Braces and Supports

Section: Orthotic & Prosthetic Devices
Effective Date: February 01, 2019
Revised Date: January 22, 2020


Braces and supports are prosthetic or orthotic devices which steady, align, protect, or strengthen weakened, injured, or deformed body parts.

Custom fitted orthotics are prefabricated, may require some assembly, and are substantially modified for individual fitting at the time of delivery by a certified orthotist, or an individual with equivalent specialized training.

Substantial modifications are changes by a certified orthotist or an individual with equivalent specialized training in compliance with licensure and regulatory requirements to achieve an individualized fit using CAD/CAM technology.

Minimal self-adjustment can be performed by the member and does not require expertise of a certified orthotist.

Off-the-shelf (OTS) orthotics are prefabricated, may require some assembly and/or minimal self-adjustment, but not requiring expertise of a certified orthotist.


Braces and supports addressed in this medical policy may be considered medically necessary when ALL of the following general criteria are met, AND any category specific criteria:

General Criteria

  • Appropriate for the individual's condition; and
  • Is a rigid or semi-rigid device that:
    • Supports weak or deformed body part; or
    • Restricts or eliminates motion in diseased or injured body part; and
  • Provides support and counterforce; and
  • Is prefabricated or custom-fabricated; and
  • Able to withstand long term use.

Devices not meeting the above criteria are considered not medically necessary.

Purchase of more than two (2) of the same type of device on the same day is considered not medically necessary.

Dispensing a device for post-operative use prior to the procedure is considered not medically necessary.

Hernia supports (corset or truss style) may be considered medically necessary when ALL of the following criteria are met:

  • General criteria; and
  • Hernia is reducible.

Hernia supports (corset or truss style) are considered not medically necessary for all other indications

Procedure Codes

L0628 L0629 L8300 L8310 L8320 L8330 L8499

Supportive back braces may be considered medically necessary when ANY ONE of the following are met:

  • General criteria are met; and
  • To facilitate healing following an injury to the spine or related soft tissues; or
  • To facilitate healing following a surgical procedure on the spine or related soft tissue; or
  • To reduce pain by restricting mobility of the trunk; or
  • To support weak spinal muscles and/or a deformed spine.

Supportive back braces are considered not medically necessary for all other indications.

Procedure Codes

L0220 L0450 L0452 L0454 L0455 L0456 L0457
L0458 L0460 L0462 L0464 L0466 L0467 L0468
L0469 L0470 L0472 L0480 L0482 L0484 L0486
L0488 L0490 L0491 L0492 L0621 L0623 L0625
L0628 L0635 L0641 L0642 L0643 L0648 L0649
L0650 L0651 L0970 L0972 L0974 L0976 L0978
L0980 L0982 L0999 L1310

Custom-fitted and custom-fabricated back braces may be considered medically necessary when criteria for supportive back braces AND ONE of the following are met:

  • A prefabricated back brace modified to fit a specific individual is required due to failure, contraindication, or intolerance to an unmodified, prefabricated back brace; or
  • As the initial brace after surgical stabilization of the spine following traumatic injury; or
  • A custom-fabricated back brace (individually constructed to fit a specific individual from component materials) is required due to a failure, contraindication, or intolerance to a custom-fitted back brace.

Custom-fitted or custom-fabricated back braces are considered not medically necessary for all other indications.

Procedure Codes

L0452 L0480 L0482 L0484 L0486 L0622 L0624
L0626 L0627 L0629 L0630 L0631 L0632 L0633
L0634 L0636 L0637 L0638 L0639 L0640

Postoperative back braces may be considered medically necessary when ALL of the following are met:

  • General criteria are met; and
  • It is considered part of the surgical protocol; and
  • It will facilitate healing; and
  • Is applied within six (6) weeks following a surgical procedure on the spine or related soft tissue.

Postoperative back braces are considered not medically necessary for all other indications.

Procedure Codes


Quantity Level Limits (QLL) for all back braces

One (1) back brace per every five (5) years may be considered medically necessary as the reasonable lifetime of a back brace is no less than five (5) years.

Quantity level limits or quantity of supplies that exceed the frequency guidelines listed above will be denied as not medically necessary.

Procedure Codes

L0220 L0450 L0452 L0454 L0455 L0456 L0457
L0458 L0460 L0462 L0464 L0466 L0467 L0468
L0469 L0470 L0472 L0480 L0482 L0484 L0486
L0488 L0490 L0491 L0492 L0621 L0622 L0623
L0624 L0625 L0626 L0627 L0628 L0629 L0630
L0631 L0632 L0633 L0634 L0635 L0636 L0637
L0638 L0639 L0640 L0641 L0642 L0643 L0648
L0649 L0650 L0651 L0970 L0972 L0974 L0976
L0978 L0980 L0982 L1310

Postoperative Hip Braces may be considered medically necessary after ANY ONE of the following procedures:

  • Partial hip hemiarthroplasty; or
  • Total hip arthroplasty; or
  • Conversion of previous hip surgery to total hip arthroplasty; or
  • Revision of total hip arthroplasty; or
  • Osteotomy and transfer of greater trochanter of femur; or
  • Arthroscopy with removal of loose body or foreign body, debridement or with synovectomy; or
  • Arthroscopy with femoroplasty; or
  • Arthroscopy with acetabuloplasty; or
  • Arthroscopy with labral repair.

Postoperative hip braces are considered not medically necessary for all other indications.

Procedure Codes

27125 27130 27132 27134 27137 27138 27140
29861 29862 29863 29914 29915 29916 L1685

Cast-braces (fracture braces)

Comfort, non-therapeutic cast-braces (Cam Walker) may be considered medically necessary when BOTH of the following criteria are met:

  • General criteria; and
  • After a fracture or surgery.

