Notification

PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Notification Issue Date: 02/14/2020



Policy Attachment



Attachment to Policy # 00.01.25ax


Attachment:A2

Policy #:00.01.25ax

Description:DME Network Rules and Limited Circumstances cont'd.

Title:PPO Network Rules for Provision of Specialty Services for Durable Medical Equipment and Laboratory, Radiology, and Physical Medicine and Rehabilitative Services


Inclusion of a code in this table does not imply reimbursement. Eligibility, benefits, limitations, exclusions, precertification/referral requirements, provider contracts, and Company policies apply.

The codes listed below are updated on a regular basis, in accordance with nationally accepted coding guidelines. Therefore, this policy applies to any and all future applicable coding changes, revisions, or updates.

In order to ensure optimal reimbursement, all health care services, devices, and pharmaceuticals should be reported using the billing codes and modifiers that most accurately represent the services rendered, unless otherwise directed by the Company.



DURABLE MEDICAL EQUIPMENT NETWORK RULES AND LIMITED CIRCUMSTANCES


NETWORK RULES PROCEDURE CODE LIST (continued)

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
E2366
Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or nonsealed, each
01-01-2004
E2367
Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or nonsealed, each
01-01-2004
E2368
Power wheelchair component, drive wheel motor, replacement only
01-01-2005
E2369
Power wheelchair component, drive wheel gear box, replacement only
01-01-2005
E2370
Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only
01-01-2005
E2371
Power wheelchair accessory, group 27 sealed lead acid battery, (e.g. gel cell, absorbed glassmat), each
01-01-2006
E2372
Power wheelchair accessory, group 27 non-sealed lead acid battery, each
01-01-2006
E2373
Power wheelchair accessory, hand or chin control interface, compact remote joystick proportional, including fixed mounting hardware
01-01-2007
E2374
Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only
01-01-2007
E2375
Power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only
01-01-2007
E2376
Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only
01-01-2007
E2377
Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue
01-01-2007
E2378
Power wheelchair component, actuator, replacement only
01-01-2013
E2381
Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each
01-01-2007
E2382
Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each
01-01-2007
E2383
Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each
01-01-2007
E2384
Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each
01-01-2007
E2385
Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each
01-01-2007
E2386
Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each
01-01-2007
E2387
Power wheelchair accessory, foam filled caster tire, any size, replacement only, each
01-01-2007
E2388
Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each
01-01-2007
E2389
Power wheelchair accessory, foam caster tire, any size, replacement only, each
01-01-2007
E2390
Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each
01-01-2007
E2391
Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each
01-01-2007
E2392
Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each
01-01-2007
E2393
Power wheelchair accessory, valve for pneumatic tire tube, any type, replacement only, each
01-01-2007
12-31-2009
E2394
Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each
01-01-2007
E2395
Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each
01-01-2007
E2396
Power wheelchair accessory, caster fork, any size, replacement only, each
01-01-2007
E2397
Power wheelchair accessory, lithium-based battery, each
01-01-2008
E2398
Wheelchair accessory, dynamic positioning hardware for back
01-01-2020
E2399
Power wheelchair accessory, not otherwise classified interface, including all related electronics and any type mounting hardware
01-01-2004
12-31-2009
E2402
Negative pressure wound therapy electrical pump, stationary or portable
01-01-2004
E2500
Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time
01-01-2004
E2502
Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time
01-01-2004
E2504
Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time
01-01-2004
E2506
Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time
01-01-2004
E2508
Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device
01-01-2004
E2510
Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access
01-01-2004
E2511
Speech generating software program, for personal computer or personal digital assistant
01-01-2004
E2512
Accessory for speech generating device, mounting system
01-01-2004
E2599
Accessory for speech generating device, not otherwise classified
01-01-2004
E2601
General use wheelchair seat cushion, width less than 22 in., any depth
01-01-2005
E2602
General use wheelchair seat cushion, width 22 in. Or greater, any depth
01-01-2005
E2603
Skin protection wheelchair seat cushion, width less than 22 in., any depth
01-01-2005
E2604
Skin protection wheelchair seat cushion, width 22 in. Or greater, any depth
01-01-2005
E2605
Positioning wheelchair seat cushion, width less than 22 in., any depth
01-01-2005
E2606
Positioning wheelchair seat cushion, width 22 in. Or greater, any depth
01-01-2005
E2607
Skin protection and positioning wheelchair seat cushion, width less than 22 in., any depth
01-01-2005
E2608
Skin protection and positioning wheelchair seat cushion, width 22 in. Or greater, any depth
01-01-2005
E2609
Custom fabricated wheelchair seat cushion, any size
01-01-2005
E2610
Wheelchair seat cushion, powered
01-01-2005
E2611
General use wheelchair back cushion, width less than 22 in., any height, including any type mounting hardware
01-01-2005
E2612
General use wheelchair back cushion, width 22 in. Or greater, any height, including any type mounting hardware
01-01-2005
E2613
Positioning wheelchair back cushion, posterior, width less than 22 in., any height, including any type mounting hardware
01-01-2005
E2614
Positioning wheelchair back cushion, posterior, width 22 in. Or greater, any height, including any type mounting hardware
01-01-2005
E2615
Positioning wheelchair back cushion, posterior-lateral, width less than 22 in., any height, including any type mounting hardware
01-01-2005
E2616
Positioning wheelchair back cushion, posterior-lateral, width 22 in. Or greater, any height, including any type mounting hardware
01-01-2005
E2617
Custom fabricated wheelchair back cushion, any size, including any type mounting hardware
01-01-2005
E2618
Wheelchair accessory, solid seat support base (replaces sling seat), for use with manual wheelchair or lightweight power wheelchair, includes any type mounting hardware
01-01-2005
12-31-2007
E2619
Replacement cover for wheelchair seat cushion or back cushion, each
01-01-2005
E2620
Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 in., any height, including any type mounting hardware
01-01-2005
E2621
Positioning wheelchair back cushion, planar back with lateral supports, width 22 in. Or greater, any height, including any type mounting hardware
01-01-2005
E2622
Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth
01-01-2011
E2623
Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
01-01-2011
E2624
Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth
01-01-2011
E2625
Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
01-01-2011
E2626
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable
01-01-2012
E2627
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable rancho type
01-01-2012
E2628
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining
01-01-2012
E2629
Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints)
01-01-2012
E2630
Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support
01-01-2012
E2631
Wheelchair accessory, addition to mobile arm support, elevating proximal arm
01-01-2012
E2632
Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
01-01-2012
E2633
Wheelchair accessory, addition to mobile arm support, supinator
01-01-2012
E8000
Gait trainer, pediatric size, posterior support, includes all accessories and components
01-01-2005
E8001
Gait trainer, pediatric size, upright support, includes all accessories and components
01-01-2005
E8002
Gait trainer, pediatric size, anterior support, includes all accessories and components
01-01-2005
J7340
Dermal and epidermal, (substitute) tissue of human origin, with or without bioengineered or processed elements, with metabolically active elements, per square centimeter
01-01-2002
12-31-2008
J7341
Dermal (substitute) tissue of non-human origin, with or without other bioengineered or processed elements, with metabolically active elements, per square centimeter
01-01-2006
12-31-2008
J7342
Dermal (substitute) tissue of human origin, with or without other bioengineered or processed elements, with metabolically active elements, per square centimeter
01-01-2003
12-31-2008
J7343
Dermal and epidermal, (substitute) tissue of non-human origin, with or without other bioengineered or processed elements, without metabolically active elements, per square centimeter
01-01-2005
12-31-2008
J7344
Dermal (substitute) tissue of human origin, with or without other bioengineered or processed elements, without metabolically active elements, per square centimeter
01-01-2005
12-31-2008
J7345
Dermal (substitute) tissue of non-human origin, with or without other bioengineered or processed elements, without metabolically active elements, per square centimeter
01-01-2007
12-31-2008
J7346
Dermal (substitute) tissue of human origin, injectable, with or without other bioengineered or processed elements, but without metabolically active elements, 1 cc
01-01-2007
12-31-2008
J7347
Dermal (substitute) tissue of nonhuman origin, with or without other bioengineered or processed elements, without metabolically active elements (integra matrix), per square centimeter
01-01-2008
12-31-2008
J7348
Dermal (substitute) tissue of nonhuman origin, with or without other bioengineered or processed elements, without metabolically active elements (tissuemend), per square centimeter
01-01-2008
12-31-2008
J7349
Dermal (substitute) tissue of nonhuman origin, with or without other bioengineered or processed elements, without metabolically active elements (primatrix), per square centimeter
01-01-2008
12-31-2008
J7627
Budesonide, inhalation solution, compounded product, administered through dme, unit dose form, up to 0.5 mg
01-01-2006
J7640
Formoterol, inhalation solution, compounded product, administered through dme, unit dose form, 12 micrograms
01-01-2006
K0001
Standard wheelchair
01-01-1994
K0002
Standard hemi (low seat) wheelchair
01-01-1994
K0003
Lightweight wheelchair
01-01-1994
K0004
High strength, lightweight wheelchair
01-01-1994
K0005
Ultralightweight wheelchair
01-01-1994
K0006
Heavy-duty wheelchair
01-01-1994
K0007
Extra heavy-duty wheelchair
01-01-1994
K0008
Custom manual wheelchair base
07-01-2013
K0009
Other manual wheelchair/base
01-01-1994
K0010
Standard-weight frame motorized/power wheelchair
01-01-1994
K0011
Standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking
01-01-1994
K0012
Lightweight portable motorized/power wheelchair
01-01-1994
K0013
Custom motorized/power wheelchair base
07-01-2013
K0014
Other motorized/power wheelchair base
01-01-1994
K0015
Detachable, nonadjustable height armrest, each
01-01-1994
K0017
Detachable, adjustable height armrest, base, each
01-01-1994
K0018
Detachable, adjustable height armrest, upper portion, each
01-01-1994
K0019
Arm pad, each
01-01-1994
K0020
Fixed, adjustable height armrest, pair
01-01-1994
K0037
High mount flip-up footrest, each
01-01-1994
K0038
Leg strap, each
01-01-1994
K0039
Leg strap, h style, each
01-01-1994
K0040
Adjustable angle footplate, each
01-01-1994
K0041
Large size footplate, each
01-01-1994
K0042
Standard size footplate, each
01-01-1994
K0043
Footrest, lower extension tube, each
01-01-1994
K0044
Footrest, upper hanger bracket, each
01-01-1994
K0045
Footrest, complete assembly
01-01-1994
K0046
Elevating legrest, lower extension tube, each
01-01-1994
K0047
Elevating legrest, upper hanger bracket, each
01-01-1994
K0050
Ratchet assembly
01-01-1994
K0051
Cam release assembly, footrest or legrest, each
01-01-1994
K0052
Swingaway, detachable footrests, each
01-01-1994
K0053
Elevating footrests, articulating (telescoping), each
01-01-1994
K0056
Seat height less than 17 in. Or equal to or greater than 21 in. For a high strength, lightweight, or ultralightweight wheelchair
01-01-1994
K0065
Spoke protectors, each
01-01-1994
K0069
Rear wheel assembly, complete, with solid tire, spokes or molded, each
01-01-1994
K0070
Rear wheel assembly, complete with pneumatic tire, spokes or molded, each
01-01-1994
K0071
Front caster assembly, complete, with pneumatic tire, each
01-01-1994
K0072
Front caster assembly, complete, with semipneumatic tire, each
01-01-1994
K0073
Caster pin lock, each
01-01-1994
K0077
Front caster assembly, complete, with solid tire, each
01-01-1994
K0098
Drive belt for power wheelchair
01-01-1994
K0105
Iv hanger, each
01-01-1994
K0108
Wheelchair component or accessory, not otherwise specified
01-01-1994
K0195
Elevating legrest, pair (for use with capped rental wheelchair base)
01-01-1993
K0455
Infusion pump used for uninterrupted parenteral administration of medication, (e.g., epoprostenol or treprostinol)
01-01-1998
K0462
Temporary replacement for patient owned equipment being repaired, any type
01-01-1998
K0552
Supplies for external drug infusion pump, syringe type cartridge, sterile, each
04-01-2003
K0553
Supply allowance for therapeutic continuous glucose monitor (CGM), includes all supplies and accessories, 1 month supply = 1 unit of service
07-01-2017
K0554
Receiver (monitor), dedicated, for use with therapeutic glucose continueous monitor system
07-01-2017
K0555
Nasal pillows for combination oral/nasal mask, replacement only, pair
07-01-2007
12-31-2007
K0601
Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each
04-01-2003
K0602
Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each
04-01-2003
K0603
Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each
04-01-2003
K0604
Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each
04-01-2003
K0605
Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each
04-01-2003
K0606
Automatic external defibrillator, with integrated electrocardiogram analysis, garment type
07-01-2003
K0607
Replacement battery for automated external defibrillator, garment type only, each
07-01-2003
K0608
Replacement garment for use with automated external defibrillator, each
07-01-2003
K0609
Replacement electrodes for use with automated external defibrillator, garment type only, each
07-01-2003
K0672
Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each
04-01-2008
K0730
Controlled dose inhalation drug delivery system
07-01-2005
K0733
Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g. gel cell, absorbed glassmat)
07-01-2006
K0734
Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth
07-01-2006
01-01-2011
K0735
Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
07-01-2006
01-01-2011
K0736
Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth
07-01-2006
01-01-2011
K0737
Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any depth
07-01-2006
01-01-2011
K0738
Portable gaseous oxygen system, rental: home compressor used to fill portable oxygen cylinders, includes containers, regulator, flowmeter, regulator, flometer, humidifier, cannula or mask and tubing
10-01-2006
K0739
Repair or nonroutine service for durable medical equipment other than oxygen requiring the skill of a technician, labor component, per 15 minutes
04-01-2009
K0740
Repair or nonroutine service for oxygen equipment requiring the skill of a technician, labor component, per 15 minutes
04-01-2009
K0741
Portable gaseous oxygen system, rental, includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing, for cluster headaches
07-01-2011
01-01-2013
K0742
Portable oxygen contents, gaseous, 1 month's supply = 1 unit, for cluster headaches, for initial months supply or to replace used contents
07-01-2011
01-01-2013
K0800
Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds
10-01-2006
K0801
Power operated vehicle, group 1 heavy duty, patient weight capacity, 301 to 450 lbs
10-01-2006
K0802
Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds
10-01-2006
K0806
Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds
10-01-2006
K0807
Power operated vehicle, group 2 heavy duty, patient weight capacity 301 to 450 pounds
10-01-2006
K0808
Power operated vehicle, group 1 very heavy duty, patient weight capacity 451 to 600 pounds
10-01-2006
K0812
Power operated vehicle, not otherwise classified
10-01-2006
K0813
Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds
10-01-2006
K0814
Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds
10-01-2006
K0815
Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds
10-01-2006
K0816
Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds
10-01-2006
K0820
Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds
10-01-2006
K0821
Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds
10-01-2006
K0822
Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
10-01-2006
K0823
Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds
10-01-2006
K0824
Power wheelchair, group 2 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10-01-2006
K0825
Power wheelchair, group 2 heavy duty, captains chair, patient weight capacity 451 to 600 pounds
10-01-2006
K0826
Power wheelchair, group 2 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
10-01-2006
K0827
Power wheelchair, group 2 very heavy duty, captains chair, patient weight capacity 451 to 600 pounds
10-01-2006
K0828
Power wheelchair, group 2 extra heavy duty, sling/solid seat/back, patient weight capacity 600 pounds or more
10-01-2006
K0829
Power wheelchair, group 2 extra heavy duty, captains chair, patient weight capacity 601 pounds or more
10-01-2006
K0835
Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient, patient weight capacity up to and including 300 pounds
10-01-2006
K0836
Power wheelchair, group 2 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
10-01-2006
K0837
Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10-01-2006
K0838
Power wheelchair, group 2 heavy duty, single power option, captains chair, patient capacity 301 to 450 pounds
10-01-2006
K0839
Power wheelchair, group 2 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
10-01-2006
K0840
Power wheelchair, group 2 extra heavy duty, single power option sling/solid seat/back, patient capacity 601 pounds or more
10-01-2006
K0841
Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
10-01-2006
K0842
Power wheelchair, group 2 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds
10-01-2006
K0843
Power wheelchair, group 2 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10-01-2006
K0848
Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds
10-01-2006
K0849
Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds
10-01-2006
K0850
Power wheelchair, group 3 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10-01-2006
K0851
Power wheelchair, group 3 heavy duty, captains chair, patient weight capacity 301 to 450 pounds
10-01-2006
K0852
Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
10-01-2006
K0853
Power wheelchair, group 3 very heavy duty, captains chair, patient weighty capacity, 451 to 600 pounds
10-01-2006
K0854
Power wheelchair, group 3 extra heavy duty, sling/solid seat/back, patient weight capacity 601 pounds or more
10-01-2006
K0855
Power wheelchair, group 3 extra heavy duty, captains chair, patient weight capacity 601 pounds or more
10-01-2006
K0856
Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
10-01-2006
K0857
Power wheelchair, group 3 standard, single power option, captains chair, weight capacity up to and including 300 pounds
10-01-2006
K0858
Power wheelchair, group 3 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10-01-2006
K0859
Power wheelchair, group 3 heavy duty, single power option, captains chair, patient weight capacity 301 to 450 pounds
10-01-2006
K0860
Power wheelchair, group 3 very heavy duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
10-01-2006
K0861
Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
10-01-2006
K0862
Power wheelchair, group 3 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10-01-2006
K0863
Power wheelchair, group 3 very heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds
10-01-2006
K0864
Power wheelchair, group 3 extra heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more
10-01-2006
K0868
Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including up to and including 300 pounds
10-01-2006
K0869
Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds
10-01-2006
K0870
Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10-01-2006
K0871
Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds
10-01-2006
K0877
Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds
10-01-2006
K0878
Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds
10-01-2006
K0879
Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10-01-2006
K0880
Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient 451 to 600 pounds
10-01-2006
K0884
Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient capacity up to and including 300 pounds
10-01-2006
K0885
Power wheelchair, group 4 standard, multiple power option, captains chair, weight capacity up to and including 300 pounds
10-01-2006
K0886
Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds
10-01-2006
K0890
Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
10-01-2006
K0891
Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds
10-01-2006
K0898
Power wheelchair, not otherwise classified
10-01-2006
K0900
Customized durable medical equipment, other than wheelchair
07-01-2013
K0901
Knee orthosis (KO), 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, off-the-shelf
10-01-2014
12-31-2016
K0902
Knee orthosis (KO), double upright, thigh and
calf, with adjustable flexion and extension joint
(unicentric or polycentric), medial-lateral and rotation
control, with or without varus/valgus adjustment,
prefabricated, off-the-shelf
10-01-2014
12-31-2016
K0903
For diabetics only, multiple density insert, made by direct carving with cam technology from a rectified cad model created from a digitized scan of the patient, 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
04-01-2018
01-01-2019
K1001
Electronic positional obstructive sleep apnea treatment, with sensor, includes all components and accessories, any type
01-01-2020
K1002
Cranial electrotherapy stimulation (ces) system, includes all supplies and accessories, any type
01-01-2020
K1003
Whirlpool tub, walk-in, portable
01-01-2020
K1004
Low frequency ultrasonic diathermy treatment device for home use, includes all components and accessories
01-01-2020
K1005
Disposable collection and storage bag for breast milk, any size, any type, each
01-01-2020
Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
L0112
Cranial cervical orthosis, congenital torticollis type, with or without soft interface material, adjustable range of motion joint, custom fabricated
01-01-2004
L0113
Cranial cervical orthosis, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment
01-01-2009
L0120
Cervical, flexible, non-adjustable, prefabricated, off-the-shelf (foam collar)
01-01-1982
L0130
Cervical, flexible, thermoplastic collar, molded to patient
01-01-1984
L0140
Cervical, semi-rigid, adjustable (plastic collar)
01-01-1982
L0150
Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece)
01-01-1982
L0160
Cervical, semi-rigid, wire frame occipital/mandibular support, prefabricated, off-the-shelf
01-01-1982
L0170
Cervical, collar, molded to patient model
01-01-1986
L0172
Cervical, collar, semi-rigid thermoplastic foam, two-piece, prefabricated, off-the-shelf
01-01-1988
L0174
Cervical, collar, semi-rigid, thermoplastic foam, two piece with thoracic extension, prefabricated, off-the-shelf
01-01-1988
L0180
Cervical, multiple post collar, occipital/mandibular supports, adjustable
01-01-1984
L0190
Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (somi, guilford, taylor types)
01-01-1982
L0200
Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension
01-01-1984
L0210
Thoracic, rib belt
01-01-1982
12-31-2009
L0220
Thoracic, rib belt, custom fabricated
01-01-1982
L0430
Spinal orthosis, anterior-posterior-lateral control, with interface material, custom fitted (dewall posture protector only)
01-01-1988
12-31-2013
L0450
Tlso, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf
01-01-2003
L0452
Tlso, flexible, provides trunk support, upper thoracic region, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, custom fabricated
01-01-2003
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
01-01-2003
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
01-01-2014
L0456
Tlso, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
01-01-2003
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
01-01-2014
L0458
Tlso, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
01-01-2003
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
01-01-2003
L0462
Tlso, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment
01-01-2003
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
01-01-2003
L0466
Tlso, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
01-01-2003
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
01-01-2014
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
01-01-2003
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
01-01-2014
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, produces intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment
01-01-2003
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
01-01-2003
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
01-01-2003
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
01-01-2003
L0484
Tlso, triplanar control, two piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated
01-01-2003
L0486
Tlso, triplanar control, two piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or cad-cam model, custom fabricated
01-01-2003
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
01-01-2003
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 sym
01-01-2003
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
01-01-2006
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
01-01-2006
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
01-01-2006
L0622
Sacroiliac orthosis, flexible, provides pelvic-sacral support, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated
01-01-2006
L0623
Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, prefabricated, off-the-shelf
01-01-2006
L0624
Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated
01-01-2006
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
01-01-2006
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
01-01-2006
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
01-01-2006
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
01-01-2006
L0629
Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated
01-01-2006
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
01-01-2006
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
01-01-2006
L0632
Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated
01-01-2006
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
01-01-2006
L0634
Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated
01-01-2006
L0635
Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment
01-01-2006
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
01-01-2006
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
01-01-2006
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
01-01-2006
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
01-01-2006
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
01-01-2006
L0641
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, off-the-shelf
01-01-2014
L0642
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, off-the-shelf
01-01-2014
L0643
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, off-the-shelf
01-01-2014
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
01-01-2014
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
01-01-2014
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
01-01-2014
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
01-01-2014
L0700
Ctlso, anterior-posterior-lateral control, molded to patient model (minerva type)
01-01-1984
L0710
Ctlso, anterior-posterior-lateral control, molded to patient model, with interface material (minerva type)
01-01-1984
L0810
Halo procedure, cervical halo incorporated into jacket vest
01-01-1986
L0820
Halo procedure, cervical halo incorporated into plaster body jacket
01-01-1986
L0830
Halo procedure, cervical halo incorporated into milwaukee type orthosis
01-01-1986
L0859
Addition to halo procedure, magnetic resonance image compatible systems, rings and pins, any material
01-01-2006
L0861
Addition to halo procedure, replacement liner/interface material
01-01-2004
L0960
Torso support, postsurgical support, pads for postsurgical support
01-01-1986
12-31-2007
L0970
Tlso, corset front
01-01-1982
L0972
Lso, corset front
01-01-1982
L0974
Tlso, full corset
01-01-1982
L0976
Lso, full corset
01-01-1982
L0978
Axillary crutch extension
01-01-1982
L0980
Peroneal straps, prefabricated, off-the-shelf, pair
01-01-1986
L0982
Stocking supporter grips, set of four (4)
01-01-1982
L0984
Protective body sock, prefabricated, off-the-shelf, each
01-01-1994
L0999
Addition to spinal orthosis, nos
01-01-1998
L1000
Ctlso (milwaukee), inclusive of furnishing initial orthosis, including model
01-01-1986
L1001
Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, each
01-01-2007
L1005
Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment
01-01-2002
L1010
Addition to ctlso or scoliosis orthosis, axilla sling
01-01-1986
L1020
Addition to ctlso or scoliosis orthosis, kyphosis pad
01-01-1986
L1025
Addition to ctlso or scoliosis orthosis, kyphosis pad, floating
01-01-1988
L1030
Addition to ctlso or scoliosis orthosis, lumbar bolster pad
01-01-1986
L1040
Addition to ctlso or scoliosis orthosis, lumbar or lumbar rib pad
01-01-1986
L1050
Addition to ctlso or scoliosis orthosis, sternal pad
01-01-1986
L1060
Addition to ctlso or scoliosis orthosis, thoracic pad
01-01-1986
L1070
Addition to ctlso or scoliosis orthosis, trapezius sling
01-01-1986
L1080
Addition to ctlso or scoliosis orthosis, outrigger
01-01-1986
L1085
Addition to ctlso or scoliosis orthosis, outrigger, bilateral with vertical extensions
01-01-1988
L1090
Addition to ctlso or scoliosis orthosis, lumbar sling
01-01-1986
L1100
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather
01-01-1986
L1110
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather, molded to patient model
01-01-1986
L1120
Addition to ctlso, scoliosis orthosis, cover for upright, each
01-01-1986
L1200
Tlso, inclusive of furnishing initial orthosis only
01-01-1986
L1210
Addition to tlso, (low profile), lateral thoracic extension
01-01-1986
L1220
Addition to tlso, (low profile), anterior thoracic extension
01-01-1986
L1230
Addition to tlso, (low profile), milwaukee type superstructure
01-01-1986
L1240
Addition to tlso, (low profile), lumbar derotation pad
01-01-1988
L1250
Addition to tlso, (low profile), anterior asis pad
01-01-1988
L1260
Addition to tlso, (low profile), anterior thoracic derotation pad
01-01-1988
L1270
Addition to tlso, (low profile), abdominal pad
01-01-1988
L1280
Addition to tlso, (low profile), rib gusset (elastic), each
01-01-1988
L1290
Addition to tlso, (low profile), lateral trochanteric pad
01-01-1988
L1300
Other scoliosis procedure, body jacket molded to patient model
01-01-1986
L1310
Other scoliosis procedure, postoperative body jacket
01-01-1986
L1499
Spinal orthosis, not otherwise specified
01-01-1982
L1500
Thkao, mobility frame (newington, parapodium types)
01-01-1986
12-31-2011
L1510
Thkao, standing frame, with or without tray and accessories
01-01-1982
12-31-2011
L1520
Thkao, swivel walker
01-01-1982
12-31-2011
L1600
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 individual with expertise
01-01-1986
L1610
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
01-01-1982
L1620
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
01-01-1982
L1630
Ho, abduction control of hip joints, semi-flexible (von rosen type), custom fabricated
01-01-1982
L1640
Ho, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated
01-01-1982
L1650
Ho, abduction control of hip joints, static, adjustable (ilfled type), prefabricated, includes fitting and adjustment
01-01-1982
L1652
Ho, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type
01-01-2003
L1660
Ho, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment
01-01-1982
L1680
Ho, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (rancho hip action type), custom fabricated
01-01-1982
L1685
Ho, abduction control of hip joint, postoperative hip abduction type, custom fabricated
01-01-1988
L1686
Ho, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustments
01-01-1989
L1690
Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment
01-01-1999
L1700
Legg perthes orthosis, (toronto type), custom fabricated
01-01-1982
L1710
Legg perthes orthosis, (newington type), custom fabricated
01-01-1982
L1720
Legg perthes orthosis, trilateral, (tachdijan type), custom fabricated
01-01-1985
L1730
Legg perthes orthosis, (scottish rite type), custom fabricated
01-01-1982
L1755
Legg perthes orthosis, (patten bottom type), custom fabricated
01-01-1988

