Braces and Supports

Policy ID: O-8-038

Effective Date: July 01, 2018

Revised Date: March 18, 2025

Revision Effective Date: April 01, 2025

Last Reviewed: May 13, 2025

Applies To: Commercial and Medicaid Expansion

Description

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 individual 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.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of processing, regardless of service date; and/or

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

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

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

(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

L9900

Supportive back braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Custom-fitted and custom-fabricated back braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Postoperative back braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L1310

L1681

L9900

Quantity Level Limits (QLL) for all back braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Postoperative Hip Braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L1681

L1685

L1686

L9900

Cast-Braces-Splints

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Comfort, non-therapeutic cast-braces (Cam Walker) may be considered medically necessary when ALL 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

L4360

L4361

L4386

L4387

L9900

Functional cast-braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

(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 ALL 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

L9900

Rehabilitation braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

May be considered medically necessary when ALL 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

L1653

L1660

L1680

L1685

L1686

L1690

L9900

Cervical (neck) braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Childhood hip braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

(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

L1653

L1660

L1680

L1685

L1686

L1690

L9900

Braces for congenital defects or advanced neuromuscular conditions

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Cervical-thoracic-lumbar-sacral or thoracic-lumbar-sacral orthoses

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L0720

L1000

L1001

L1005

L1006

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

L9900

Wheaton braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L1836

L1930

L9900

Splints and immobilizers

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Q4049

Air casts/air splints

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Miscellaneous covered services

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Diagnosis Codes

Covered Diagnosis Codes for Procedure Codes L0130, L0140, L0150, L0160, L0170, L0172, L0174, L0180, L0190, L0200 (Cervical Region) and L0720