Comfort, non-therapeutic cast-braces are considered not medically necessary for all other indications.

Procedure Codes

L2106 L2108 L2112 L2114 L2116 L2126 L2128
L2132 L2134 L2136 L3980 L3981 L3982 L3984

Functional cast-braces (patella tendon bearing (PTB) cast brace, PTB fracture brace, molded ankle-foot orthosis (MAFO), fracture brace with pelvic band, achilles tendon hinged brace) may be considered medically necessary when BOTH of the following criteria are met:

  • General criteria; and
  • After a fracture or surgery.

Functional cast-braces are considered not medically necessary for all other indications.

Procedure Codes

L2106 L2108 L2112 L2114 L2116 L2128 L2132
L2134 L2136 L2180 L2182 L2184 L2186 L2188
L2190 L2192

Rehabilitation braces may be considered medically necessary when BOTH of the following criteria are met:

  • General criteria; and
  • Applied within six (6) weeks of surgery or injury.

Rehabilitation braces are considered not medically necessary for all other indications.

Procedure Codes

L1600 L1610 L1620 L1630 L1640 L1650 L1652
L1660 L1680 L1685 L1686 L1690

Cervical (neck) braces may be considered medically necessary when ALL of the following criteria are met:

  • General criteria; and
  • Neck injury is documented.

Cervical (neck) braces are considered not medically necessary for all other indications.

Procedure Codes

L0130 L0140 L0150 L0160 L0170 L0172 L0174
L0180 L0190 L0200

Childhood hip braces (Pavlik harness, Frejka pillow splint, Friedman strap) may be considered medically necessary for children with hip disorders when ALL of the following criteria are met:

  • General criteria; and
  • To stabilize the hip; or
  • To correct and maintain hip abduction.

Childhood hip braces are considered not medically necessary for all other indications

Procedure Codes

L1600 L1610 L1620 L1630 L1640 L1650 L1652
L1660 L1680 L1685 L1686 L1690

Braces for congenital defects or advanced neuromuscular conditions may be considered medically necessary when general criteria are met.

Replacement braces may be considered medically necessary when:

  • The individual has outgrown the previous brace; or
  • The condition has changed making the previous brace unusable.

Braces for congenital defects or advanced neuromuscular conditions are considered not medically necessary for all other indications not listed above.

Procedure Codes

L1000 L1001 L1005 L1010 L1020 L1025 L1030
L1040 L1050 L1060 L1070 L1080 L1085 L1090
L1100 L1110 L1120 L1200 L1210 L1220 L1230
L1240 L1250 L1260 L1270 L1280 L1290 L1300
L1310 L1499

Cervical-thoracic-lumbar-sacral or thoracic-lumbar-sacral orthoses may be considered medically necessary for the treatment of scoliosis in juvenile and adolescent individuals at high-risk of progression when ALL of the following criteria are met:

  • General criteria; and
  • Idiopathic spinal curve angle between 25 and 60 degrees; and
  • Spinal growth has not been completed (Risser grade 0-3; no more than one (1) year post-menarche in females); or
  • Idiopathic spinal curve angle greater than 20 degrees; and
  • There is documented increase in the curve angle; and
  • At least two (2) years growth remains (Risser grade 0 or 1; pre-menarche in females).

Cervical-thoracic-lumbar-sacral or thoracic-lumbar-sacral orthoses are considered not medically necessary for all other indications.

Procedure Codes

L1000 L1001 L1005 L1010 L1020 L1025 L1030
L1040 L1050 L1060 L1070 L1080 L1085 L1090
L1100 L1110 L1120 L1200 L1210 L1220 L1230
L1240 L1250 L1260 L1270 L1280 L1290 L1300
L1310 L1499

Wheaton braces may be considered medically necessary to treat metatarsus adductus in infants, replacing the need for serial casting when general criteria are met.

Wheaton braces are considered not medically necessary for all other indications.

Procedure Codes


Splints and immobilizers – The following devices may be considered medically necessary when general criteria are met:

  • Acromio-clavicular splint (Zimmer splint)
  • Wrist extension control cock-up splint
  • Clavicle splint (Figure-8 splint)
  • Denis Browne splint (for children with clubfoot or metatarsus valgus to maintain and correct abduction)
  • Finger splints
  • Shoulder immobilizer

Splints and immobilizers are considered not medically necessary for all other indications.

Procedure Codes

L3140 L3150 L3640 L3650 L3660 L3670 L3678
L3908 Q4049

Unna boots may be considered medically necessary for the following non-fracture care indications:

  • To treat sprains and torn ligaments; or
  • To provide protection for other soft tissue injuries; or
  • As a protective cover to promote healing after certain surgical procedures.

Unna boots are considered not medically necessary for all other indications.

Procedure Codes


Air casts/air splints may be considered medically necessary for treatment of fractures or other injuries (i.e., sprains, torn ligaments) when general criteria are met.

Air casts/air splints are considered not medically necessary for all other indications.

Procedure Codes

L4350 L4360 L4361 L4370

 Miscellaneous covered services

Casting of a sprain or casting following a surgical procedure may be considered medically necessary.

Casting for all other indications is considered not medically necessary.

The following braces and supports do not meet the definition of covered durable medical equipment because they are not made to withstand long term use; and are therefore considered non-covered:

  • Completely elastic supports (e.g., athletic supporter, joint supports, non-rigid trusses, etc.);
  • Inflatable lumbar supports;
  • Protective body socks;
  • Cervical foam neck collars.