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
L1800
Ko, elastic with stays, prefabricated, includes fitting and adjustment
01-01-1986
12-31-2009
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
01-01-1982
L1812
Knee orthosis, elastic with joints, prefabricated, off-the-shelf
01-01-2014
L1815
Ko, elastic or other elastic type material with condylar pad(s), prefabricated, includes fitting and adjustment
01-01-1988
12-31-2009
L1820
Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment
01-01-1986
L1825
Ko, elastic knee cap, prefabricated, includes fitting and adjustment
01-01-1985
12-31-2009
L1830
Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf
01-01-1986
L1831
Ko, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment
01-01-2004
L1832
Knee 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
01-01-1989
L1833
Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf
01-01-2014
L1834
Ko, without knee joint, rigid, custom fabricated
01-01-1989
L1836
Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf
01-01-2003
L1840
Ko, derotation, medial-lateral, anterior cruciate ligament, custom fabricated
01-01-1986
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
01-01-1998
L1844
Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
01-01-1993
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
01-01-1988
L1846
Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
01-01-1988
L1847
Knee 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
01-01-1999
L1848
Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf
01-01-2014
L1850
Knee orthosis, swedish type, prefabricated, off-the-shelf
01-01-1982
L1851
Knee orthosis (ko), 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, off-the-shelf
01-01-2017
L1852
Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
01-01-2017
L1855
Ko, molded plastic, thigh and calf sections, with double upright knee joints, custom fabricated
01-01-1988
12-31-2007
L1858
Ko, molded plastic, polycentric knee joints, pneumatic knee pads (cti), custom fabricated
01-01-1988
12-31-2007
L1860
Ko, modification of supracondylar prosthetic socket, custom fabricated (sk)
01-01-1982
L1870
Ko, double upright, thigh and calf lacers, with knee joints, custom fabricated
01-01-1982
12-31-2007
L1880
Ko, double upright, nonmolded thigh and calf cuffs/lacers with knee joints, custom fabricated
01-01-1982
12-31-2007
L1900
Afo, spring wire, dorsiflexion assist calf band, custom fabricated
01-01-1986
L1901
Ankle orthosis, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)
01-01-2003
12-31-2009
L1902
Ankle foot orthosis, ankle gauntlet, prefabricated, off-the-shelf
01-01-1988
L1904
Ankle orthosis, ankle gauntlet, custom-fabricated
01-01-1988
L1906
Ankle foot orthosis, multiligamentus ankle support, prefabricated, off-the-shelf
01-01-1988
L1907
Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated
01-01-2004
L1910
Afo, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment
01-01-1982
L1920
Afo, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated
01-01-1982
L1930
Afo, plastic or other material, prefabricated, includes fitting and adjustment
01-01-1982
L1932
Afo, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment
01-01-2005
L1940
Afo, plastic or other material, custom-fabricated
01-01-1982
L1945
Afo, molded to patient model, plastic, rigid anterior tibial section (floor reaction), custom fabricated
01-01-1989
L1950
Afo, spiral, (institute of rehabilitative medicine type), plastic, custom-fabricated
01-01-1982
L1951
Afo, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment
01-01-2004
L1960
Afo, posterior solid ankle, plastic, custom fabricated
01-01-1982
L1970
Afo, plastic, with ankle joint, custom fabricated
01-01-1982
L1971
Afo, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment
01-01-2004
L1980
Afo, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar bk orthosis), custom fabricated
01-01-1982
L1990
Afo, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar bk orthosis), custom fabricated
01-01-1982
L2000
Kafo, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ak orthosis), custom fabricated
01-01-1985
L2005
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
01-01-2005
L2010
Kafo, single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar ak orthosis), without knee joint, custom fabricated
01-01-1986
L2020
Kafo, double upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar ak orthosis), custom fabricated
01-01-1985
L2030
Kafo, double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar ak orthosis), without knee joint, custom fabricated
01-01-1986
L2034
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
01-01-2006
L2035
Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment
01-01-1998
L2036
Knee ankle foot orthosis, full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated
01-01-1988
L2037
Knee ankle foot orthosis, full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated
01-01-1989
L2038
Knee ankle foot orthosis, full plastic, with or without free motion knee joint , multi-axis ankle, custom fabricated
01-01-1989
L2040
Hkafo, torsion control, bilateral rotation straps, pelvic band/belt, custom fabricated
01-01-1986
L2050
Hkafo, torsion control, bilateral torsion cables, hip joint, pelvic band/belt, custom fabricated
01-01-1982
L2060
Hkafo, torsion control, bilateral torsion cables, ball bearing hip joint, pelvic band/ belt, custom fabricated
01-01-1982
L2070
Hkafo, torsion control, unilateral rotation straps, pelvic band/belt, custom fabricated
01-01-1982
L2080
Hkafo, torsion control, unilateral torsion cable, hip joint, pelvic band/belt, custom fabricated
01-01-1986
L2090
Hkafo, torsion control, unilateral torsion cable, ball bearing hip joint, pelvic band/belt, custom fabricated
01-01-1984
L2106
Afo, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated
01-01-1988
L2108
Afo, fracture orthosis, tibial fracture cast orthosis, custom fabricated
01-01-1988
L2112
Afo, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment
01-01-1988
L2114
Afo, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment
01-01-1988
L2116
Afo, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment
01-01-1988
L2126
Kafo, fracture orthosis, femoral fracture cast orthosis, thermoplastic type casting material, custom fabricated
01-01-1988
L2128
Kafo, fracture orthosis, femoral fracture cast orthosis, custom fabricated
01-01-1988
L2132
Kafo, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment
01-01-1988
L2134
Kafo, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment
01-01-1988
L2136
Kafo, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment
01-01-1988
L2180
Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints
01-01-1988
L2182
Addition to lower extremity fracture orthosis, drop lock knee joint
01-01-1988
L2184
Addition to lower extremity fracture orthosis, limited motion knee joint
01-01-1988
L2186
Addition to lower extremity fracture orthosis, adjustable motion knee joint, lerman type
01-01-1988
L2188
Addition to lower extremity fracture orthosis, quadrilateral brim
01-01-1988
L2190
Addition to lower extremity fracture orthosis, waist belt
01-01-1988
L2192
Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt
01-01-1988
L2200
Addition to lower extremity, limited ankle motion, each joint
01-01-1986
L2210
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
01-01-1986
L2220
Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
01-01-1986
L2230
Addition to lower extremity, split flat caliper stirrups and plate attachment
01-01-1986
L2232
Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only
01-01-2005
L2240
Addition to lower extremity, round caliper and plate attachment
01-01-1986
L2250
Addition to lower extremity, foot plate, molded to patient model, stirrup attachment
01-01-1986
L2260
Addition to lower extremity, reinforced solid stirrup (scott-craig type)
01-01-1986
L2265
Addition to lower extremity, long tongue stirrup
01-01-1989
L2270
Addition to lower extremity, varus/valgus correction (t) strap, padded/lined or malleolus pad
01-01-1986
L2275
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
01-01-1994
L2280
Addition to lower extremity, molded inner boot
01-01-1986
L2300
Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
01-01-1986
L2310
Addition to lower extremity, abduction bar, straight
01-01-1986
L2320
Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only
01-01-1986
L2330
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
01-01-1986
L2335
Addition to lower extremity, anterior swing band
01-01-1988
L2340
Addition to lower extremity, pretibial shell, molded to patient model
01-01-1986
L2350
Addition to lower extremity, prosthetic type, (bk) socket, molded to patient model, (used for ptb, afo orthoses)
01-01-1986
L2360
Addition to lower extremity, extended steel shank
01-01-1986
L2370
Addition to lower extremity, patten bottom
01-01-1988
L2375
Addition to lower extremity, torsion control, ankle joint and half solid stirrup
01-01-1988
L2380
Addition to lower extremity, torsion control, straight knee joint, each joint
01-01-1988
L2385
Addition to lower extremity, straight knee joint, heavy duty, each joint
01-01-1988
L2387
Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint
01-01-2006
L2390
Addition to lower extremity, offset knee joint, each joint
01-01-1988
L2395
Addition to lower extremity, offset knee joint, heavy duty, each joint
01-01-1988
L2397
Addition to lower extremity orthosis, suspension sleeve
01-01-1994
L2405
Addition to knee joint drop, lock, each
01-01-1988
L2415
Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each joint
01-01-1988
L2425
Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint
01-01-1988
L2430
Addition to knee joint, ratchet lock for active and progressive knee extension, each joint
01-01-1997
L2492
Addition to knee joint, lift loop for drop lock ring
01-01-1988
L2500
Addition to lower extremity, thigh/weight bearing, gluteal/ischial weight bearing, ring
01-01-1986
L2510
Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, molded to patient model
01-01-1986
L2520
Addition to lower extremity, thigh/weight bearing, quadri-lateral brim, custom fitted
01-01-1986
L2525
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim molded to patient model
01-01-1989
L2526
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim, custom fitted
01-01-1989
L2530
Addition to lower extremity, thigh/weight bearing, lacer, nonmolded
01-01-1986
L2540
Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model
01-01-1986
L2550
Addition to lower extremity, thigh/weight bearing, high roll cuff
01-01-1986
L2570
Addition to lower extremity, pelvic control, hip joint, clevis type, two position joint, each
01-01-1986
L2580
Addition to lower extremity, pelvic control, pelvic sling
01-01-1986
L2600
Addition to lower extremity, pelvic control, hip joint, clevis type, or thrust bearing, free, each
01-01-1986
L2610
Addition to lower extremity, pelvic control, hip joint, clevis or thrust bearing, lock, each
01-01-1986
L2620
Addition to lower extremity, pelvic control, hip joint, heavy-duty, each
01-01-1986
L2622
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each
01-01-1988
L2624
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each
01-01-1988
L2627
Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables
01-01-1989
L2628
Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables
01-01-1989
L2630
Addition to lower extremity, pelvic control, band and belt, unilateral
01-01-1986
L2640
Addition to lower extremity, pelvic control, band and belt, bilateral
01-01-1986
L2650
Addition to lower extremity, pelvic and thoracic control, gluteal pad, each
01-01-1986
L2660
Addition to lower extremity, thoracic control, thoracic band
01-01-1986
L2670
Addition to lower extremity, thoracic control, paraspinal uprights
01-01-1986
L2680
Addition to lower extremity, thoracic control, lateral support uprights
01-01-1986
L2750
Addition to lower extremity orthosis, plating chrome or nickel, per bar
01-01-1986
L2755
Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only
01-01-1997
L2760
Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth)
01-01-1986
L2768
Orthotic side bar disconnect device, per bar
01-01-2002
L2770
Addition to lower extremity orthosis, any material, per bar or joint
01-01-1986
12-31-2009
L2780
Addition to lower extremity orthosis, noncorrosive finish, per bar
01-01-1986
L2785
Addition to lower extremity orthosis, drop lock retainer, each
01-01-1988
L2795
Addition to lower extremity orthosis, knee control, full kneecap
01-01-1988
L2800
Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only
01-01-1988
L2810
Addition to lower extremity orthosis, knee control, condylar pad
01-01-1988
L2820
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
01-01-1988
L2830
Addition to lower extremity orthosis, soft interface for molded plastic, above knee section
01-01-1988
L2840
Addition to lower extremity orthosis, tibial length sock, fracture or equal, each
01-01-1989
L2850
Addition to lower extremity orthosis, femoral length sock, fracture or equal, each
01-01-1989
L2860
Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism, each
01-01-1995
12-31-2008
L2861
Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each
01-01-2010
L2999
Lower extremity orthoses, nos
01-01-1982
L3000
Foot insert, removable, molded to patient model, ucb type, berkeley shell, each
01-01-1982
L3001
Foot insert, removable, molded to patient model, spenco, each
01-01-1984
L3002
Foot insert, removable, molded to patient model, plastazote or equal, each
01-01-1984
L3003
Foot insert, removable, molded to patient model, silicone gel, each
01-01-1984
L3010
Foot insert, removable, molded to patient model, longitudinal arch support, each
01-01-1982
L3020
Foot insert, removable, molded to patient model, longitudinal/metatarsal support, each
01-01-1986
L3030
Foot insert, removable, formed to patient foot, each
01-01-1986
L3031
Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each
01-01-2004
L3040
Foot, arch support, removable, premolded, longitudinal, each
01-01-1982
L3050
Foot, arch support, removable, premolded, metatarsal, each
01-01-1982
L3060
Foot, arch support, removable, premolded, longitudinal/metatarsal, each
01-01-1982
L3070
Foot, arch support, nonremovable, attached to shoe, longitudinal, each
01-01-1984
L3080
Foot, arch support, nonremovable, attached to shoe, metatarsal, each
01-01-1984
L3090
Foot, arch support, nonremovable, attached to shoe, longitudinal/metatarsal, each
01-01-1984
L3100
Hallus-valgus night dynamic splint, prefabricated, off-the-shelf
01-01-1985
L3140
Foot, abduction rotation bar, including shoes
01-01-1982
L3150
Foot, abduction rotation bar, without shoes
01-01-1984
L3160
Foot, adjustable shoe-styled positioning device
01-01-1986
L3170
Foot, plastic, silicone or equal, heel stabilizer, prafabricated, off-the-shelf, each
01-01-1984
L3201
Orthopedic shoe, oxford with supinator or pronator, infant
01-01-1984
L3202
Orthopedic shoe, oxford with supinator or pronator, child
01-01-1984
L3203
Orthopedic shoe, oxford with supinator or pronator, junior
01-01-1984
L3204
Orthopedic shoe, hightop with supinator or pronator, infant
01-01-1984
L3206
Orthopedic shoe, hightop with supinator or pronator, child
01-01-1984
L3207
Orthopedic shoe, hightop with supinator or pronator, junior
01-01-1984
L3208
Surgical boot, each, infant
01-01-1984
L3209
Surgical boot, each, child
01-01-1984
L3211
Surgical boot, each, junior
01-01-1984
L3212
Benesch boot, pair, infant
01-01-1984
L3213
Benesch boot, pair, child
01-01-1984
L3214
Benesch boot, pair, junior
01-01-1984
L3215
Orthopedic footwear, ladies shoe, oxford, each
01-01-1984
L3216
Orthopedic footwear, ladies shoe, depth inlay, each
01-01-1984
L3217
Orthopedic footwear, ladies shoe, hightop, depth inlay, each
01-01-1984
L3219
Orthopedic footwear, men's shoe, oxford, each
01-01-1984
L3221
Orthopedic footwear, men's shoe, depth inlay, each
01-01-1984
L3222
Orthopedic footwear, men's shoe, hightop, depth inlay, each
01-01-1984
L3224
Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis)
01-01-1995
L3225
Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)
01-01-1995
L3230
Orthopedic footwear, custom shoe, depth inlay, each
01-01-1984
L3250
Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
01-01-1984
L3251
Foot, shoe molded to patient model, silicone shoe, each
01-01-1984
L3252
Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each
01-01-1984
L3253
Foot, molded shoe plastazote (or similar), custom fitted, each
01-01-1984
L3254
Nonstandard size or width
01-01-1984
L3255
Nonstandard size or length
01-01-1984
L3257
Orthopedic footwear, additional charge for split size
01-01-1988
L3260
Surgical boot/shoe, each
01-01-1984
L3265
Plastazote sandal, each
01-01-1984
L3300
Lift, elevation, heel, tapered to metatarsals, per in.
01-01-1986
L3310
Lift, elevation, heel and sole, neoprene, per in.
01-01-1986
L3320
Lift, elevation, heel and sole, cork, per in.
01-01-1986
L3330
Lift, elevation, metal extension (skate)
01-01-1986
L3332
Lift, elevation, inside shoe, tapered, up to one-half in.
01-01-1986
L3334
Lift, elevation, heel, per in.
01-01-1986
L3340
Heel wedge, sach
01-01-1982

