Medicare Advantage Preferred Provider Organization (MA PPO)

Applicable to enrollees from other Blue Cross Blue Shield Medicare Advantage Plans who obtain health care services within the 5-county Philadelphia service area.

Notification

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

Notification Issued Date: N/A

This policy has been identified for the Quarterly Code Update. This version of the policy will become effective 07/01/2020.

The following CPT codes have been

deleted

from this policy:

0124U, 0125U, 0126U, 0127U, 0128U.

The following CPT codes have been

added

to this policy:

0172U, 0173U, 0174U, 0175U, 0176U, 0177U, 0178U, 0179U, 0180U, 0181U, 0182U, 0183U, 0184U, 0185U, 0186U, 0187U, 0188U, 0189U, 0190U, 0191U, 0192U, 0193U, 0194U, 0195U, 0196U, 0197U, 0198U, 0199U, 0200U, 0201U, 0202U, 0223U, 0224U, 87426, 77063

The following CPT codes have been

revised

in this policy:

0165U

Policy Attachment

Attachment to Policy #

MA00.010as

Attachment:

Policy #:

MA00.010as

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

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
E2513	Accessory for speech generating device, electromyographic sensor	10-01-2024
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
E3000	Speech volume modulation system, any type, including all components and accessories	01-01-2024
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	01-01-2024
K1002	Cranial electrotherapy stimulation (ces) system, includes all supplies and accessories, any type	01-01-2020	01-01-2024
K1003	Whirlpool tub, walk-in, portable	01-01-2020	01-01-2024
K1004	Low frequency ultrasonic diathermy treatment device for home use	01-01-2020
K1005	Disposable collection and storage bag for breast milk, any size, any type, each	01-01-2020	01-01-2024
K1006	Suction pump, home model, portable or stationary, electric, any type, for use with external urine management system	10-01-2020	01-01-2024
K1009	Speech volume modulation system, any type, including all components and accessories	10-01-2020	01-01-2024
K1010	Indwelling intraurethral drainage device with valve, patient inserted, replacement only, each	10-01-2020
K1011	Activation device for intraurethral drainage device with valve, replacement only, each	10-01-2020
K1012	Charger and base station for intraurethral activation device, replacement only	10-01-2020
K1013	Enema tube, with or without adapter, any type, replacement only, each	04-01-2021	01-01-2024
K1020	Non-invasive vagus nerve stimulator	04-01-2021	01-01-2024
K1021	Exsufflation belt, includes all supplies and accessories	10-01-2021
K1023	Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm	10-01-2021	01-01-2024
K1024	Non-pneumatic compression controller with sequential calibrated gradient pressure	10-01-2021	01-01-2024
K1025	Non-pneumatic sequential compression garment, full arm	10-01-2021	01-01-2024
K1026	Mechanical allergen particle barrier/inhalation filter, cream, nasal, topical	10-01-2021	01-01-2024
K1027	Oral device/appliance used to reduce upper airway collapsibility, without fixed mechanical hinge, custom fabricated, includes fitting and adjustment	10-01-2021
K1035	Molecular diagnostic test reader, nonprescription self-administered and self-collected use, fda approved, authorized or cleared	04-01-2023
K1036	Supplies and accessories (e.g., transducer) for low frequency ultrasonic diathermy treatment device, per month	10-01-2023
K1037	Docking station for use with oral device/appliance used to reduce upper airway collapsibility	04-01-2024

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
L1006	Scoliosis orthosis, sagittal-coronal control provided by a rigid lateral frame, extends from axilla to trochanter, includes all accessory pads, straps and interface, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise	10-01-2024
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
L1320	Thoracic, pectus carinatum orthosis, sternal compression, rigid circumferential frame with anterior and posterior rigid pads, custom fabricated	04-01-2024
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	Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise	01-01-2003
L1653	Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, off the shelf	10-01-2024
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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise	01-01-1986
L1821	Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, off the shelf	10-01-2024
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
L5783	Addition to lower extremity, user adjustable, mechanical, residual limb volume management system	04-01-2024
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
L5841	Addition, endoskeletal knee-shin system, polycentric, pneumatic swing, and stance phase control	04-01-2024
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
L8678	Electrical stimulator supplies (external) for use with implantable neurostimulator, per month	04-01-2023
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
L8720	External lower extremity sensory prosthesis, cutaneous stimulation of mechanoreceptors proximal to the ankle, per leg	10-01-2024
L8721	Receptor sole for use with l8720, replacement, each	10-01-2024
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
S4988	Penile contracture device, manual, greater than 3 lbs traction force	04-01-2024
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
S9002	Intra-vaginal motion sensor system, provides biofeedback for pelvic floor muscle rehabilitation device	04-01-2024
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:

01/01/2025

Version Issued Date:

01/31/2025

Version Reissued Date:

N/A