Procedure Codes

L0120 L0984

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200 (Cervical Region)

A18.01 G90.1 M08.1 M25.78 M43.6 M45.0 M45.1
M45.2 M45.3 M45.4 M45.5 M45.6 M45.7 M45.8
M45.9 M46.00 M46.01 M46.02 M46.03 M46.04 M46.05
M46.06 M46.07 M46.08 M46.09 M46.1 M46.40 M46.41
M46.42 M46.43 M46.48 M46.49 M46.50 M46.51 M46.52
M46.53 M46.54 M46.55 M46.56 M46.57 M46.58 M46.59
M46.80 M46.81 M46.82 M46.83 M46.84 M46.85 M46.86
M46.87 M46.88 M46.89 M46.90 M46.91 M46.92 M46.93
M46.94 M46.95 M46.96 M46.97 M46.98 M46.99 M47.011
M47.012 M47.013 M47.014 M47.015 M47.016 M47.019 M47.021
M47.022 M47.029 M47.10 M47.11 M47.12 M47.13 M47.20
M47.21 M47.22 M47.23 M47.811 M47.812 M47.813 M47.819
M47.891 M47.892 M47.893 M47.899 M47.9 M48.00 M48.01
M48.02 M48.03 M48.10 M48.11 M48.12 M48.13 M48.14
M48.15 M48.16 M48.17 M48.18 M48.19 M48.20 M48.21
M48.22 M48.23 M48.24 M48.25 M48.26 M48.27 M48.30
M48.31 M48.32 M48.33 M48.34 M48.35 M48.36 M48.37
M48.38 M48.8X1 M48.8X2 M48.8X3 M48.8X4 M48.8X5 M48.8X6
M48.8X7 M48.8X8 M48.8X9 M48.9 M49.80 M49.81 M49.82
M49.83 M49.84 M49.85 M49.86 M49.87 M49.88 M49.89
M50.00 M50.01 M50.020 M50.021 M50.022 M50.023 M50.03
M50.10 M50.11 M50.120 M50.121 M50.122 M50.123 M50.13
M50.20 M50.21 M50.220 M50.221 M50.222 M50.223 M50.23
M50.30 M50.31 M50.320 M50.321 M50.322 M50.323 M50.33
M50.80 M50.81 M50.820 M50.821 M50.822 M50.823 M50.83
M50.90 M50.91 M50.920 M50.921 M50.922 M50.923 M50.93
M51.34 M51.35 M51.36 M51.37 M51.9 M53.0 M53.1
M53.81 M53.82 M53.83 M54.11 M54.12 M54.13 M54.2
M54.81 M67.88 M81.0 M81.6 M81.8 M96.1 M99.10
M99.11 M99.20 M99.21 M99.30 M99.31 M99.40 M99.41
M99.50 M99.51 M99.60 M99.61 M99.70 M99.71 Q04.9
Q05.0 Q05.5 Q06.9 Q07.8 Q07.9 Q76.0 Q76.1
Q76.411 Q76.412 Q76.413 Q76.414 Q76.415 Q76.419 Q76.49
S11.90XA S12.000A S12.000B S12.001A S12.001B S12.01XA S12.01XB
S12.02XA S12.02XB S12.030A S12.030B S12.031A S12.031B S12.040A
S12.040B S12.041A S12.041B S12.090A S12.090B S12.091A S12.091B
S12.100A S12.100B S12.101A S12.101B S12.110A S12.110B S12.111A
S12.111B S12.112A S12.112B S12.120A S12.120B S12.121A S12.121B
S12.130A S12.130B S12.131A S12.131B S12.14XA S12.14XB S12.150A
S12.150B S12.151A S12.151B S12.190A S12.190B S12.191A S12.191B
S12.200A S12.200B S12.201A S12.201B S12.230A S12.230B S12.231A
S12.231B S12.24XA S12.24XB S12.250A S12.250B S12.251A S12.251B
S12.290A S12.290B S12.291A S12.291B S12.300A S12.300B S12.301A
S12.301B S12.330A S12.330B S12.331A S12.331B S12.34XA S12.34XB
S12.350A S12.350B S12.351A S12.351B S12.390A S12.390B S12.391A
S12.391B S12.400A S12.400B S12.401A S12.401B S12.430A S12.430B
S12.431A S12.431B S12.44XA S12.44XB S12.450A S12.450B S12.451A
S12.451B S12.490A S12.490B S12.491A S12.491B S12.500A S12.500B
S12.501A S12.501B S12.530A S12.530B S12.531A S12.531B S12.54XA
S12.54XB S12.550A S12.550B S12.551A S12.551B S12.590A S12.590B
S12.591A S12.591B S12.600A S12.600B S12.601A S12.601B S12.630A
S12.630B S12.631A S12.631B S12.64XA S12.64XB S12.650A S12.650B
S12.651A S12.651B S12.690A S12.690B S12.691A S12.691B S12.9XXA
S13.0XXA S13.100A S13.101A S13.110A S13.111A S13.120A S13.121A
S13.130A S13.131A S13.140A S13.141A S13.150A S13.151A S13.160A
S13.161A S13.170A S13.171A S13.180A S13.181A S13.20XA S13.29XA
S13.4XXA S13.8XXA S14.0XXA S14.101A S14.102A S14.103A S14.104A
S14.105A S14.106A S14.107A S14.108A S14.109A S14.111A S14.112A
S14.113A S14.114A S14.115A S14.116A S14.117A S14.118A S14.121A
S14.122A S14.123A S14.124A S14.125A S14.126A S14.127A S14.128A
S14.131A S14.132A S14.133A S14.134A S14.135A S14.136A S14.137A
S14.138A S14.141A S14.142A S14.143A S14.144A S14.145A S14.146A
S14.147A S14.148A S14.151A S14.152A S14.153A S14.154A S14.155A
S14.156A S14.157A S14.158A S14.2XXA S16.1XXA S22.009A S22.009B
S24.109A S32.009A S32.009B S32.10XA S32.10XB S32.2XXA S32.2XXB
S34.109A S34.139A