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
L3350
Heel wedge
01-01-1982
L3360
Sole wedge, outside sole
01-01-1984
L3370
Sole wedge, between sole
01-01-1984
L3380
Clubfoot wedge
01-01-1982
L3390
Outflare wedge
01-01-1982
L3400
Metatarsal bar wedge, rocker
01-01-1984
L3410
Metatarsal bar wedge, between sole
01-01-1984
L3420
Full sole and heel wedge, between sole
01-01-1984
L3430
Heel, counter, plastic reinforced
01-01-1985
L3440
Heel, counter, leather reinforced
01-01-1984
L3450
Heel, sach cushion type
01-01-1984
L3455
Heel, new leather, standard
01-01-1984
L3460
Heel, new rubber, standard
01-01-1984
L3465
Heel, thomas with wedge
01-01-1984
L3470
Heel, thomas extended to ball
01-01-1984
L3480
Heel, pad and depression for spur
01-01-1984
L3485
Heel, pad, removable for spur
01-01-1984
L3500
Orthopedic shoe addition, insole, leather
01-01-1986
L3510
Orthopedic shoe addition, insole, rubber
01-01-1986
L3520
Orthopedic shoe addition, insole, felt covered with leather
01-01-1986
L3530
Orthopedic shoe addition, sole, half
01-01-1986
L3540
Orthopedic shoe addition, sole, full
01-01-1986
L3550
Orthopedic shoe addition, toe tap, standard
01-01-1986
L3560
Orthopedic shoe addition, toe tap, horseshoe
01-01-1986
L3570
Orthopedic shoe addition, special extension to instep (leather with eyelets)
01-01-1986
L3580
Orthopedic shoe addition, convert instep to velcro closure
01-01-1986
L3590
Orthopedic shoe addition, convert firm shoe counter to soft counter
01-01-1986
L3595
Orthopedic shoe addition, march bar
01-01-1986
L3600
Transfer of an orthosis from one shoe to another, caliper plate, existing
01-01-1986
L3610
Transfer of an orthosis from one shoe to another, caliper plate, new
01-01-1986
L3620
Transfer of an orthosis from one shoe to another, solid stirrup, existing
01-01-1986
L3630
Transfer of an orthosis from one shoe to another, solid stirrup, new
01-01-1986
L3640
Transfer of an orthosis from one shoe to another, dennis browne splint (riveton), both shoes
01-01-1986
L3649
Orthopedic shoe, modification, addition or transfer, nos
01-01-1982
L3650
Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
01-01-1986
L3651
So, single shoulder, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)
01-01-2003
12-31-2009
L3652
So, double shoulder, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)
01-01-2003
12-31-2009
L3660
Shoulder orthosis, figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf
01-01-1982
L3670
Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf
01-01-1982
L3671
Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3672
Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
01-01-2011
L3673
Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, includes nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
01-01-2011
L3674
Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2011
L3675
houlder orthosis, vest type abduction restrainer, canvas webbing type or equal, prefabricated, off-the-shelf
01-01-1999
L3677
Shoulder orthosis, shoulder joint design, 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
01-01-2002
L3678
Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated, off-the-shelf
01-01-2014
L3700
Eo, elastic with stays, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2009
L3701
Eo, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)
01-01-2003
12-31-2009
L3702
Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3710
Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf
01-01-1986
L3720
Eo, double upright with forearm/arm cuffs, free motion, custom fabricated
01-01-1984
L3730
Eo, double upright with forearm/arm cuffs, extension/flexion assist, custom fabricated
01-01-1982
L3740
Eo, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated
01-01-1982
L3760
Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
01-01-2001
L3761
Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf
01-01-2018
L3762
Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf
01-01-2003
L3763
Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
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
01-01-2006
L3765
Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
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
01-01-2006
L3800
Whfo, short opponens, no attachments, custom fabricated
01-01-1982
12-31-2007
L3805
Whfo, long opponens, no attachment, custom fabricated
01-01-1982
12-31-2007
L3806
Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment
01-01-2007
L3807
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
01-01-2000
L3808
Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment
01-01-2007
L3809
Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type
01-01-2014
L3810
Whfo, addition to short and long opponens, thumb abduction (c) bar
01-01-1986
12-31-2007
L3815
Whfo, addition to short and long opponens, second m.p. abduction assist
01-01-1986
12-31-2007
L3820
Whfo, addition to short and long opponens, i.p. extension assist, with m.p. extension stop
01-01-1986
12-31-2007
L3825
Whfo, addition to short and long opponens, m.p. extension stop
01-01-1986
12-31-2007
L3830
Whfo, addition to short and long opponens, m.p. extension assist
01-01-1986
12-31-2007
L3835
Whfo, addition to short and long opponens, m.p. spring extension assist
01-01-1986
12-31-2007
L3840
Whfo, addition to short and long opponens, spring swivel thumb
01-01-1986
12-31-2007
L3845
Whfo, addition to short and long opponens, thumb i.p. extension assist, with m.p. stop
01-01-1986
12-31-2007
L3850
Whfo, addition to short and long opponens, action wrist, with dorsiflexion assist
01-01-1986
12-31-2007
L3855
Whfo, addition to short and long opponens, adjustable m.p. flexion control
01-01-1986
12-31-2007
L3860
Whfo, addition to short and long opponens, adjustable m.p. flexion control and i.p.
01-01-1986
12-31-2007
L3890
Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism, each
01-01-1995
12-31-2007
L3891
Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each
01-01-2010
L3900
Whfo, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, wrist or finger driven, custom fabricated
01-01-1986
L3901
Whfo, dynamic flexor hinge, reciprocal wrist extension/flexion, finger flexion/extension, cable driven, custom fabricated
01-01-1984
L3904
Whfo, external powered, electric, custom fabricated
01-01-1982
L3905
Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3906
Wrist hand orthosis, custom 'fabricated, includes fitting and adjustment
01-01-1986
L3907
Whfo, wrist gauntlet with thumb spica, molded to patient model, custom fabricated
01-01-1988
12-31-2007
L3908
Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf
01-01-1986
L3909
Wo, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)
01-01-2003
12-31-2009
L3910
Whfo, swanson design, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3911
Whfo, elastic, prefabricated, includes fitting and adjustment (e.g., neoprene, lycra)
01-01-2003
12-31-2009
L3912
Hand finger orthosis (hfo), flexion glove with elastic finger control, prefabricated, off-the-shelf
01-01-1982
L3913
Hand finger orthosis, without joints, may include soft interface, straps, 'custom fabricated, includes fitting and adjustment
01-01-2006
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
01-01-2007
L3916
Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf
01-01-2014
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
01-01-2004
L3918
Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf
01-01-2014
L3919
Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3920
Hfo, knuckle bender, with outrigger, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3921
Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3922
Hfo, knuckle bender, two segment to flex joints, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3923
Hand 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
01-01-2001
L3924
Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-the-shelf
01-01-2014
L3925
Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf
01-01-2008
L3926
Whfo, thomas suspension, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3927
Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (e.g. static or ring type), may include soft interface material, prefabricated, off-the-shelf
01-01-2008
L3928
Hfo, finger extension, with clock spring, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
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
01-01-2008
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
01-01-2014
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
01-01-2008
L3932
Fo, safety pin, spring wire, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3933
Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment
01-01-2006
L3934
Fo, safety pin, modified, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3935
Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment
01-01-2006
L3936
Whfo, palmer, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3938
Whfo, dorsal wrist, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3940
Whfo, dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3942
Hfo, reverse knuckle bender, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3944
Hfo, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3946
Hfo, composite elastic, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3948
Fo, finger knuckle bender, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3950
Whfo, combination oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3952
Whfo, combination oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3954
Hfo, spreading hand, prefabricated, includes fitting and adjustment
01-01-1982
12-31-2007
L3956
Addition of joint to upper extremity orthosis, any material; per joint
01-01-1997
L3960
Sewho, abduction positioning, airplane design, prefabricated, includes fitting and adjustment
01-01-1986
L3961
Shoulder elbow wrist hand orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3962
Sewho, abduction positioning, erb's palsy design, prefabricated, includes fitting and adjustment
01-01-1982
L3964
Seo, mobile arm support attached to wheelchair, balanced, adjustable, prefabricated, includes fitting and adjustment
01-01-1986
12-31-2011
L3965
Seo, mobile arm support attached to wheelchair, balanced, adjustable rancho type, prefabricated, includes fitting and adjustment
01-01-1984
12-31-2011
L3966
Seo, mobile arm support attached to wheelchair, balanced, reclining, prefabricated, includes fitting and adjustment
01-01-1986
12-31-2011
L3967
Shoulder 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
01-01-2006
L3968
Seo, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints), prefabricated, includes fitting and adjustment
01-01-1986
12-31-2011
L3969
Seo, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type arm suspension support, prefabricated, includes fitting and adjustment
01-01-1988
12-31-2011
L3970
Seo, addition to mobile arm support, elevating proximal arm
01-01-1986
12-31-2011
L3971
Shoulder elbow wrist hand orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3972
Seo, addition to mobile arm support, offset or lateral rocker arm with elastic balance control
01-01-1986
12-31-2011
L3973
Shoulder elbow wrist hand orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3974
Seo, addition to mobile arm support, supinator
01-01-1986
12-31-2011
L3975
Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3976
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3977
Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3978
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
01-01-2006
L3980
Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment
01-01-1982
L3981
Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments
01-01-2015
L3982
Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment
01-01-1984
L3984
Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment
01-01-1982
L3985
Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom fabricated
01-01-1988
12-31-2007
L3986
Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example: colles' fracture), custom fabricated
01-01-1984
12-31-2007
L3995
Addition to upper extremity orthosis, sock, fracture or equal, each
01-01-1989
L3999
Upper limb orthosis, nos
01-01-1982
L4000
Replace girdle for spinal orthosis (ctlso or so)
01-01-1985
L4002
Replacement strap, any orthosis, includes all components, any length, any type
01-01-2005
L4010
Replace trilateral socket brim
01-01-1985
L4020
Replace quadrilateral socket brim, molded to patient model
01-01-1985
L4030
Replace quadrilateral socket brim, custom fitted
01-01-1985
L4040
Replace molded thigh lacer, for custom fabricated orthosis only
01-01-1985
L4045
Replace non-molded thigh lacer, for custom fabricated orthosis only
01-01-1988
L4050
Replace molded calf lacer, for custom fabricated orthosis only
01-01-1985
L4055
Replace non-molded calf lacer, for custom fabricated orthosis only
01-01-1988
L4060
Replace high roll cuff
01-01-1985
L4070
Replace proximal and distal upright for kafo
01-01-1986
L4080
Replace metal bands kafo, proximal thigh
01-01-1986
L4090
Replace metal bands kafo-afo, calf or distal thigh
01-01-1985
L4100
Replace leather cuff kafo, proximal thigh
01-01-1986
L4110
Replace leather cuff kafo-afo, calf or distal thigh
01-01-1985
L4130
Replace pretibial shell
01-01-1984
L4205
Repair of orthotic device, labor component, per 15 minutes
01-01-1997
L4210
Repair of orthotic device, repair or replace minor parts
01-01-1985
L4350
Ankle control orthosis, stirrup style, rigid, includes any type interface (e.g., pneumatic, gel), prefabricated, off-the-shelf
01-01-1989
L4360
Walking 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
01-01-1989
L4361
Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf
01-01-2014
L4370
Pneumatic full leg splint, prefabricated, off-the-shelf
01-01-1989
L4380
Pneumatic knee splint, prefabricated, includes fitting and adjustment
01-01-1989
12-31-2011
L4386
Walking 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
01-01-2003
L4387
Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf
01-01-2014
L4392
Replacement soft interface material, static afo
01-01-1997
L4394
Replace soft interface material, foot drop splint
01-01-1997
L4396
Static 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
01-01-1997
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
01-01-2014
L4398
Foot drop splint, recumbent positioning device, prefabricated, off-the-shelf
01-01-1997
L4631
Ankle foot orthosis, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated
01-01-2011
L5000
Partial foot, shoe insert with longitudinal arch, toe filler
01-01-1982
L5010
Partial foot, molded socket, ankle height, with toe filler
01-01-1982
L5020
Partial foot, molded socket, tibial tubercle height, with toe filler
01-01-1982
L5050
Ankle, symes, molded socket, sach foot
01-01-1985
L5060
Ankle, symes, metal frame, molded leather socket, articulated ankle/foot
01-01-1985
L5100
Below knee, molded socket, shin, sach foot
01-01-1982
L5105
Below knee, plastic socket, joints and thigh lacer, sach foot
01-01-1989
L5150
Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot
01-01-1982
L5160
Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, sach foot
01-01-1982
L5200
Above knee, molded socket, single axis constant friction knee, shin, sach foot
01-01-1982
L5210
Above knee, short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, each
01-01-1982
L5220
Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each
01-01-1982
L5230
Above knee, for proximal femoral focal deficiency, constant friction knee, shin, sach foot
01-01-1982
L5250
Hip disarticulation, canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot
01-01-1982
L5270
Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, sach foot
01-01-1982
L5280
Hemipelvectomy, canadian type; molded socket, hip joint, single axis constant friction knee, shin, sach foot
01-01-1982
L5301
Below knee, molded socket, shin, sach foot, endoskeletal system
01-01-2002
L5311
Knee disarticulation (or through knee), molded socket, external knee joints, shin, sach foot, endoskeletal system
01-01-2002
12-31-2011
L5312
Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system
01-01-2012
L5321
Above knee, molded socket, open end, sach foot, endoskeletal system, single axis knee
01-01-2002
L5331
Hip disarticulation, canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot
01-01-2002
L5341
Hemipelvectomy, canadian type, molded socket, endoskeletal system, hip joint, single axis knee, sach foot
01-01-2002
L5400
Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee
01-01-1982
L5410
Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment
01-01-1986
L5420
Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change ak or knee disarticulation
01-01-1982
L5430
Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, ak or knee disarticulation, each additional cast change and realignment
01-01-1986
L5450
Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, below knee
01-01-1982
L5460
Immediate postsurgical or early fitting, application of nonweight bearing rigid dressing, above knee
01-01-1982
L5500
Initial, below knee ptb type socket, nonalignable system, pylon, no cover, sach foot, plaster socket, direct formed
01-01-1986
L5505
Initial, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, sach foot plaster socket, direct formed
01-01-1986
L5510
Preparatory, below knee ptb type socket, nonalignable system, pylon, no cover, sach foot, plaster socket, molded to model
01-01-1986
L5520
Preparatory, below knee ptb type socket, nonalignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed
01-01-1986
L5530
Preparatory, below knee ptb type socket, nonalignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model
01-01-1986
L5535
Preparatory, below knee ptb type socket, nonalignable system, pylon, no cover, sach foot, prefabricated, adjustable open end socket
01-01-1989
L5540
Preparatory, below knee ptb type socket, nonalignable system, pylon, no cover, sach foot, laminated socket, molded to model
01-01-1986
L5560
Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, sach foot, plaster socket, molded to model
01-01-1986
L5570
Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed
01-01-1986
L5580
Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model
01-01-1986
L5585
Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, sach foot, prefabricated adjustable open end socket
01-01-1988
L5590
Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, sach foot, laminated socket, molded to model
01-01-1986
L5595
Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model
01-01-1989
L5600
Preparatory, hip disarticulation - hemipelvectomy, pylon, no cover, sach foot, laminated socket, molded to patient model
01-01-1989
L5610
Addition to lower extremity, endoskeletal system, above knee, hydracadence system
01-01-1986
L5611
Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with friction swing phase control
01-01-1989
L5613
Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with hydraulic swing phase control
01-01-1989
L5614
Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4-bar linkage, with pneumatic swing phase control
01-01-1994
L5616
Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control
01-01-1986
L5617
Addition to lower extremity, quick change self-aligning unit, above or below knee, each
01-01-1996
L5618
Addition to lower extremity, test socket, symes
01-01-1986
L5620
Addition to lower extremity, test socket, below knee
01-01-1986
L5622
Addition to lower extremity, test socket, knee disarticulation
01-01-1986
L5624
Addition to lower extremity, test socket, above knee
01-01-1986
L5626
Addition to lower extremity, test socket, hip disarticulation
01-01-1986
L5628
Addition to lower extremity, test socket, hemipelvectomy
01-01-1986
L5629
Addition to lower extremity, below knee, acrylic socket
01-01-1989
L5630
Addition to lower extremity, symes type, expandable wall socket
01-01-1986
L5631
Addition to lower extremity, above knee or knee disarticulation, acrylic socket
01-01-1989
L5632
Addition to lower extremity, symes type, ptb brim design socket
01-01-1986
L5634
Addition to lower extremity, symes type, posterior opening (canadian) socket
01-01-1986
L5636
Addition to lower extremity, symes type, medial opening socket
01-01-1986
L5637
Addition to lower extremity, below knee, total contact
01-01-1989

