIPLE PLY, UPPER LIMB, EACH 16.55 LT-6 RT-6 12 6 months

No Fitter

10/15L8440 PROSTHETIC SHRINKER, BELOW KNEE, EACH 35.09 LT-2


L8460 PROSTHETIC SHRINKER, ABOVE KNEE, EACH 48.82 LT-2 RT-2 4 6 months

No Fitter

L8465 PROSTHETIC SHRINKER, UPPER LIMB, EACH 43.52 LT-2 RT-2 4 6 months

No Fitter

10/15L8470 PROSTHETIC SOCK, SINGLE PLY, FITTING, BELOW KNEE, EACH 4.46 LT-6


10/15L8480 PROSTHETIC SOCK, SINGLE PLY, FITTING, ABOVE KNEE, EACH 6.16 LT-6


L8485 PROSTHETIC SOCK, SINGLE PLY, FITTING, UPPER LIMB, EACH 7.44 LT-3 RT-3 6 6 months

No Fitter

L8615 HEADSET/HEADPIECE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT 305.20 2 2 years Yes CCC-A XL8616 MICROPHONE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT 71.09 2 2 years Yes CCC-A XL8617 TRANSMITTING COIL FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT 62.09 2 1 year Yes CCC-A XL8618 TRANSMITTER CABLE FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT 17.73 2 1 year Yes CCC-A XL8619 COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR AND CONTROLLER, INTEGRATED SYSTEM, REPLACEMENT 5495.42 1 3 years Yes CCC-A XL8619 COCHLEAR IMPLANT, EXTERNAL SPEECH PROCESSOR ONLY, REPLACEMENT 3995.42 U1 1 3 years Yes CCC-A XL8619 COCHLEAR IMPLANT, EXTERNAL CONTROLLER ONLY, REPLACEMENT 1500.00 U2 1 3 years Yes CCC-A XL8621 ZINC AIR BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, REPLACEMENT, EACH 0.42 180 6 months Yes CCC-A XL8622 ALKALINE BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE, ANY SIZE, REPLACEMENT, EACH (1 unit = 2 pack) 0.22 2 1 year Yes CCC-A X

L8623 LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, OTHER THAN EAR LEVEL, REPLACEMENT, EACH 43.78

1 6 monthsYes CCC-A

X

07/15L8624 LITHIUM ION BATTERY FOR USE WITH COCHLEAR IMPLANT DEVICE SPEECH PROCESSOR, EAR LEVEL, REPLACEMENT, EACH 109.10

2 1 yearYes CCC-A

X07/17 L8690 AUDITORY OSSEOINTEGRATED DEVICE, INCLUDES ALL INTERNAL AND EXTERNAL COMPONENTS 1731.37 1 3 years Yes CCC-A X04/15 L8691 AUDITORY OSSEOINTEGRATED DEVICE, EXTERNAL SOUND PROCESSOR, REPLACEMENT 1731.37 1 3 years Yes CCC-A X

04/15

L8699PROSTHETIC IMPLANT, NOT OTHERWISE SPECIFIED (Preestablished Limitations: Battery Pack 1 per year $116.80 each; i-Connect 1 per 6 months $83.20 each; Battery charger kit 1 per 1year ABC-$127.20, Med El $64.00; All external accessories and parts for cochlear implant device with no separate code may be requested with L8699 (i.e. ABC Firefly 1 per year; Cochlear Mic-lock; Ear hooks 1 per year $9.00 (Med El/Cochlear); Repairs 2 per year, all requests for items without capped rates must be submitted an invoice) BR ----- 1 ----- Yes

CCC-A

X

L9900 ORTHOTIC AND PROSTHETIC SUPPLY, ACCESSORY, AND/OR SERVICE COMPONENT OF ANOTHER HCPCS "L" CODE (FDA Approval Required for any item submitted as well as MSRP pricing from the manufacturer) BR ----- 1 ----- Yes CO/CP ------

S1040 CRANIAL REMOLDING ORTHOSIS, PEDIATRIC, RIGID, WITH SOFT INTERFACE MATERIAL, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT(S) 2100.00 1 2 years Yes ABC/CO/CP

Under 2 years

V2623PROSTHETIC EYE, PLASTIC, CUSTOM

600.66 LT-1 RT-1 2 5 years Yes BCO

V2624POLISHING/RESURFACING OF OCULAR PROSTHESIS

40.74 LT-1 RT-1 2 1 year No BCO

V2625ENLARGEMENT OF OCULAR PROSTHESIS

263.86 LT-1 RT-1 2 1 year Yes BCO

V2626REDUCTION OF OCULAR PROSTHESIS

167.40 LT-1 RT-1 2 1 year Yes BCO

V2627SCLERAL COVER SHELL


V2628FABRICATION AND FITTING OF OCULAR CONFORMER


01/10, 04/16 V5014

REPAIR/MODIFICATION OF A HEARING AID (6 repair units annually per hearing aid) 45.00LT-2 RT-2 4 3 months No < 21 yrs

01/10, 04/16 V5040

HEARING AID, MONAURAL, BODY WORN, BONE CONDUCTION 832.50LT-1 RT-1 2 3 years Yes < 21 yrs

01/10, 04/16 V5050

HEARING AID, MONAURAL, IN THE EAR 832.50LT-1 RT-1 2 3 years Yes < 21 yrs

01/10, 04/16 V5060

HEARING AID, MONAURAL, BEHIND THE EAR 832.50LT-1 RT-1 2 3 years Yes < 21 yrs

01/10, 04/16 V5170

HEARING AID, CROS, IN THE EAR 832.50LT-1 RT-1 2 3 years Yes < 21 yrs

01/10, 04/16 V5180

HEARING AID, CROS, BEHIND THE EAR 832.50LT-1 RT-1 2 3 years Yes < 21 yrs

01/10, 04/16 V5210

HEARING AID, BICROS, IN THE EAR 832.50LT-1 RT-1 2 3 years Yes < 21 yrs

01/10, 04/16 V5220

HEARING AID, BICROS, BEHIND THE EAR 832.50LT-1 RT-1 2 3 years Yes < 21 yrs

01/10, 04/16 V5246

HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, ITE (IN THE EAR) 1325.50LT-1 RT-1 2 3 years Yes < 21 yrs

01/10, 04/16 V5247

HEARING AID, DIGITALLY PROGRAMMABLE ANALOG, MONAURAL, BTE (BEHIND THE EAR) 1325.50LT-1 RT-1 2 3 years Yes < 21 yrs

01/10, 04/16 V5264

EAR MOLD/INSERT, NOT DISPOSABLE, ANY TYPE 45.00LT-2 RT-2 4 3 months No < 21 yrs

V5266 BATTERY FOR USE IN HEARING DEVICE 5.40 8 3 months No < 21 yrs

V5267 HEARING AID OR ASSISTIVE LISTENING DEVICE/SUPPLIES/ACCESSORIES, NOT OTHERWISE SPECIFIED (Replacement Cord report 9.00 allowed 1 time per 5 years) 41.40 2 2 years Yes < 21 yrs

V5299 HEARING SERVICE, MISCELLANEOUS BR ----- 1 ----- Yes < 21 yrs

RT/LT MODIFIER REQUIREMENT WILL BE IMPLEMENTED October 1 ... · GA Medicaid Orthotic & Prosthetic...

Documents

Transcript of RT/LT MODIFIER REQUIREMENT WILL BE IMPLEMENTED October 1 ... · GA Medicaid Orthotic & Prosthetic...