Covered Diagnosis Codes for Procedure Code L1499 (Chest Orthotic)


Covered Diagnosis Codes for Procedure Codes L0220, L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651, L0970, L0972, L0974, L0976, L0978, L0980, L0982, L0999 (Back Braces)

A18.01 G90.1 M08.1 M25.78 M40.00 M40.03 M40.04
M40.05 M40.10 M40.12 M40.13 M40.14 M40.15 M40.202
M40.203 M40.204 M40.205 M40.209 M40.292 M40.293 M40.294
M40.295 M40.299 M40.30 M40.35 M40.36 M40.37 M40.40
M40.45 M40.46 M40.47 M40.50 M40.55 M40.56 M40.57
M41.00 M41.02 M41.03 M41.04 M41.05 M41.06 M41.07
M41.08 M41.112 M41.113 M41.114 M41.115 M41.116 M41.117
M41.119 M41.122 M41.123 M41.124 M41.125 M41.126 M41.127
M41.129 M41.20 M41.22 M41.23 M41.24 M41.25 M41.26
M41.27 M41.30 M41.34 M41.35 M41.40 M41.41 M41.42
M41.43 M41.44 M41.45 M41.46 M41.47 M41.50 M41.52
M41.53 M41.54 M41.55 M41.56 M41.57 M41.80 M41.82
M41.83 M41.84 M41.85 M41.86 M41.87 M41.9 M43.20
M43.21 M43.22 M43.23 M43.24 M43.25 M43.26 M43.27
M43.28 M43.8X1 M43.8X2 M43.8X3 M43.8X4 M43.8X5 M43.8X6
M43.8X7 M43.8X8 M43.8X9 M43.9 M45.0 M45.1 M45.2
M45.3 M45.4 M45.5 M45.6 M45.7 M45.8 M45.9
M46.00 M46.01 M46.02 M46.03 M46.04 M46.05 M46.07
M46.08 M46.09 M46.1 M46.40 M46.44 M46.45 M46.46
M46.47 M46.48 M46.49 M46.50 M46.51 M46.52 M46.53
M46.54 M46.55 M46.56 M46.57 M46.58 M46.59 M46.80
M46.81 M46.82 M46.83 M46.84 M46.85 M46.86 M46.87
M46.88 M46.89 M46.90 M46.91 M46.92 M46.93 M46.94
M46.95 M46.96 M46.97 M46.98 M46.99 M47.10 M47.14
M47.15 M47.16 M47.17 M47.18 M47.20 M47.24 M47.25
M47.26 M47.27 M47.28 M47.814 M47.815 M47.816 M47.817
M47.818 M47.819 M47.894 M47.895 M47.896 M47.897 M47.898
M47.899 M47.9 M48.00 M48.04 M48.05 M48.061 M48.062
M48.07 M48.08 M48.10 M48.11 M48.12 M48.13 M48.14
M48.15 M48.16 M48.17 M48.18 M48.19 M48.20 M48.21
M48.22 M48.23 M48.24 M48.25 M48.26 M48.27 M48.30
M48.31 M48.32 M48.33 M48.34 M48.35 M48.36 M48.37
M48.38 M48.8X1 M48.8X2 M48.8X3 M48.8X4 M48.8X5 M48.8X6
M48.8X7 M48.8X8 M48.8X9 M48.9 M49.80 M49.81 M49.82
M49.83 M49.84 M49.85 M49.86 M49.87 M49.88 M49.89
M51.04 M51.05 M51.06 M51.07 M51.14 M51.15 M51.16
M51.17 M51.24 M51.25 M51.26 M51.27 M51.34 M51.35
M51.36 M51.37 M51.44 M51.45 M51.46 M51.47 M51.84
M51.85 M51.86 M51.87 M51.9 M53.2X7 M53.2X8 M53.3
M53.80 M53.84 M53.85 M53.86 M53.87 M53.88 M53.9
M54.03 M54.04 M54.05 M54.06 M54.07 M54.08 M54.09
M54.14 M54.15 M54.16 M54.17 M54.30 M54.31 M54.32
M54.40 M54.41 M54.42 M54.5 M54.6 M54.89 M54.9
M62.830 M81.0 M81.6 M81.8 M96.1 M96.2 M96.3
M96.4 M96.5 M99.12 M99.13 M99.14 M99.15 M99.22
M99.23 M99.24 M99.25 M99.26 M99.27 M99.28 M99.29
M99.32 M99.33 M99.34 M99.35 M99.36 M99.37 M99.38
M99.39 M99.42 M99.43 M99.44 M99.45 M99.46 M99.47
M99.48 M99.49 M99.52 M99.53 M99.54 M99.55 M99.56
M99.57 M99.58 M99.59 M99.62 M99.63 M99.64 M99.65
M99.66 M99.67 M99.68 M99.69 M99.72 M99.73 M99.74
M99.75 M99.76 M99.77 M99.78 M99.79 M99.83 M99.84
Q04.9 Q05.1 Q05.2 Q05.3 Q05.4 Q05.6 Q05.7
Q05.8 Q05.9 Q06.0 Q06.1 Q06.2 Q06.3 Q06.4
Q06.8 Q06.9 Q07.00 Q07.01 Q07.02 Q07.03 Q07.8
Q07.9 Q76.0 Q76.2 Q76.411 Q76.412 Q76.413 Q76.414
Q76.415 Q76.419 Q76.49 S12.9XXA S13.9XXA S14.109A S14.119A
S14.129A S14.139A S14.149A S14.159A S14.2XXA S14.3XXA S21.209A
S22.000A S22.000B S22.001A S22.001B S22.002A S22.002B S22.008A
S22.008B S22.009A S22.009B S22.010A S22.010B S22.011A S22.011B
S22.012A S22.012B S22.018A S22.018B S22.019A S22.019B S22.020A
S22.020B S22.021A S22.021B S22.022A S22.022B S22.028A S22.028B
S22.029A S22.029B S22.030A S22.030B S22.031A S22.031B S22.032A
S22.032B S22.038A S22.038B S22.039A S22.039B S22.040A S22.040B
S22.041A S22.041B S22.042A S22.042B S22.048A S22.048B S22.049A
S22.049B S22.050A S22.050B S22.051A S22.051B S22.052A S22.052B
S22.058A S22.058B S22.059A S22.059B S22.060A S22.060B S22.061A
S22.061B S22.062A S22.062B S22.068A S22.068B S22.069A S22.069B
S22.070A S22.070B S22.071A S22.071B S22.072A S22.072B S22.078A
S22.078B S22.079A S22.079B S22.080A S22.080B S22.081A S22.081B
S22.082A S22.082B S22.088A S22.088B S22.089A S22.089B S23.0XXA
S23.100A S23.101A S23.110A S23.111A S23.120A S23.121A S23.122A
S23.123A S23.130A S23.131A S23.132A S23.133A S23.140A S23.141A
S23.142A S23.143A S23.150A S23.151A S23.152A S23.153A S23.160A
S23.161A S23.162A S23.163A S23.170A S23.171A S23.20XA S23.29XA
S23.3XXA S23.8XXA S23.9XXA S24.0XXA S24.101A S24.102A S24.103A
S24.104A S24.109A S24.111A S24.112A S24.113A S24.114A S24.119A
S24.131A S24.132A S24.133A S24.134A S24.139A S24.141A S24.142A
S24.143A S24.144A S24.149A S24.151A S24.152A S24.153A S24.154A
S24.159A S24.2XXA S31.000A S32.000A S32.000B S32.001A S32.001B
S32.002A S32.002B S32.008A S32.008B S32.009A S32.009B S32.010A
S32.010B S32.011A S32.011B S32.012A S32.012B S32.018A S32.018B
S32.019A S32.019B S32.020A S32.020B S32.021A S32.021B S32.022A
S32.022B S32.028A S32.028B S32.029A S32.029B S32.030A S32.030B
S32.031A S32.031B S32.032A S32.032B S32.038A S32.038B S32.039A
S32.039B S32.040A S32.040B S32.041A S32.041B S32.042A S32.042B
S32.048A S32.048B S32.049A S32.049B S32.050A S32.050B S32.051A
S32.051B S32.052A S32.052B S32.058A S32.058B S32.059A S32.059B
S32.10XA S32.10XB S32.110A S32.110B S32.111A S32.111B S32.112A
S32.112B S32.119A S32.119B S32.120A S32.120B S32.121A S32.121B
S32.122A S32.122B S32.129A S32.129B S32.130A S32.130B S32.131A
S32.131B S32.132A S32.132B S32.139A S32.139B S32.14XA S32.14XB
S32.15XA S32.15XB S32.16XA S32.16XB S32.17XA S32.17XB S32.19XA
S32.19XB S32.2XXA S32.2XXB S33.0XXA S33.100A S33.101A S33.110A
S33.111A S33.120A S33.121A S33.130A S33.131A S33.140A S33.141A
S33.2XXA S33.39XA S33.5XXA S33.6XXA S33.8XXA S33.9XXA S34.01XA
S34.02XA S34.101A S34.102A S34.103A S34.104A S34.105A S34.109A
S34.111A S34.112A S34.113A S34.114A S34.115A S34.119A S34.121A
S34.122A S34.123A S34.124A S34.125A S34.129A S34.131A S34.132A
S34.139A S34.21XA S34.22XA S34.3XXA S34.4XXA