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
L5638
Addition to lower extremity, below knee, leather socket
01-01-1986
L5639
Addition to lower extremity, below knee, wood socket
01-01-1989
L5640
Addition to lower extremity, knee disarticulation, leather socket
01-01-1986
L5642
Addition to lower extremity, above knee, leather socket
01-01-1986
L5643
Addition to lower extremity, hip disarticulation, flexible inner socket, external frame
01-01-1988
L5644
Addition to lower extremity, above knee, wood socket
01-01-1986
L5645
Addition to lower extremity, below knee, flexible inner socket, external frame
01-01-1988
L5646
Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket
01-01-1986
L5647
Addition to lower extremity, below knee, suction socket
01-01-1988
L5648
Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket
01-01-1986
L5649
Addition to lower extremity, ischial containment/narrow m-l socket
01-01-1988
L5650
Addition to lower extremity, total contact, above knee or knee disarticulation socket
01-01-1986
L5651
Addition to lower extremity, above knee, flexible inner socket, external frame
01-01-1988
L5652
Addition to lower extremity, suction suspension, above knee or knee disarticulation socket
01-01-1986
L5653
Addition to lower extremity, knee disarticulation, expandable wall socket
01-01-1986
L5654
Addition to lower extremity, socket insert, symes (kemblo, pelite, aliplast, plastazote or equal)
01-01-1986
L5655
Addition to lower extremity, socket insert, below knee (kemblo, pelite, aliplast, plastazote or equal)
01-01-1986
L5656
Addition to lower extremity, socket insert, knee disarticulation (kemblo, pelite, aliplast, plastazote or equal)
01-01-1986
L5658
Addition to lower extremity, socket insert, above knee (kemblo, pelite, aliplast, plastazote or equal)
01-01-1986
L5661
Addition to lower extremity, socket insert, multidurometer, symes
01-01-1988
L5665
Addition to lower extremity, socket insert, multidurometer, below knee
01-01-1988
L5666
Addition to lower extremity, below knee, cuff suspension
01-01-1986
L5668
Addition to lower extremity, below knee, molded distal cushion
01-01-1986
L5670
Addition to lower extremity, below knee, molded supracondylar suspension (pts or similar)
01-01-1986
L5671
Addition to lower extremity, below knee/above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert
01-01-2002
L5672
Addition to lower extremity, below knee, removable medial brim suspension
01-01-1986
L5673
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
01-01-2004
L5676
Addition to lower extremity, below knee, knee joints, single axis, pair
01-01-1986
L5677
Addition to lower extremity, below knee, knee joints, polycentric, pair
01-01-1988
L5678
Addition to lower extremity, below knee joint covers, pair
01-01-1984
L5679
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
01-01-2004
L5680
Addition to lower extremity, below knee, thigh lacer, nonmolded
01-01-1986
L5681
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 cod
01-01-2004
L5682
Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded
01-01-1986
L5683
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
01-01-2004
L5684
Addition to lower extremity, below knee, fork strap
01-01-1986
L5685
Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each
01-01-2005
L5686
Addition to lower extremity, below knee, back check (extension control)
01-01-1986
L5688
Addition to lower extremity, below knee, waist belt, webbing
01-01-1986
L5690
Addition to lower extremity, below knee, waist belt, padded and lined
01-01-1986
L5692
Addition to lower extremity, above knee, pelvic control belt, light
01-01-1986
L5694
Addition to lower extremity, above knee, pelvic control belt, padded and lined
01-01-1986
L5695
Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each
01-01-1989
L5696
Addition to lower extremity, above knee or knee disarticulation, pelvic joint
01-01-1986
L5697
Addition to lower extremity, above knee or knee disarticulation, pelvic band
01-01-1986
L5698
Addition to lower extremity, above knee or knee disarticulation, silesian bandage
01-01-1986
L5699
All lower extremity prostheses, shoulder harness
01-01-1986
L5700
Replacement, socket, below knee, molded to patient model
01-01-1994
L5701
Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model
01-01-1994
L5702
Replacement, socket, hip disarticulation, including hip joint, molded to patient model
01-01-1994
L5703
Ankle, symes, molded to patient model, socket without solid ankle cushion heel (sach) foot, replacement only
01-01-2006
L5704
Custom shaped protective cover, below knee
01-01-1994
L5705
Custom shaped protective cover, above knee
01-01-1994
L5706
Custom shaped protective cover, knee disarticulation
01-01-1994
L5707
Custom shaped protective cover, hip disarticulation
01-01-1994
L5710
Addition, exoskeletal knee-shin system, single axis, manual lock
01-01-1986
L5711
Addition, exoskeletal knee-shin system, single axis, manual lock, ultra-light material
01-01-1988
L5712
Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)
01-01-1986
L5714
Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control
01-01-1986
L5716
Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock
01-01-1986
L5718
Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control
01-01-1986
L5722
Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control
01-01-1986
L5724
Addition, exoskeletal knee-shin system, single axis, fluid swing phase control
01-01-1986
L5726
Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control
01-01-1986
L5728
Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control
01-01-1986
L5780
Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control
01-01-1986
L5781
Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system
01-01-2003
L5782
Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy duty
01-01-2003
L5785
Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)
01-01-1988
L5790
Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)
01-01-1988
L5795
Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)
01-01-1988
L5810
Addition, endoskeletal knee-shin system, single axis, manual lock
01-01-1988
L5811
Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material
01-01-1988
L5812
Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee)
01-01-1988
L5814
Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock
01-01-1997
L5816
Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock
01-01-1988
L5818
Addition, endoskeletal knee-shin system, polycentric, friction swing and stance phase control
01-01-1988
L5822
Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control
01-01-1988
L5824
Addition, endoskeletal knee-shin system, single axis, fluid swing phase control
01-01-1988
L5826
Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame
01-01-1998
L5828
Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control
01-01-1988
L5830
Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control
01-01-1988
L5840
Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control
01-01-1994
L5845
Addition, endoskeletal knee-shin system, stance flexion feature, adjustable
01-01-1996
L5848
Addition to endoskeletal knee-shin system, hydraulic fluid stance extension, dampening feature, with or without adjustability
01-01-2003
L5850
Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist
01-01-1988
L5855
Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist
01-01-1994
L5856
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
01-01-2005
L5857
Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type
01-01-2005
L5858
Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type
01-01-2006
L5859
Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)
01-01-2013
L5910
Addition, endoskeletal system, below knee, alignable system
01-01-1988
L5920
Addition, endoskeletal system, above knee or hip disarticulation, alignable system
01-01-1988
L5925
Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock
01-01-1994
L5930
Addition, endoskeletal system, high activity knee control frame
01-01-1996
L5940
Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal)
01-01-1988
L5950
Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal)
01-01-1988
L5960
Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)
01-01-1988
L5961
Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control
01-01-2011
L5962
Addition, endoskeletal system, below knee, flexible protective outer surface covering system
01-01-1994
L5964
Addition, endoskeletal system, above knee, flexible protective outer surface covering system
01-01-1994
L5966
Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system
01-01-1994
L5968
Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature
01-01-1999
L5969
Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s)
01-01-2014
L5970
All lower extremity prostheses, foot, external keel, sach foot
01-01-1989
L5971
All lower extremity prosthesis, solid ankle cushion heel (sach) foot, replacement only
01-01-2006
L5972
All lower extremity prostheses, foot, flexible keel
01-01-1989
L5973
Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source
01-01-2010
L5974
All lower extremity prostheses, foot, single axis ankle/foot
01-01-1989
L5975
All lower extremity prosthesis, combination single axis ankle and flexible keel foot
01-01-1999
L5976
All lower extremity prostheses, energy storing foot (seattle carbon copy ii or equal)
01-01-1989
L5978
All lower extremity prostheses, foot, multiaxial ankle/foot
01-01-1989
L5979
All lower extremity prostheses, multiaxial ankle, dynamic response foot, one piece system
01-01-1994
L5980
All lower extremity prostheses, flex-foot system
01-01-1989
L5981
All lower extremity prostheses, flex-walk system or equal
01-01-1994
L5982
All exoskeletal lower extremity prostheses, axial rotation unit
01-01-1989
L5984
All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability
01-01-1989
L5985
All endoskeletal lower extremity prostheses, dynamic prosthetic pylon
01-01-1996
L5986
All lower extremity prostheses, multiaxial rotation unit (mcp or equal)
01-01-1989
L5987
All lower extremity prosthesis, shank foot system with vertical loading pylon
01-01-1997
L5988
Addition to lower limb prosthesis, vertical shock reducing pylon feature
01-01-1999
L5990
Addition to lower extremity prosthesis, user adjustable heel height
01-01-2002
L5993
Addition to lower extremity prosthesis, heavy duty feature, foot only, (for patient weight greater than 300 lbs)
01-01-2007
12-31-2008
L5994
Addition to lower extremity prosthesis, heavy duty feature, knee only, (for patient weight greater than 300 lbs)
01-01-2007
12-31-2008
L5995
Addition to lower extremity prosthesis, heavy duty feature, other than foot or knee, (for patient weight greater than 300 lbs)
01-01-2003
12-31-2008
L5999
Lower extremity prosthesis, not otherwise specified
01-01-1982
L6000
Partial hand, thumb remaining
01-01-1982
L6010
Partial hand, little and/or ring finger remaining
01-01-1982
L6020
Partial hand, no finger remaining
01-01-1982
L6025
Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device
01-01-2003
12-31-2014
L6026
Transcarpal/metacarpal or partial hand disarticulation prosthesis, external power, self-suspended, inner socket with removable forearm section, electrodes and cables, two batteries, charger, myoelectric control of terminal device, excludes terminal device(s)
01-01-2015
L6050
Wrist disarticulation, molded socket, flexible elbow hinges, triceps pad
01-01-1982
L6055
Wrist disarticulation, molded socket with expandable interface, flexible elbow hinges, triceps pad
01-01-1988
L6100
Below elbow, molded socket, flexible elbow hinge, triceps pad
01-01-1982
L6110
Below elbow, molded socket (muenster or northwestern suspension types)
01-01-1982
L6120
Below elbow, molded double wall split socket, step-up hinges, half cuff
01-01-1982
L6130
Below elbow, molded double wall split socket, stump activated locking hinge, half cuff
01-01-1982
L6200
Elbow disarticulation, molded socket, outside locking hinge, forearm
01-01-1982
L6205
Elbow disarticulation, molded socket with expandable interface, outside locking hinges, forearm
01-01-1988
L6250
Above elbow, molded double wall socket, internal locking elbow, forearm
01-01-1982
L6300
Shoulder disarticulation, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm
01-01-1982
L6310
Shoulder disarticulation, passive restoration (complete prosthesis)
01-01-1982
L6320
Shoulder disarticulation, passive restoration (shoulder cap only)
01-01-1982
L6350
Interscapular thoracic, molded socket, shoulder bulkhead, humeral section, internal locking elbow, forearm
01-01-1984
L6360
Interscapular thoracic, passive restoration (complete prosthesis)
01-01-1986
L6370
Interscapular thoracic, passive restoration (shoulder cap only)
01-01-1986
L6380
Immediate postsurgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, wrist disarticulation or below elbow
01-01-1988
L6382
Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, elbow disarticulation or above elbow
01-01-1988
L6384
Immediate postsurgical or early fitting, application of initial rigid dressing including fitting alignment and suspension of components, and one cast change, shoulder disarticulation or interscapular thoracic
01-01-1988
L6386
Immediate postsurgical or early fitting, each additional cast change and realignment
01-01-1988
L6388
Immediate postsurgical or early fitting, application of rigid dressing only
01-01-1988
L6400
Below elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping
01-01-1982
L6450
Elbow disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping
01-01-1982
L6500
Above elbow, molded socket, endoskeletal system, including soft prosthetic tissue shaping
01-01-1982
L6550
Shoulder disarticulation, molded socket, endoskeletal system, including soft prosthetic tissue shaping
01-01-1984
L6570
Interscapular thoracic, molded socket, endoskeletal system, including soft prosthetic tissue shaping
01-01-1984
L6580
Preparatory, 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
01-01-1988
L6582
Preparatory, 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
01-01-1988
L6584
Preparatory, 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
01-01-1988
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
01-01-1988
L6588
Preparatory, 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
01-01-1988
L6590
Preparatory, 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
01-01-1988
L6600
Upper extremity additions, polycentric hinge, pair
01-01-1982
L6605
Upper extremity additions, single pivot hinge, pair
01-01-1982
L6610
Upper extremity additions, flexible metal hinge, pair
01-01-1982
L6611
Addition to upper extremity prosthesis, external powered, additional switch, any type
01-01-2007
L6615
Upper extremity addition, disconnect locking wrist unit
01-01-1986
L6616
Upper extremity addition, additional disconnect insert for locking wrist unit, each
01-01-1989
L6620
Upper extremity addition, flexion/extension wrist unit, with or without friction
01-01-1986
L6621
Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device
01-01-2006
L6623
Upper extremity addition, spring assisted rotational wrist unit with latch release
01-01-1988
L6624
Upper extremity addition, flexion/extension and rotation wrist unit
01-01-2007
L6625
Upper extremity addition, rotation wrist unit with cable lock
01-01-1986
L6628
Upper extremity addition, quick disconnect hook adapter, otto bock or equal
01-01-1988
L6629
Upper extremity addition, quick disconnect lamination collar with coupling piece, otto bock or equal
01-01-1988
L6630
Upper extremity addition, stainless steel, any wrist
01-01-1986
L6632
Upper extremity addition, latex suspension sleeve, each
01-01-1988
L6635
Upper extremity addition, lift assist for elbow
01-01-1986
L6637
Upper extremity addition, nudge control elbow lock
01-01-1988
L6638
Upper extremity addition to prosthesis, electric locking feature, only for use with manually powered elbow
01-01-2003
L6639
Upper extremity addition, heavy duty feature, any elbow
01-01-2007
12-31-2009
L6640
Upper extremity additions, shoulder abduction joint, pair
01-01-1982
L6641
Upper extremity addition, excursion amplifier, pulley type
01-01-1988
L6642
Upper extremity addition, excursion amplifier, lever type
01-01-1988
L6645
Upper extremity addition, shoulder flexion-abduction joint, each
01-01-1986
L6646
Upper extremity addition, shoulder joint, multipositional locking, flexion, adjustable abduction friction control, for use with body powered or external powered system
01-01-2003
L6647
Upper extremity addition, shoulder lock mechanism, body powered actuator
01-01-2003
L6648
Upper extremity addition, shoulder lock mechanism, external powered actuator
01-01-2003
L6650
Upper extremity addition, shoulder universal joint, each
01-01-1986
L6655
Upper extremity addition, standard control cable, extra
01-01-1986
L6660
Upper extremity addition, heavy duty control cable
01-01-1986
L6665
Upper extremity addition, teflon, or equal, cable lining
01-01-1986
L6670
Upper extremity addition, hook to hand, cable adapter
01-01-1986
L6672
Upper extremity addition, harness, chest or shoulder, saddle type
01-01-1986
L6675
Upper extremity addition, harness, (e.g. figure of eight type), single cable design
01-01-1986
L6676
Upper extremity addition, harness, (e.g. figure of eight type), dual cable design
01-01-1986
L6677
Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow
01-01-2006
L6680
Upper extremity addition, test socket, wrist disarticulation or below elbow
01-01-1986
L6682
Upper extremity addition, test socket, elbow disarticulation or above elbow
01-01-1986
L6684
Upper extremity addition, test socket, shoulder disarticulation or interscapular thoracic
01-01-1986
L6686
Upper extremity addition, suction socket
01-01-1988
L6687
Upper extremity addition, frame type socket, below elbow or wrist disarticulation
01-01-1988
L6688
Upper extremity addition, frame type socket, above elbow or elbow disarticulation
01-01-1988
L6689
Upper extremity addition, frame type socket, shoulder disarticulation
01-01-1988
L6690
Upper extremity addition, frame type socket, interscapular-thoracic
01-01-1988
L6691
Upper extremity addition, removable insert, each
01-01-1988
L6692
Upper extremity addition, silicone gel insert or equal, each
01-01-1989
L6693
Upper extremity addition, locking elbow, forearm counterbalance
01-01-1999
L6694
Addition 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
01-01-2005
L6695
Addition 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
01-01-2005
L6696
Addition 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)
01-01-2005
L6697
Addition 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)
01-01-2005
L6698
Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert
01-01-2005
L6703
Terminal device, passive hand/mitt, any material, any size
01-01-2007
L6704
Terminal device, sport/recreational/work attachment, any material, any size
01-01-2007
L6706
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined
01-01-2007
L6707
Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined
01-01-2007
L6708
Terminal device, hand, mechanical, voluntary opening, any material, any size
01-01-2007
L6709
Terminal device, hand, mechanical, voluntary closing, any material, any size
01-01-2007
L6711
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric
01-01-2009
L6712
Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric
01-01-2009
L6713
Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric
01-01-2009
L6714
Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric
01-01-2009
L6715
Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement
01-01-2012
L6721
Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined
01-01-2009
L6722
Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined
01-01-2009
L6805
Addition to terminal device, modifier wrist unit
01-01-1985
L6810
Addition to terminal device, pincher tool, otto bock or equal precision pinch device
01-01-1988
L6880
Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)
01-01-2012
L6881
Automatic grasp feature, addition to upper limb electric prosthetic terminal device
01-01-2002