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

M46.1

M46.00

M46.01

M46.02

M46.03

M46.04

M46.05

M46.06

M46.07

M46.08

M46.09

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

M47.9

M47.10

M47.11

M47.12

M47.13

M47.20

M47.21

M47.22

M47.23

M47.011

M47.012

M47.013

M47.014

M47.015

M47.016

M47.019

M47.021

M47.022

M47.029

M47.811

M47.812

M47.813

M47.819

M47.891

M47.892

M47.893

M47.899

M48.8X1

M48.8X2

M48.8X3

M48.8X4

M48.8X5

M48.8X6

M48.8X7

M48.8X8

M48.8X9

M48.9

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

M49.80

M49.81

M49.82

M49.83

M49.84

M49.85

M49.86

M49.87

M49.88

M49.89

M50.00

M50.01

M50.03

M50.10

M50.11

M50.13

M50.20

M50.21

M50.23

M50.30

M50.31

M50.33

M50.80

M50.81

M50.83

M50.90

M50.91

M50.93

M50.020

M50.021

M50.022

M50.023

M50.120

M50.121

M50.122

M50.123

M50.220

M50.221

M50.222

M50.223

M50.320

M50.321

M50.322

M50.323

M50.820

M50.821

M50.822

M50.823

M50.920

M50.921

M50.922

M50.923

M51.9

M51.34

M51.35

M51.36

M51.37

M53.0

M53.1

M53.81

M53.82

M53.83

M54.2

M54.11

M54.12

M54.13

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

Q76.49

Q76.411

Q76.412

Q76.413

Q76.414

Q76.415

Q76.419

S11.90XA

S12.9XXA

S12.01XA

S12.01XB

S12.02XA

S12.02XB

S12.14XA

S12.14XB

S12.24XA

S12.24XB

S12.34XA

S12.34XB

S12.44XA

S12.44XB

S12.54XA

S12.54XB

S12.64XA

S12.64XB

S12.000A

S12.000B

S12.001A

S12.001B

S12.030A

S12.030B

S12.031A

S12.031 B

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

S12.150A

S12.150B

S12.151A

S12.151B

S12.190A

S12.190B

S12.191A

S12.191B

S12.200A

S12.200B

S12.201A

S12.201 B

S12.230A

S12.230B

S12.231A

S12.231B

S12.250A

S12.250B

S12.251A

S12.251B

S12.290A

S12.290B

S12.291A

S12.291 B

S12.300A

S12.300B

S12.301A

S12.301B

S12.330A

S12.330B

S12.331A

S12.331B

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

S12.450A

S12.450B

S12.451A

S12.451B

S12.490A

S12.490B

S12.491A

S12.491B

S12.500A

S12.500B

S12.501A

S12.501B

S1 2.530A

S12.530B

S12.531A

S12.531B

S12.550A

S12.550B

S12.551A

S12.551B

S12.590A

S12.590B

S12.591A

S12.591B

S12.600A

S12.600B

S12.601A

S12.601 B

S12.630A

S12.630B

S12.631A

S12.631B

S12.650A

S12.650B

S12.651A

S12.651B

S12.690A

S12.690B

S12.691A

S12.691B

S13.0XXA

S13.4XXA

S13.8XXA

S13.20XA

S13.29XA

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

S14.0XXA

S14.2XXA

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

S16.1XXA

S22.009A

S22.009B

S24.109A

S32.2XXA

S32.2XXB

S32.10XA

S32.10XB

S32.009A

S32.009B

S34.109A

S34.139A

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

S16.1XXA

S22.009A

S22.009B

S24.109A

S32.2XXA

S32.2XXB

S32.10XA

S32.10XB

S32.009A

S32.009B

S34.109A

S34.139A

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

S16.1XXA

S22.009A

S22.009B

S24.109A

S32.2XXA

S32.2XXB

S32.10XA

S32.10XB

S32.009A

S32.009B

S34.109A

S34.139A

Covered Diagnosis Codes for Procedure Code L1499 (Chest Orthotic)

Q67.7

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, and 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