Covered Diagnosis Codes for Procedure Codes L1600, L1610, L1620, L1630, L1640, L1650, L1652, L1660, L1680, L1685, L1686, and L1690 (Hip Braces)

C41.4 M12.251 M12.252 M12.259 M12.551 M12.552 M12.559
M16.0 M16.10 M16.11 M16.12 M24.151 M24.152 M24.159
M24.851 M24.852 M24.859 M25.251 M25.252 M25.259 M25.351
M25.352 M25.359 M25.451 M25.452 M25.459 M25.551 M25.552
M25.559 M87.051 M87.052 M87.059 M87.150 M87.151 M87.152
M87.159 M87.251 M87.252 M87.256 M87.350 M87.351 M87.352
M87.353 M87.850 M87.851 M87.852 M87.859 M90.551 M90.552
M90.559 Q65.00 Q65.01 Q65.02 Q65.1 Q65.2 Q65.30
Q65.31 Q65.32 Q65.4 Q65.5 Q65.6 Q65.89 Q65.9
R29.4 S72.001A S72.002A S72.009A S72.141A S72.142A S72.143A
S72.144A S72.145A S72.146A T84.010A T84.011A T84.012A T84.013A
T84.018A T84.019A

Covered Diagnosis Codes for Procedure Codes L1000, L1001, L1005, L1010, L1020, L1025, L1030, L1040, L1050, L1060, L1070, L1080, L1085, L1090, L1100, L1110, L1120, L1200, L1210, L1220, L1230, L1240, L1250, L1260, L1270, L1280, L1290, L1300, L1310, L1499 (Scoliosis Braces)

A18.01 M40.00 M40.03 M40.04 M40.05 M40.10 M40.12
M40.13 M40.14 M40.15 M40.202 M40.203 M40.204 M40.205
M40.209 M40.292 M40.293 M40.294 M40.295 M40.299 M40.30
M40.35 M40.36 M40.37 M40.40 M40.45 M40.46 M40.47
M40.50 M40.55 M40.56 M40.57 M41.00 M41.02 M41.03
M41.04 M41.05 M41.06 M41.07 M41.08 M41.112 M41.113
M41.114 M41.115 M41.116 M41.117 M41.119 M41.122 M41.123
M41.124 M41.125 M41.126 M41.127 M41.129 M41.20 M41.22
M41.23 M41.24 M41.25 M41.26 M41.27 M41.30 M41.34
M41.35 M41.40 M41.41 M41.42 M41.43 M41.44 M41.45
M41.46 M41.47 M41.50 M41.52 M41.53 M41.54 M41.55
M41.56 M41.57 M41.80 M41.82 M41.83 M41.84 M41.85
M41.86 M41.87 M41.9 M43.8X1 M43.8X2 M43.8X3 M43.8X4
M43.8X5 M43.8X6 M43.8X7 M43.8X8 M43.8X9 M43.9 M96.2
M96.3 M96.4 M96.5 Q67.5 Q67.7 Q76.3 Q76.425
Q76.426 Q76.427 Q76.428 Q76.429

Covered Diagnosis Codes for Procedure Code L3908 (Wrist hand orthosis, wrist extension control cock-up)