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
L6882
Microprocessor control feature, addition to upper limb prosthetic terminal device
01-01-2002
L6883
Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power
01-01-2006
L6884
Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power
01-01-2006
L6885
Replacement socket, shoulder disarticulation/interscapular thoracic, molded to patient model, for use with or without external power
01-01-2006
L6890
Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment
01-01-1986
L6895
Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated
01-01-1986
L6900
Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining
01-01-1982
L6905
Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining
01-01-1986
L6910
Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining
01-01-1982
L6915
Hand restoration (shading and measurements included), replacement glove for above
01-01-1982
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
01-01-1988
L6925
Wrist 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
01-01-1988
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
01-01-1988
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
01-01-1988
L6940
Elbow 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
01-01-1988
L6945
Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, otto bock or equal electrodes, cables, two batteries and one charger, myoelectronic control of terminal device
01-01-1988
L6950
Above 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
01-01-1988
L6955
Above 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
01-01-1988
L6960
Shoulder 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
01-01-1988
L6965
Shoulder 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
01-01-1988
L6970
Interscapular-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
01-01-1988
L6975
Interscapular-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
01-01-1988
L7007
Electric hand, switch or myoelectric controlled, adult
01-01-2007
L7008
Electric hand, switch or myoelectric, controlled, pediatric
01-01-2007
L7009
Electric hook, switch or myoelectric controlled, adult
01-01-2007
L7040
Prehensile actuator, hosmer or equal switch controlled
01-01-1988
L7045
Electric hook, child, michigan or equal switch or myoelectric controlled, pediatric
01-01-1988
L7170
Electronic elbow, hosmer or equal, switch controlled
01-01-1988
L7180
Electronic elbow, microprocessor sequential control of elbow and terminal device
01-01-1988
L7181
Electronic elbow, microprocessor simultaneous control of elbow and terminal device
01-01-2005
L7185
Electronic elbow, adolescent, variety village or equal, switch controlled
01-01-1988
L7186
Electronic elbow, child, variety village or equal, switch controlled
01-01-1989
L7190
Electronic elbow, adolescent, variety village or equal, myoelectronically controlled
01-01-1988
L7191
Electronic elbow, child, variety village or equal, myoelectronically controlled
01-01-1989
L7259
Electronic wrist rotator, any type
01-01-2015
L7260
Electronic wrist rotator, otto bock or equal
01-01-1988
12-31-2014
L7261
Electronic wrist rotator, for utah arm
01-01-1988
12-31-2014
L7266
Servo control, steeper or equal
01-01-1988
12-31-2011
L7272
Analogue control, unb or equal
01-01-1988
12-31-2011
L7274
Proportional control, 6-12 volt, liberty, utah or equal
01-01-1988
12-31-2011
L7360
Six volt battery, each
01-01-1988
L7362
Battery charger, six volt, each
01-01-1988
L7364
Twelve volt battery, each
01-01-1988
L7366
Battery charger, twelve volt, each
01-01-1988
L7367
Lithium ion battery, rechargeable, replacement
01-01-2003
L7368
Lithium ion battery charger, replacement only
01-01-2003
L7400
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal)
01-01-2006
L7401
Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal)
01-01-2006
L7402
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, ultralight material (titanium, carbon fiber or equal)
01-01-2006
L7403
Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material
01-01-2006
L7404
Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material
01-01-2006
L7405
Addition to upper extremity prosthesis, shoulder disarticulation/interscapular thoracic, acrylic material
01-01-2006
L7499
Upper extremity prosthesis, nos
01-01-1985
L7500
Repair of prosthetic device, hourly rate
01-01-1982
12-31-2011
L7510
Repair of prosthetic device, repair or replace minor parts
01-01-1985
L7520
Repair prosthetic device, labor component, per 15 minutes
01-01-1997
L7600
Prosthetic donning sleeve, any material, each
01-01-2006
L7611
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric
01-01-2008
12-31-2008
L7612
Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric
01-01-2008
12-31-2008
L7613
Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric
01-01-2008
12-31-2008
L7614
Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric
01-01-2008
12-31-2008
L7621
Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined
01-01-2008
12-31-2008
L7622
Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined
01-01-2008
12-31-2008
L7700
Gasket or seal, for use with prosthetic socket insert, any type, each
01-01-2018
L7900
Male vacuum erection system
01-01-1997
L7902
Tension ring, for vacuum erection device, any type, replacement only, each
01-01-2013
L8000
Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type
01-01-1986
L8001
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type
01-01-2002
L8002
Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type
01-01-2002
L8010
Breast prosthesis, mastectomy sleeve
01-01-1986
L8015
External breast prosthesis garment, with mastectomy form, post-mastectomy
01-01-1999
L8020
Breast prosthesis, mastectomy form
01-01-1986
L8030
Breast prosthesis, silicone or equal, without integral adhesive
01-01-1989
L8031
Breast prosthesis, silicone or equal, with integral adhesive
01-01-2010
L8032
Nipple prosthesis, prefabricated, reusable, any type, each
01-01-2010
L8033
Nipple prosthesis, custom fabricated, reusable, any material, any type, each
01-01-2020
L8035
Custom breast prosthesis, post mastectomy, molded to patient model
01-01-1999
L8039
Breast prosthesis, nos
01-01-1998
L8040
Nasal prosthesis, provided by a nonphysician
01-01-2001
L8041
Midfacial prosthesis, provided by a nonphysician
01-01-2001
L8042
Orbital prosthesis, provided by a nonphysician
01-01-2001
L8043
Upper facial prosthesis, provided by a nonphysician
01-01-2001
L8044
Hemi-facial prosthesis, provided by a nonphysician
01-01-2001
L8045
Auricular prosthesis, provided by a nonphysician
01-01-2001
L8046
Partial facial prosthesis, provided by a nonphysician
01-01-2001
L8047
Nasal septal prosthesis, provided by a nonphysician
01-01-2001
L8048
Unspecified maxillofacial prosthesis, by report, provided by a nonphysician
01-01-2001
L8049
Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a nonphysician
01-01-2001
L8300
Truss, single with standard pad
01-01-1986
L8310
Truss, double with standard pads
01-01-1986
L8320
Truss, addition to standard pad, water pad
01-01-1986
L8330
Truss, addition to standard pad, scrotal pad
01-01-1986
L8400
Prosthetic sheath, below knee, each
01-01-1982
L8410
Prosthetic sheath, above knee, each
01-01-1982
L8415
Prosthetic sheath, upper limb, each
01-01-1988
L8417
Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each
01-01-1997
L8420
Prosthetic sock, multiple ply, below knee, each
01-01-1982
L8430
Prosthetic sock, multiple ply, above knee, each
01-01-1982
L8435
Prosthetic sock, multiple ply, upper limb, each
01-01-1988
L8440
Prosthetic shrinker, below knee, each
01-01-1982
L8460
Prosthetic shrinker, above knee, each
01-01-1982
L8465
Prosthetic shrinker, upper limb, each
01-01-1988
L8470
Prosthetic sock, single ply, fitting, below knee, each
01-01-1982
L8480
Prosthetic sock, single ply, fitting, above knee, each
01-01-1982
L8485
Prosthetic sock, single ply, fitting, upper limb, each
01-01-1994
L8499
Unlisted procedure for miscellaneous prosthetic services
01-01-1982
L8500
Artificial larynx, any type
01-01-1990
L8501
Tracheostomy speaking valve
01-01-1990
L8505
Artificial larynx replacement battery/accessory, any type
01-01-2002
L8507
Tracheo-esophageal voice prosthesis, patient inserted, any type, each
01-01-2002
L8509
Tracheo-esophageal voice prosthesis, inserted by a licensed health care provider, any type
01-01-2002
L8510
Voice amplifier
01-01-2002
L8511
Insert for indwelling tracheoesophageal prosthesis, with or without valve, replacement only, each
01-01-2004
L8512
Gelatin capsules or equivalent, for use with tracheoesophageal voice prosthesis, replacement only, per 10
01-01-2004
L8513
Cleaning device used with tracheoesophageal voice prosthesis, pipet, brush, or equal, replacement only, each
01-01-2004
L8514
Tracheoesophageal puncture dilator, replacement only, each
01-01-2004
L8515
Gelatin capsule, application device for use with tracheoesophageal voice prosthesis, each
01-01-2005
L8600
Implantable breast prosthesis, silicone or equal
01-01-1992
L8603
Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies
01-01-1995
L8604
Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies
01-01-2009
L8605
Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, anal canal, 1 ml, includes shipping and necessary supplies
01-01-2013
L8606
Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies
01-01-2001
L8609
Artificial cornea
01-01-2006
L8610
Ocular implant
01-01-1992
L8612
Aqueous shunt
01-01-1992
L8613
Ossicular implant
01-01-1992
L8614
Cochlear device/system, includes all internal and external components
01-01-1992
L8615
Headset/headpiece for use with cochlear implant device, replacement
01-01-2005
L8616
Microphone for use with cochlear implant device, replacement
01-01-2005
L8617
Transmitting coil for use with cochlear implant device, replacement
01-01-2005
L8618
Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement
01-01-2005
L8619
Cochlear implant, external speech processor and controller, integrated system, replacement
01-01-1996
L8621
Zinc air battery for use with cochlear implant device, replacement, each
01-01-2005
L8622
Alkaline battery for use with cochlear implant device, any size, replacement, each
01-01-2005
L8623
Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each
01-01-2006
L8624
Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each
01-01-2006
L8625
External recharging system for battery for use with cochlear implant or auditory osseointegrated device, replacement only, each
01-01-2018
L8627
Cochlear implant, external speech processor, component, replacement
01-01-2010
L8628
Cochlear implant, external controller component, replacement
01-01-2010
L8629
Transmitting coil and cable, integrated, for use with cochlear implant device, replacement
01-01-2010
L8630
Metacarpophalangeal joint implant
01-01-1992
L8631
Metacarpal phalangeal joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon), for surgical implantation (all sizes, includes entire system)
01-01-2004
L8641
Metatarsal joint implant
01-01-1992
L8642
Hallux implant
01-01-1992
L8658
Interphalangeal joint spacer, silicone or equal, each
01-01-1992
L8659
Interphalangeal finger joint replacement, two or more pieces, metal (e.g., stainless steel or cobalt chrome), ceramic-like material (e.g., pyrocarbon) for surgical implantation, any size
01-01-2004
L8670
Vascular graft material, synthetic, implant
01-01-1992
L8679
implantable neurostimulator, pulse generator, any type
01-01-2014
L8681
Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
01-01-2006
L8682
Implantable neurostimulator radiofrequency receiver
01-01-2006
L8683
Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver
01-01-2006
L8684
Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement
01-01-2006
L8685
Implantable neurostimulator pulse generator, single array, rechargeable, includes extension
01-01-2006
L8686
Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension
01-01-2006
L8687
Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension
01-01-2006
L8688
Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension
01-01-2006
L8689
External recharging system for battery (internal) for use with implantable neurostimulator, replacement only
01-01-2006
L8690
Auditory osseointegrated device, includes all internal and external components
01-01-2007
L8691
Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each
01-01-2007
L8692
Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment
01-01-2010
L8693
Auditory osseointegrated device abutment, any length, replacement only
01-01-2011
L8694
Auditory osseointegrated device, transducer/actuator, replacement only, each
01-01-2018
L8695
External recharging system for battery (external) for use with implantable neurostimulator, replacement only
01-01-2007
L8696
Antenna (external) for use with implantable diaphragmatic/phrenic nerve stimulation device, replacement, each
01-01-2015
L8699
Prosthetic implant, not otherwise specified
01-01-1998
L9900
Orthotic and prosthetic supply, accessory, and/or service component of another hcpcs l code
01-01-2000
Q0478
Power adapter for use with electric or electric/pneumatic ventricular assist device, vehicle type
01-01-2011
Q0479
Power module for use with electric or electric/pneumatic ventricular assist device, replacement only
01-01-2011
Q0480
Driver for use with pneumatic ventricular assist device, replacement only
10-01-2005
Q0481
Microprocessor control unit for use with electric ventricular assist device, replacement only
10-01-2005
Q0482
Microprocessor control unit for use with electric/pneumatic combination ventricular assist device, replacement only
10-01-2005
Q0483
Monitor/display module for use with electric ventricular assist device, replacement only
10-01-2005
Q0484
Monitor/display module for use with electric or electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0485
Monitor control cable for use with electric ventricular assist device, replacement only
10-01-2005
Q0486
Monitor control cable for use with electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0487
Leads (pneumatic/electrical) for use with any type electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0488
Power pack base for use with electric ventricular assist device, replacement only
10-01-2005
Q0489
Power pack base for use with electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0490
Emergency power source for use with electric ventricular assist device, replacement only
10-01-2005
Q0491
Emergency power source for use with electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0492
Emergency power supply cable for use with electric ventricular assist device, replacement only
10-01-2005
Q0493
Emergency power supply cable for use with electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0494
Emergency hand pump for use with electric or electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0495
Battery/power pack charger for use with electric or electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0496
Battery, other than lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0497
Battery clips for use with electric or electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0498
Holster for use with electric or electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0499
Belt/vest/bag for use to carry external peripheral components of any type ventricular assist device, replacement only
10-01-2005
Q0500
Filters for use with electric or electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0501
Shower cover for use with electric or electric/pneumatic ventricular assist device, replacement only
10-01-2005
Q0502
Mobility cart for pneumatic ventricular assist device, replacement only
10-01-2005
Q0503
Battery for pneumatic ventricular assist device, replacement only, each
10-01-2005
Q0504
Power adapter for pneumatic ventricular assist device, replacement only, vehicle type
10-01-2005
Q0505
Miscellaneous supply or accessory for use with ventricular assist device
10-01-2005
04-01-2013
Q0506
Battery, lithium-ion, for use with electric or electric/pneumatic ventricular assist device, replacement only
01-01-2010
Q1002
New technology intraocular lens category 2 as defined in federal register notice, vol. 65, dated may 3, 2000
01-01-2000
Q1003
New technology intraocular lens category 3 as defined in federal register notice
01-01-2000
04-01-2011
Q1004
New technology intraocular lens category 4 as defined in federal register notice
01-01-2000
Q1005
New technology intraocular lens category 5 as defined in federal register notice
01-01-2000
Q4001
Casting supplies, body cast adult, with or without head, plaster
01-01-2002
Q4002
Cast supplies, body cast adult, with or without head, fiberglass
01-01-2002
Q4003
Cast supplies, shoulder cast, adult (11 years +), plaster
01-01-2002
Q4004
Cast supplies, shoulder cast, adult (11 years +), fiberglass
01-01-2002
Q4005
Cast supplies, long arm cast, adult (11 years +), plaster
01-01-2002
Q4006
Cast supplies, long arm cast, adult (11 years +), fiberglass
01-01-2002
Q4007
Cast supplies, long arm cast, pediatric (0-10 years), plaster
01-01-2002
Q4008
Cast supplies, long arm cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4009
Cast supplies, short arm cast, adult (11 years +), plaster
01-01-2002
Q4010
Cast supplies, short arm cast, adult (11 years +), fiberglass
01-01-2002
Q4011
Cast supplies, short arm cast, pediatric (0-10 years), plaster
01-01-2002
Q4012
Cast supplies, short arm cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4013
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), plaster
01-01-2002
Q4014
Cast supplies, gauntlet cast (includes lower forearm and hand), adult (11 years +), fiberglass
01-01-2002
Q4015
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), plaster
01-01-2002
Q4016
Cast supplies, gauntlet cast (includes lower forearm and hand), pediatric (0-10 years), fiberglass
01-01-2002
Q4017
Cast supplies, long arm splint, adult (11 years +), plaster
01-01-2002
Q4018
Cast supplies, long arm splint, adult (11 years +), fiberglass
01-01-2002
Q4019
Cast supplies, long arm splint, pediatric (0-10 years), plaster
01-01-2002
Q4020
Cast supplies, long arm splint, pediatric (0-10 years), fiberglass
01-01-2002
Q4021
Cast supplies, short arm splint, adult (11 years +), plaster
01-01-2002
Q4022
Cast supplies, short arm splint, adult (11 years +), fiberglass
01-01-2002
Q4023
Cast supplies, short arm splint, pediatric (0-10 years), plaster
01-01-2002
Q4024
Cast supplies, short arm splint, pediatric (0-10 years), fiberglass
01-01-2002
Q4025
Cast supplies, hip spica (one or both legs), adult (11 years +), plaster
01-01-2002
Q4026
Cast supplies, hip spica (one or both legs), adult (11 years +), fiberglass
01-01-2002
Q4027
Cast supplies, hip spica (one or both legs), pediatric (0-10 years), plaster
01-01-2002
Q4028
Cast supplies, hip spica (one or both legs), pediatric (0-10 years), fiberglass
01-01-2002
Q4029
Cast supplies, long leg cast, adult (11 years +), plaster
01-01-2002
Q4030
Cast supplies, long leg cast, adult (11 years +), fiberglass
01-01-2002
Q4031
Cast supplies, long leg cast, pediatric (0-10 years), plaster
01-01-2002
Q4032
Cast supplies, long leg cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4033
Cast supplies, long leg cylinder cast, adult (11 years +), plaster
01-01-2002
Q4034
Cast supplies, long leg cylinder cast, adult (11 years +), fiberglass
01-01-2002
Q4035
Cast supplies, long leg cylinder cast, pediatric (0-10 years), plaster
01-01-2002
Q4036
Cast supplies, long leg cylinder cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4037
Cast supplies, short leg cast, adult (11 years +), plaster
01-01-2002
Q4038
Cast supplies, short leg cast, adult (11 years +), fiberglass
01-01-2002