M40.30

M40.35

M40.36

M40.37

M40.40

M40.45

M40.46

M40.47

M40.50

M40.55

M40.56

M40.57

M40.202

M40.203

M40.204

M40.205

M40.209

M40.292

M40.293

M40.294

M40.295

M40.299

M41.9

M41.00

M41.02

M41.03

M41.04

M41.05

M41.06

M41.07

M41.08

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

M41.112

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

M43.6

M43.8X1

M43.8X2

M43.8X3

M43.8X4

M43.8X5

M43.8X6

M43.8X7

M43.8X8

M43.8X9

M43.9

M43.20

M43.21

M43.22

M43.23

M43.24

M43.25

M43.26

M43.27

M43.28

M45.0

M45.1

M45.2

M45.3

M45.4

M45.5

M45.6

M45.7

M45.8

M45.9

M46.1

M46.00

M46.01

M46.02

M46.03

M46.04

M46.05

M46.06

M46.07

M46.08

M46.09

M46.40

M46.41

M46.42

M46.43

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

M47.9

M47.10

M47.11

M47.12

M47.13

M47.14

M47.15

M47.16

M47.17

M47.18

M47.20

M47.21

M47.22

M47.23

M47.24

M47.25

M47.26

M47.27

M47.28

M47.011

M47.012

M47.013

M47.014

M47.015

M47.016

M47.019

M47.021

M47.022

M47.029

M47.81 1

M47.812

M47.813

M47.814

M47.815

M47.816

M47.817

M47.81 8

M47.819

M47.891

M47.892

M47.893

M47.894

M47.895

M47.896

M47.897

M47.898

M47.899

M48.8X1

M48.8X2

M48.8X3

M48.8X4

M48.8X5

M48.8X6

M48.8X7

M48.8X8

M48.8X9

M48.9

M48.00

M48.01

M48.02

M48.03

M48.04

M48.05

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

M48.061

M48.062

M49.80

M49.81

M49.82

M49.83

M49.84

M49.85

M49.86

M49.87

M49.88

M49.89

M50.00

M50.01

M50.03

M50.10

M50.11

M50.13

M50.20

M50.21

M50.23

M50.30

M50.31

M50.33

M50.80

M50.81

M50.83

M50.90

M50.91

M50.93

M50.020

M50.021

M50.022

M50.023

M50.120

M50.121

M50.122

M50.123

M50.220

M50.221

M50.222

M50.223

M50.320

M50.321

M50.322

M50.323

M50.820

M50.821

M50.822

M50.823

M50.920

M50.921

M50.922

M50.923

M51.9

M51.04

M51.05

M51.06

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

M53.0

M53.1

M53.2X7

M53.2X8

M53.3

M53.9

M53.80

M53.81

M53.82

M53.83

M53.84

M53.85

M53.86

M53.87

M53.88

M54.2

M54.50

M54.51

M54.59

M54.6

M54.9

M54.03

M54.04

M54.05

M54.06

M54.07

M54.08

M54.09

M54.11

M54.12

M54.13

M54.14

M54.15

M54.16

M54.17

M54.30

M54.31

M54.32

M54.40

M54.41

M54.42

M54.81

M54.89

M62.830

M67.88

M81.0

M81.6

M81.8

M96.1

M96.2

M96.3

M96.4

M96.5

M99.10

M99.11

M99.12

M99.13

M99.14

M99.15

M99.20

M99.21

M99.22

M99.23

M99.24

M99.25

M99.26

M99.27

M99.28

M99.29

M99.30

M99.31

M99.32

M99.33

M99.34

M99.35

M99.36

M99.37

M99.38

M99.39

M99.40

M99.41

M99.42

M99.43

M99.44

M99.45

M99.46

M99.47

M99.48

M99.49

M99.50

M99.51

M99.52

M99.53

M99.54

M99.55

M99.56

M99.57

M99.58

M99.59

M99.60

M99.61

M99.62

M99.63

M99.64

M99.65

M99.66

M99.67

M99.68

M99.69

M99.70

M99.71

M99.72

M99.73

M99.74

M99.75

M99.76

M99.77

M99.78

M99.79

M99.83

M99.84

Q04.9

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q06.0

Q06.1

Q06.2

Q06.3

Q06.4

Q06.8

Q06.9

Q07.8

Q07.9

Q07.00

Q07.01

Q07.02

Q07.03

Q76.0

Q76.1

Q76.2

Q76.49

Q76.411

Q76.412

Q76.413

Q76.414

Q76.415

Q76.419

S11.90XA

S12.9XXA

S12.01XA

S12.01XB

S12.02XA

S12.02XB

S12.14XA

S12.14XB

S12.24XA

S12.24XB

S12.34XA

S12.34XB

S12.44XA

S12.44XB

S12.54XA

S12.54XB

S12.64XA

S12.64XB

S12.000A

S12.000B

S12.001A

S12.001B

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

S12.150A

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

S12.250A

S12.250B

S12.251A

S12.251B

S12.290A

S12.290B

S12.291A

S12.291 B

S12.300A

S12.300B

S12.301A

S12.301 B

S12.330A

S12.330B

S12.331A

S12.331 B

S12.350A

S12.350B

S12.351A

S12.351B

S12.390A

S12.390B