G56.00 G56.01 G56.02 G56.03 G56.10 G56.11 G56.12
G56.13 G56.20 G56.21 G56.22 G56.23 G56.30 G56.31
G56.32 G56.33 G56.40 G56.41 G56.42 G56.43 G56.80
G56.81 G56.82 G56.83 G56.90 G56.91 G56.92 G56.93
M24.131 M24.132 M24.139 M67.431 M67.432 M67.439 S52.001A
S52.001B S52.001C S52.001D S52.001E S52.001F S52.001G S52.001H
S52.001J S52.001K S52.001M S52.001N S52.001P S52.001Q S52.001R
S52.001S S52.002A S52.002B S52.002C S52.002D S52.002E S52.002F
S52.002G S52.002H S52.002J S52.002K S52.002M S52.002N S52.002P
S52.002Q S52.002R S52.002S S52.009A S52.009B S52.009C S52.009D
S52.009E S52.009F S52.009G S52.009H S52.009J S52.009K S52.009M
S52.009N S52.009P S52.009Q S52.009R S52.009S S52.011A S52.011D
S52.011G S52.011K S52.011P S52.011S S52.012A S52.012D S52.012G
S52.012K S52.012P S52.012S S52.019A S52.019D S52.019G S52.019K
S52.019P S52.019S S52.021A S52.021B S52.021C S52.021D S52.021E
S52.021F S52.021G S52.021H S52.021J S52.021K S52.021M S52.021N
S52.021P S52.021Q S52.021R S52.021S S52.022A S52.022B S52.022C
S52.022D S52.022E S52.022F S52.022G S52.022H S52.022J S52.022K
S52.022M S52.022N S52.022P S52.022Q S52.022R S52.022S S52.023A
S52.023B S52.023C S52.023D S52.023E S52.023F S52.023G S52.023H
S52.023J S52.023K S52.023M S52.023N S52.023P S52.023Q S52.023R
S52.023S S52.024A S52.024B S52.024C S52.024D S52.024E S52.024F
S52.024G S52.024H S52.024J S52.024K S52.024M S52.024N S52.024P
S52.024Q S52.024R S52.024S S52.025A S52.025B S52.025C S52.025D
S52.025E S52.025F S52.025G S52.025H S52.025J S52.025K S52.025M
S52.025N S52.025P S52.025Q S52.025R S52.025S S52.026A S52.026B
S52.026C S52.026D S52.026E S52.026F S52.026G S52.026H S52.026J
S52.026K S52.026M S52.026N S52.026P S52.026Q S52.026R S52.026S
S52.031A S52.031B S52.031C S52.031D S52.031E S52.031F S52.031G
S52.031H S52.031J S52.031K S52.031M S52.031N S52.031P S52.031Q
S52.031R S52.031S S52.032A S52.032B S52.032C S52.032D S52.032E
S52.032F S52.032G S52.032H S52.032J S52.032K S52.032M S52.032N
S52.032P S52.032Q S52.032R S52.032S S52.033A S52.033B S52.033C
S52.033D S52.033E S52.033F S52.033G S52.033H S52.033J S52.033K
S52.033M S52.033N S52.033P S52.033Q S52.033R S52.033S S52.034A
S52.034B S52.034C S52.034D S52.034E S52.034F S52.034G S52.034H
S52.034J S52.034K S52.034M S52.034N S52.034P S52.034Q S52.034R
S52.034S S52.035A S52.035B S52.035C S52.035D S52.035E S52.035F
S52.035G S52.035H S52.035J S52.035K S52.035M S52.035N S52.035P
S52.035Q S52.035R S52.035S S52.036A S52.036B S52.036C S52.036D
S52.036E S52.036F S52.036G S52.036H S52.036J S52.036K S52.036M
S52.036N S52.036P S52.036Q S52.036R S52.036S S52.041A S52.041B
S52.041C S52.041D S52.041E S52.041F S52.041G S52.041H S52.041J
S52.041K S52.041M S52.041N S52.041P S52.041Q S52.041R S52.041S
S52.042A S52.042B S52.042C S52.042D S52.042E S52.042F S52.042G
S52.042H S52.042J S52.042K S52.042M S52.042N S52.042P S52.042Q
S52.042R S52.042S S52.043A S52.043B S52.043C S52.043D S52.043E
S52.043F S52.043G S52.043H S52.043J S52.043K S52.043M S52.043N
S52.043P S52.043Q S52.043R S52.043S S52.044A S52.044B S52.044C
S52.044D S52.044E S52.044F S52.044G S52.044H S52.044J S52.044K
S52.044M S52.044N S52.044P S52.044Q S52.044R S52.044S S52.045A
S52.045B S52.045C S52.045D S52.045E S52.045F S52.045G S52.045H
S52.045J S52.045K S52.045M S52.045N S52.045P S52.045Q S52.045R
S52.045S S52.046A S52.046B S52.046C S52.046D S52.046E S52.046F
S52.046G S52.046H S52.046J S52.046K S52.046M S52.046N S52.046P
S52.046Q S52.046R S52.046S S52.091A S52.091B S52.091C S52.091D