Procedure Code
Full Description
Date Code Added to the Policy
Date Code Removed from the Policy
Q4039
Cast supplies, short leg cast, pediatric (0-10 years), plaster
01-01-2002
Q4040
Cast supplies, short leg cast, pediatric (0-10 years), fiberglass
01-01-2002
Q4041
Cast supplies, long leg splint, adult (11 years +), plaster
01-01-2002
Q4042
Cast supplies, long leg splint, adult (11 years +), fiberglass
01-01-2002
Q4043
Cast supplies, long leg splint, pediatric (0-10 years), plaster
01-01-2002
Q4044
Cast supplies, long leg splint, pediatric (0-10 years), fiberglass
01-01-2002
Q4045
Cast supplies, short leg splint, adult (11 years +), plaster
01-01-2002
Q4046
Cast supplies, short leg splint, adult (11 years +), fiberglass
01-01-2002
Q4047
Cast supplies, short leg splint, pediatric (0-10 years), plaster
01-01-2002
Q4048
Cast supplies, short leg splint, pediatric (0-10 years), fiberglass
01-01-2002
Q4049
Finger splint, static
01-01-2002
Q4050
Cast supplies, for unlisted types and materials of casts
01-01-2002
Q4051
Splint supplies, miscellaneous (includes thermoplastics, strapping, fasteners, padding and other supplies)
01-01-2002
Q4099
Formoterol fumarate, inhalation solution, fda approved final product, non-compounded, administered through dme, unit dose form, 20 micrograms
04-01-2008
12-31-2008
Q0509
Miscellaneous supply or accessory for use with any implanted ventricular assist device for which payment was not made under Medicare Part A
04-01-2013
L8698
Miscellaneous component, supply or accessory for use with total artificial heart system
01-01-2019
S0196
Injectable poly-l-lactic acid, restorative implant, 1 ml, face (deep dermis, subcutaneous layers)
01-01-2005
09-30-2010
S0395
Impression casting of a foot performed by a practitioner other than the manufacturer of the orthotic
01-01-2002
S0515
Scleral lens, liquid bandage device, per lens
10-01-2004
S0596
Phakic intraocular lens for correction of refractive error
04-01-2012
S1001
Deluxe item, patient aware (list in addition to code for basic item)
01-01-2002
S1002
Customized item (list in addition to code for basic item)
01-01-2002
S1015
Iv tubing extension set
01-01-2001
S1016
Non-pvc (polyvinyl chloride) intravenous administration set, for use with drugs that are not stable in pvc e.g., paclitaxel
01-01-2001
S1030
Continuous noninvasive glucose monitoring device, purchase (for physician interpretation of data, use cpt code)
01-01-2002
S1031
Continuous noninvasive glucose monitoring device, rental, including sensor, sensor replacement, and download to monitor (for physician interpretation of data, use cpt code)
01-01-2002
S1034
Artificial Pancreas Device System (eg, Low Glucose Suspend [LGS] Feature) Including Continuous Glucose Monitor, Blood Glucose Device, Insulin Pump And Computer Algorithm That Communicates With All Of The Devices
07-01-2014
S1035
Sensor; Invasive (eg, Subcutaneous), Disposable, For Use With Artificial Pancreas Device System
07-01-2014
S1036
Transmitter; External, For Use With Artificial Pancreas Device System
07-01-2014
S1037
Receiver (Monitor); External, For Use With Artificial Pancreas Device System
07-01-2014
S1040
Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)
01-01-2003
S5560
Insulin delivery device, reusable pen; 1.5 ml size
10-01-2003
S5561
Insulin delivery device, reusable pen; 3 ml size
10-01-2003
S8096
Portable peak flow meter
01-01-2000
S8097
Asthma kit (including but not limited to portable peak expiratory flow meter, instructional video, brochure, and/or spacer)
01-01-2002
S8100
Holding chamber or spacer for use with an inhaler or nebulizer; without mask
01-01-2002
S8101
Holding chamber or spacer for use with an inhaler or nebulizer; with mask
01-01-2002
S8120
Oxygen contents, gaseous, 1 unit equals 1 cubic foot
10-01-2003
S8121
Oxygen contents, liquid, 1 unit equals 1 pound
10-01-2003
S8130
Interferential current stimulator, 2 channel
01-01-2012
S8131
Interferential current stimulator, 4 channel
01-01-2012
S8185
Flutter device
01-01-2002
S8186
Swivel adaptor
01-01-2002
S8189
Tracheostomy supply, not otherwise classified
01-01-2002
S8190
Electronic spirometer (or microspirometer)
01-01-2002
03-31-2009
S8210
Mucus trap
01-01-2001
S8260
Oral orthotic for treatment of sleep apnea, includes fitting, fabrication, and materials
01-01-2000
04-01-2006
S8262
Mandibular orthopedic repositioning device, each
04-01-2002
06-30-2015
S8265
Haberman feeder for cleft lip/palate
04-01-2002
S8270
Enuresis alarm, using auditory buzzer and/or vibration device
07-01-2005
S8301
Infection control supplies, not otherwise specified
07-01-2004
S8415
Supplies for home delivery of infant
01-01-2002
S8420
Gradient pressure aid (sleeve and glove combination), custom made
01-01-2002
S8421
Gradient pressure aid (sleeve and glove combination), ready made
01-01-2002
S8422
Gradient pressure aid (sleeve), custom made, medium weight
01-01-2002
S8423
Gradient pressure aid (sleeve), custom made, heavy weight
01-01-2002
S8424
Gradient pressure aid (sleeve), ready made
01-01-2002
S8425
Gradient pressure aid (glove), custom made, medium weight
01-01-2002
S8426
Gradient pressure aid (glove), custom made, heavy weight
01-01-2002
S8427
Gradient pressure aid (glove), ready made
01-01-2002
S8428
Gradient pressure aid (gauntlet), ready made
01-01-2002
S8429
Gradient pressure exterior wrap
01-01-2002
S8430
Padding for compression bandage, roll
01-01-2002
S8431
Compression bandage, roll
01-01-2002
S8450
Splint, prefabricated, digit (specify digit by use of modifier)
01-01-2002
S8451
Splint, prefabricated, wrist or ankle
01-01-2002
S8452
Splint, prefabricated, elbow
01-01-2002
S8460
Camisole, postmastectomy
04-01-2003
S8490
Insulin syringes (100 syringes, any size)
01-01-2002
S8999
Resuscitation bag (for use by patient on artificial respiration during power failure or other catastrophic event)
01-01-2001
S9001
Home uterine monitor with or without associated nursing services
01-01-2000
S9007
Ultrafiltration monitor
01-01-2001
S9015
Automated eeg monitoring
01-01-2001
S9097
Home visit for wound care
10-01-2004
S9109
Congestive heart failure telemonitoring, equipment rental, including telescale, computer system and software, telephone connections, and maintenance, per month
01-01-2002
01-01-2013
S9433
Medical food nutritionally complete, administered orally, providing 100% of nutritional intake
01-01-2009
S9434
Modified solid food supplements for inborn errors of metabolism
04-01-2003
S9435
Medical foods for inborn errors of metabolism
01-01-2001
T1999
Miscellaneous therapeutic items and supplies, retail purchases, not otherwise classified; identify product in remarks
01-01-2003
T4521
Adult sized disposable incontinence product, brief/diaper, small, each
01-01-2005
T4522
Adult sized disposable incontinence product, brief/diaper, medium, each
01-01-2005
T4523
Adult sized disposable incontinence product, brief/diaper, large, each
01-01-2005
T4524
Adult sized disposable incontinence product, brief/diaper, extra large, each
01-01-2005
T4525
Adult sized disposable incontinence product, protective underwear/pull-on, small size, each
01-01-2005
T4526
Adult sized disposable incontinence product, protective underwear/pull-on, medium size, each
01-01-2005
T4527
Adult sized disposable incontinence product, protective underwear/pull-on, large size, each
01-01-2005
T4528
Adult sized disposable incontinence product, protective underwear/pull-on, extra large size, each
01-01-2005
T4529
Pediatric sized disposable incontinence product, brief/diaper, small/medium size, each
01-01-2005
T4530
Pediatric sized disposable incontinence product, brief/diaper, large size, each
01-01-2005
T4531
Pediatric sized disposable incontinence product, protective underwear/pull-on, small/medium size, each
01-01-2005
T4532
Pediatric sized disposable incontinence product, protective underwear/pull-on, large size, each
01-01-2005
T4533
Youth sized disposable incontinence product, brief/diaper, each
01-01-2005
T4534
Youth sized disposable incontinence product, protective underwear/pull-on, each
01-01-2005
T4535
Disposable liner/shield/guard/pad/undergarment, for incontinence, each
01-01-2005
T4536
Incontinence product, protective underwear/pull-on, reusable, any size, each
01-01-2005
T4537
Incontinence product, protective underpad, reusable, bed size, each
01-01-2005
T4538
Diaper service, reusable diaper, each diaper
01-01-2005
T4539
Incontinence product, diaper/brief, reusable, any size, each
01-01-2005
T4540
Incontinence product, protective underpad, reusable, chair size, each
01-01-2005
T4541
Incontinence product, disposable underpad, large, each
01-01-2005
T4542
Incontinence product, disposable underpad, small size, each
01-01-2005
T5999
Supply, not otherwise specified
01-01-2004
V2623
Prosthetic eye, plastic, custom
01-01-1985
V2624
Polishing/resurfacing of ocular prosthesis
01-01-1993
V2625
Enlargement of ocular prosthesis
01-01-1993
V2626
Reduction of ocular prosthesis
01-01-1993
V2627
Scleral cover shell
01-01-1993
V2628
Fabrication and fitting of ocular conformer
01-01-1993
V2629
Prosthetic eye, other type
01-01-1985
V2787
Astigmatism correcting function of intraocular lens
01-01-2008



Version Effective Date: 05/18/2020
Version Issued Date: 05/18/2020
Version Reissued Date: N/A



2017 AmeriHealth.