S12.391A

S12.391 B

S12.400A

S12.400B

S12.401A

S12.401B

S12.430A

S12.430B

S12.431A

S12.431 B

S12.450A

S12.450B

S12.451A

S12.451B

S12.490A

S12.490B

S12.491A

S12.491B

S12.500A

S12.500B

S12.501A

S12.501 B

S12.530A

S12.530B

S12.531A

S12.531B

S1 2.550A

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

S12.650A

S12.650B

S12.651A

S12.651B

S12.690A

S12.690B

S12.691A

S12.691B

S13.0XXA

S13.4XXA

S13.8XXA

S13.9XXA

S13.20XA

S13.29XA

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

S14.0XXA

S14.2XXA

S14.3XXA

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

S14.119A

S14.121A

S14.122A

S14.123A

S14.124A

S14.125A

S14.126A

S14.127A

S14.128A

S14.129A

S14.131A

S14.132A

S14.133A

S14.134A

S14.135A

S14.136A

S14.137A

S14.138A

S14.139A

S14.141A

S14.142A

S14.143A

S14.144A

S14.145A

S14.146A

S 14.147A

S 14.148A

S14.149A

S14.151A

S14.152A

S14.153A

S14.154A

S14.155A

S14.156A

S14.157A

S14.158A

S14.159A

S16.1XXA

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

S22.041 A

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

S23.3XXA

S23.8XXA

S23.9XXA

S23.20XA

S23.29XA

S23.100A

S23.101A

S23.1 10A

S23.11 1A

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

S24.0XXA

S24.2XXA

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

S31.000A

S32.2XXA

S32.2XXB

S32.10XA

S32.10XB

S32.14XA

S32.14XB

S32.15XA

S32.15XB

S32.16XA

S32.16XB

S32.17XA

S32.17XB

S32.19XA

S32.19XB

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

S32.110A

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

S33.0XXA

S33.2XXA

S33.5XXA

S33.6XXA

S33.8XXA

S33.9XXA

S33.39XA

S33.100A

S33.101A

S33.110A

S33.111A

S33.120A

S33.121A

S33.130A

S33.131A

S33.140A

S33.141A

S34.3XXA

S34.4XXA

S34.01XA

S34.02XA

S34.21XA

S34.22XA

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

S33.110A

S33.111A

S33.120A

S33.121A

S33.130A

S33.131A

S33.140A

S33.141A

S34.3XXA

S34.4XXA

S34.01XA

S34.02XA

S34.21XA

S34.22XA

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

S34.115A

S34.119A

S34.121A

S34.122A

S34.123A

S34.124A

S34.125A

S34.129A

S34.131A

S34.132A

S34.139A

S33.110A

S33.111A

S33.120A

S33.121A

S33.130A

S33.131A

S33.140A

S33.141A

S34.3XXA

S34.4XXA

S34.01XA

S34.02XA

S34.21XA

S34.22XA

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

S33.110A

S33.111A

S33.120A

S33.121A

S33.130A

S33.131A

S33.140A

S33.141A

S34.3XXA

S34.4XXA

S34.01XA

S34.02XA

S34.21XA

S34.22XA

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

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

M12.551

M12.552

M16.0

M16.11

M16.12

M24.151

M24.152

M24.851

M24.852

M25.251

M25.252

M25.351

M25.352

M25.451

M25.452

M25.551

M25.552

M87.051

M87.052

M87.150

M87.151

M87.152

M87.251

M87.252

M87.350

M87.351

M87.352

M87.850

M87.851

M87.852

M90.551

M90.552

Q65.1

Q65.4

Q65.6

Q65.01

Q65.02

Q65.31

Q65.32

Q65.89

R29.4

S72.001A

S72.002A

S72.141A

S72.142A

S72.144A

S72.145A

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, L1 260, L1270, L1280, L1290, L1300, L1310, L1499 (Scolios)is Braces

A18.01

M40.00

M40.03

M40.04

M40.05

M40.10

M40.12

M40.13

M40.14

M40.15

M40.30

M40.35

M40.36

M40.37

M40.40

M40.45

M40.46

M40.47

M40.50

M40.55

M40.56

M40.57

M40.202

M40.203

M40.204

M40.205

M40.209

M40.292

M40.293

M40.294

M40.295

M40.299

M41.9

M41.00

M41.02

M41.03

M41.04

M41.05

M41.06

M41.07

M41.08

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

M41.112

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

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)