S52.091E S52.091F S52.091G S52.091H S52.091J S52.091K S52.091M
S52.091N S52.091P S52.091Q S52.091R S52.091S S52.092A S52.092B
S52.092C S52.092D S52.092E S52.092F S52.092G S52.092H S52.092J
S52.092K S52.092M S52.092N S52.092P S52.092Q S52.092R S52.092S
S52.099A S52.099B S52.099C S52.099D S52.099E S52.099F S52.099G
S52.099H S52.099J S52.099K S52.099M S52.099N S52.099P S52.099Q
S52.099R S52.099S S52.101A S52.101B S52.101C S52.101D S52.101E
S52.101F S52.101G S52.101H S52.101J S52.101K S52.101M S52.101N
S52.101P S52.101Q S52.101R S52.101S S52.102A S52.102B S52.102C
S52.102D S52.102E S52.102F S52.102G S52.102H S52.102J S52.102K
S52.102M S52.102N S52.102P S52.102Q S52.102R S52.102S S52.109A
S52.109B S52.109C S52.109D S52.109E S52.109F S52.109G S52.109H
S52.109J S52.109K S52.109M S52.109N S52.109P S52.109Q S52.109R
S52.109S S52.111A S52.111D S52.111G S52.111K S52.111P S52.111S
S52.112A S52.112D S52.112G S52.112K S52.112P S52.112S S52.119A
S52.119D S52.119G S52.119K S52.119P S52.119S S52.121A S52.121B
S52.121C S52.121D S52.121E S52.121F S52.121G S52.121H S52.121J
S52.121K S52.121M S52.121N S52.121P S52.121Q S52.121R S52.121S
S52.122A S52.122B S52.122C S52.122D S52.122E S52.122F S52.122G
S52.122H S52.122J S52.122K S52.122M S52.122N S52.122P S52.122Q
S52.122R S52.122S S52.123A S52.123B S52.123C S52.123D S52.123E
S52.123F S52.123G S52.123H S52.123J S52.123K S52.123M S52.123N
S52.123P S52.123Q S52.123R S52.123S S52.124A S52.124B S52.124C
S52.124D S52.124E S52.124F S52.124G S52.124H S52.124J S52.124K
S52.124M S52.124N S52.124P S52.124Q S52.124R S52.124S S52.125A
S52.125B S52.125C S52.125D S52.125E S52.125F S52.125G S52.125H
S52.125J S52.125K S52.125M S52.125N S52.125P S52.125Q S52.125R
S52.125S S52.126A S52.126B S52.126C S52.126D S52.126E S52.126F
S52.126G S52.126H S52.126J S52.126K S52.126M S52.126N S52.126P
S52.126Q S52.126R S52.126S S52.131A S52.131B S52.131C S52.131D
S52.131E S52.131F S52.131G S52.131H S52.131J S52.131K S52.131M
S52.131N S52.131P S52.131Q S52.131R S52.131S S52.132A S52.132B
S52.132C S52.132D S52.132E S52.132F S52.132G S52.132H S52.132J
S52.132K S52.132M S52.132N S52.132P S52.132Q S52.132R S52.132S
S52.133A S52.133B S52.133C S52.133D S52.133E S52.133F S52.133G
S52.133H S52.133J S52.133K S52.133M S52.133N S52.133P S52.133Q
S52.133R S52.133S S52.134A S52.134B S52.134C S52.134D S52.134E
S52.134F S52.134G S52.134H S52.134J S52.134K S52.134M S52.134N
S52.134P S52.134Q S52.134R S52.134S S52.135A S52.135B S52.135C
S52.135D S52.135E S52.135F S52.135G S52.135H S52.135J S52.135K
S52.135M S52.135N S52.135P S52.135Q S52.135R S52.135S S52.136A
S52.136B S52.136C S52.136D S52.136E S52.136F S52.136G S52.136H
S52.136J S52.136K S52.136M S52.136N S52.136P S52.136Q S52.136R
S52.136S S52.181A S52.181B S52.181C S52.181D S52.181E S52.181F
S52.181G S52.181H S52.181J S52.181K S52.181M S52.181N S52.181P
S52.181Q S52.181R S52.181S S52.182A S52.182B S52.182C S52.182D
S52.182E S52.182F S52.182G S52.182H S52.182J S52.182K S52.182M
S52.182N S52.182P S52.182Q S52.182R S52.182S S52.189A S52.189B
S52.189C S52.189D S52.189E S52.189F S52.189G S52.189H S52.189J
S52.189K S52.189M S52.189N S52.189P S52.189Q S52.189R S52.189S
S52.201A S52.201B S52.201C S52.201D S52.201E S52.201F S52.201G
S52.201H S52.201J S52.201K S52.201M S52.201N S52.201P S52.201Q
S52.201R S52.201S S52.202A S52.202B S52.202C S52.202D S52.202E
S52.202F S52.202G S52.202H S52.202J S52.202K S52.202M S52.202N
S52.202P S52.202Q S52.202R S52.202S S52.209A S52.209B S52.209C