G56.01

G56.02

G56.03

G56.1 1

G56.12

G56.13

G56.21

G56.22

G56.23

G56.31

G56.32

G56.33

G56.41

G56.42

G56.43

G56.81

G56.82

G56.83

G56.91

G56.92

G56.93

M24.131

M24.132

M25.531

M25.532

M67.431

M67.432

M77.11

M77.12

S52.91XA

S52.91XB

S52.91XC

S52.91XD

S52.91E

S52.91XF

S52.91XG

S52.91XH

S52.91XJ

S52.91XK

S52.91XM

S52.91XN

S52.91XP

S52.91XQ

S52.91XR

S52.91XS

S52.92XA

S52.92XB

S52.92XC

S52.92XD

S52.92XE

S52.92XF

S52.92XG

S52.92XH

S52.92XJ

S52.92XK

S52.92XM

S52.92XN

S52.92XP

S52.92XQ

S52.92XR

S52.92XS

S52.001A

S52.001B

S52.001C

S52.001D

S52.001E

S52.001F

S52.001G

S52.001 H

S52.001J

S52.001K

S52.001 M

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

S52.011A

S52.011D

S52.011G

S52.011K

S52.011P

S52.011S

S52.012A

S52.012D

S52.012G

S52.012K

S52.012P

S52.012S

S52.021A

S52.021B

S52.021C

S52.021D

S52.021E

S52.021 F

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

S52.024A

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

S52.031A

S52.031B

S52.031C

S52.031D

S52.031E

S52.031 F

S52.031G

S52.031H

S52.031J

S52.031K

S52.031M

S52.031N

S52.031P

S52.031G

S52.031H

S52.031J

S52.031K

S52.031M

S52.031N

S52.031P

S52.031Q

S52.031 R

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

S52.034A

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

S52.041A

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

S52.044A

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

S52.091A

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

S52.101A

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

S52.111A

S52.111D

S52.111G

S52.111K

S52.111P

S52.111S

S52.112A

S52.112D

S52.112G

S52.112K

S52.112P

S52.112S

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

S52.124A

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

S52.131A

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

S52.134A

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

S52.181A

S52.181B

S52.181C

S52.181D

S52.181E

S52.181F

S52.181G

S52.181H

S52.181J

S52.181K

S52.181M

S52.181N

S52.181 P

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

S52.201A

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

S52.201Q

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

S52.211A

S52.211D

S52.211G

S52.211K

S52.211P

S52.211S

S52.212A

S52.212D

S52.212G

S52.212K

S52.212P

S52.212S

S52.221A

S52.221B

S52.221C

S52.221D

S52.221E

S52.221F

S52.221G

S52.221H

S52.221J

S52.221K

S52.221M

S52.221 N

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

S52.221 N

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

S52.224A

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

S52.231A

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

S52.234A

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

S52.241A

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

S52.244A

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

S52.251A

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

S52.252J

S52.252K

S52.252M

S52.252N

S52.252P

S52.252Q

S52.252R

S52.252S

S52.254A

S52.254B

S52.254C

S52.254D

S52.254E

S52.254F

S52.254G

S52.254H

S52.254J

S52.254K

S52.254M

S52.254N

S52.254P

S52.254Q

S52.254R

S52.254S

S52.255A

S52.255B

S52.255C

S52.255D

S52.255E

S52.255F

S52.255G

S52.255H

S52.255J

S52.255K

S52.255M

S52.255N

S52.255P

S52.255Q

S52.255R

S52.255S

S52.261A

S52.261B

S52.261C

S52.261D

S52.261E

S52.261F

S52.261G

S52.261H

S52.261J

S52.261K

S52.261M

S52.261N

S52.261P

S52.261Q

S52.261R

S52.261S

S52.262A

S52.262B

S52.262C

S52.262D

S52.262E

S52.262F

S52.262G

S52.262H

S52.262J

S52.262K

S52.262M

S52.262N

S52.262P

S52.262Q

S52.262R

S52.262S

S52.264A

S52.264B

S52.264C

S52.264D

S52.264E

S52.264F

S52.264G

S52.264H

S52.264J

S52.264K

S52.264M

S52.264N

S52.264P

S52.264Q

S52.264R

S52.264S

S52.265A

S52.265B

S52.265C

S52.265D

S52.265E

S52.265F

S52.265G

S52.265H

S52.265J

S52.265K

S52.265M

S52.265N

S52.265P

S52.265Q

S52.265R

S52.265S

S52.271A

S52.271B

S52.271C

S52.271D

S52.271E

S52.271F

S52.271G

S52.271H

S52.271J

S52.271K

S52.271M

S52.271N

S52.271P

S52.271Q

S52.271R

S52.271S

S52.272A

S52.272B

S52.272C

S52.272D

S52.272E

S52.272F

S52.272G

S52.272H

S52.272J

S52.272K

S52.272M

S52.272N

S52.272P

S52.272Q

S52.272R

S52.272S

S52.281A

S52.281B

S52.281C

S52.281D

S52.281E

S52.281F

S52.281G

S52.281H

S52.281J

S52.281K

S52.281M

S52.281N

S52.281P

S52.281Q

S52.281R

S52.281S

S52.282A

S52.282B

S52.282C

S52.282D

S52.282E

S52.282F

S52.282G

S52.282H

S52.282J

S52.282K

S52.282M

S52.282N

S52.282P

S52.282Q

S52.282R

S52.282S

S52.291A

S52.291B

S52.291C

S52.291D

S52.291E

S52.291F

S52.291G

S52.291H

S52.291J

S52.291K

S52.291M

S52.291N

S52.291P

S52.291Q

S52.291R

S52.291S

S52.292A

S52.292B

S52.292C

S52.292D

S52.292E

S52.292F

S52.292G

S52.292H

S52.292J

S52.292K

S52.292M

S52.292N

S52.292P

S52.292Q

S52.292R

S52.292S

S52.301A

S52.301B

S52.301C

S52.301D

S52.301E

S52.301F

S52.301G

S52.301H

S52.301J

S52.301K

S52.301M

S52.301N

S52.301P

S52.301Q

S52.301R

S52.301S

S52.302A

S52.302B

S52.302C

S52.302D

S52.302E

S52.302F

S52.302G

S52.302H

S52.302J

S52.302K

S52.302M

S52.302N

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Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 7-22-2020 No changes in criteria. Processing change only.