S52.209D S52.209E S52.209F S52.209G S52.209H S52.209J S52.209K
S52.209M S52.209N S52.209P S52.209Q S52.209R S52.209S S52.211A
S52.211D S52.211G S52.211K S52.211P S52.211S S52.212A S52.212D
S52.212G S52.212K S52.212P S52.212S S52.219A S52.219D S52.219G
S52.219K S52.219P S52.219S S52.221A S52.221B S52.221C S52.221D
S52.221E S52.221F S52.221G S52.221H S52.221J S52.221K S52.221M
S52.221N S52.221P S52.221Q S52.221R S52.221S S52.222A S52.222B
S52.222C S52.222D S52.222E S52.222F S52.222G S52.222H S52.222J
S52.222K S52.222M S52.222N S52.222P S52.222Q S52.222R S52.222S
S52.223A S52.223B S52.223C S52.223D S52.223E S52.223F S52.223G
S52.223H S52.223J S52.223K S52.223M S52.223N S52.223P S52.223Q
S52.223R S52.223S S52.224A S52.224B S52.224C S52.224D S52.224E
S52.224F S52.224G S52.224H S52.224J S52.224K S52.224M S52.224N
S52.224P S52.224Q S52.224R S52.224S S52.225A S52.225B S52.225C
S52.225D S52.225E S52.225F S52.225G S52.225H S52.225J S52.225K
S52.225M S52.225N S52.225P S52.225Q S52.225R S52.225S S52.226A
S52.226B S52.226C S52.226D S52.226E S52.226F S52.226G S52.226H
S52.226J S52.226K S52.226M S52.226N S52.226P S52.226Q S52.226R
S52.226S S52.231A S52.231B S52.231C S52.231D S52.231E S52.231F
S52.231G S52.231H S52.231J S52.231K S52.231M S52.231N S52.231P
S52.231Q S52.231R S52.231S S52.232A S52.232B S52.232C S52.232D
S52.232E S52.232F S52.232G S52.232H S52.232J S52.232K S52.232M
S52.232N S52.232P S52.232Q S52.232R S52.232S S52.233A S52.233B
S52.233C S52.233D S52.233E S52.233F S52.233G S52.233H S52.233J
S52.233K S52.233M S52.233N S52.233P S52.233Q S52.233R S52.233S
S52.234A S52.234B S52.234C S52.234D S52.234E S52.234F S52.234G
S52.234H S52.234J S52.234K S52.234M S52.234N S52.234P S52.234Q
S52.234R S52.234S S52.235A S52.235B S52.235C S52.235D S52.235E
S52.235F S52.235G S52.235H S52.235J S52.235K S52.235M S52.235N
S52.235P S52.235Q S52.235R S52.235S S52.236A S52.236B S52.236C
S52.236D S52.236E S52.236F S52.236G S52.236H S52.236J S52.236K
S52.236M S52.236N S52.236P S52.236Q S52.236R S52.236S S52.241A
S52.241B S52.241C S52.241D S52.241E S52.241F S52.241G S52.241H
S52.241J S52.241K S52.241M S52.241N S52.241P S52.241Q S52.241R
S52.241S S52.242A S52.242B S52.242C S52.242D S52.242E S52.242F
S52.242G S52.242H S52.242J S52.242K S52.242M S52.242N S52.242P
S52.242Q S52.242R S52.242S S52.243A S52.243B S52.243C S52.243D
S52.243E S52.243F S52.243G S52.243H S52.243J S52.243K S52.243M
S52.243N S52.243P S52.243Q S52.243R S52.243S S52.244A S52.244B
S52.244C S52.244D S52.244E S52.244F S52.244G S52.244H S52.244J
S52.244K S52.244M S52.244N S52.244P S52.244Q S52.244R S52.244S
S52.245A S52.245B S52.245C S52.245D S52.245E S52.245F S52.245G
S52.245H S52.245J S52.245K S52.245M S52.245N S52.245P S52.245Q
S52.245R S52.245S S52.246A S52.246B S52.246C S52.246D S52.246E
S52.246F S52.246G S52.246H S52.246J S52.246K S52.246M S52.246N
S52.246P S52.246Q S52.246R S52.246S S52.251A S52.251B S52.251C
S52.251D S52.251E S52.251F S52.251G S52.251H S52.251J S52.251K
S52.251M S52.251N S52.251P S52.251Q S52.251R S52.251S S52.252A
S52.252B S52.252C S52.252D S52.252E S52.252F S52.252G S52.252H
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S62.92XP S62.92XS S63.501A S63.501S S63.502A S63.502S S63.509A
S63.509S S63.511A S63.512A S63.519A S63.521A S63.522A S63.529A
S63.599A S63.8X1A S63.8X1D S63.8X1S S63.8X2A S63.8X2D S63.8X2S
S63.8X9A S63.8X9D S63.8X9S S63.90XA S63.90XD S63.90XS S63.91XA
S63.91XD S63.91XS S63.92XA S63.92XD S63.92XS