Internal Medical Policy Committee 3-17-2021 Coding update

Added procedure code L9900

Internal Medical Policy Committee 7-22-2021 Coding update

Added procedure code A6456.

Internal Medical Policy Committee 7-21-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-16-2024 Revision with Coding - Effective September 02, 2024

Removed procedure codes 27125; 27130; 27132; 27134; 27137; 27138; 27140; 29861; 29862; 29863; 29914; 29915; & 29916 from Postoperative Hip Braces section; and
Removed Unna Boots section including procedure codes A6456 and L9900; and
Added procedure code L1681 to Postoperative Hip Braces section; and
Added Policy Applications; and
Added Diagnosis codes.

Internal Medical Policy Committee 9-14-2024 Coding - Effective October 01, 2024

Added procedure codes L1006 and L1653

Internal Medical Policy Committee 5-13-2025 Coding update - Effective April 01, 2025

Added procedure code L0720; and corrected typos to diagnosis codes

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: O-8-037

Section: Orthotic & Prosthetic Devices

Effective Date: July 01, 2018

Revised Date: September 25, 2024

Revision Effective Date: October 01, 2024

Last Reviewed: September 17, 2024

Archived Date: March 31, 2025

Applies To: Commercial and Medicaid Expansion

Description

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

Minimal self-adjustment can be performed by the individual 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.

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Criteria

Coverage is subject to the specific terms of the member's benefit plan.

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

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

(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

L9900

Supportive back braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Custom-fitted and custom-fabricated back braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Postoperative back braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L1310

L1681

L9900

Quantity Level Limits (QLL) for all back braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Postoperative Hip Braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L1681

L1685

L1686

L9900

Cast-Braces-Splints

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

Comfort, non-therapeutic cast-braces (Cam Walker) may be considered medically necessary when ALL 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

L4360

L4361

L4386

L4387

L9900

Functional cast-braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Rehabilitation braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

May be considered medically necessary when ALL 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

L1653

L1660

L1680

L1685

L1686

L1690

L9900

Cervical (neck) braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Childhood hip braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

(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

L1653

L1660

L1680

L1685

L1686

L1690

L9900

Braces for congenital defects or advanced neuromuscular conditions

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Cervical-thoracic-lumbar-sacral or thoracic-lumbar-sacral orthoses

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L1006

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

L9900

Wheaton braces

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L1836

L1930

L9900

Splints and immobilizers

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Q4049

Air casts/air splints

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

Miscellaneous covered services

Policy Application

All claims submitted under this policy's section will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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

L9900

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

M46.1

M46.00

M46.01

M46.02

M46.03

M46.04

M46.05

M46.06

M46.07

M46.08

M46.09

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

M47.9

M47.10

M47.11

M47.12

M47.13

M47.20

M47.21

M47.22

M47.23

M47.011

M47.012

M47.013

M47.014

M47.015

M47.016

M47.019

M47.021

M47.022

M47.029

M47.811

M47.812

M47.813

M47.819

M47.891

M47.892

M47.893

M47.899

M48.8X1

M48.8X2

M48.8X3

M48.8X4

M48.8X5

M48.8X6

M48.8X7

M48.8X8

M48.8X9

M48.9

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

M49.80

M49.81

M49.82

M49.83

M49.84

M49.85

M49.86

M49.87

M49.88

M49.89

M50.00

M50.01

M50.03

M50.10

M50.11

M50.13

M50.20

M50.21

M50.23

M50.30

M50.31

M50.33

M50.80

M50.81

M50.83

M50.90

M50.91

M50.93

M50.020

M50.021

M50.022

M50.023

M50.120

M50.121

M50.122

M50.123

M50.220

M50.221

M50.222

M50.223

M50.320

M50.321

M50.322

M50.323

M50.820

M50.821

M50.822

M50.823

M50.920

M50.921

M50.922

M50.923

M51.9

M51.34

M51.35

M51.36

M51.37

M53.0

M53.1

M53.81

M53.82

M53.83

M54.2

M54.11

M54.12

M54.13

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

Q76.49

Q76.411

Q76.412

Q76.413

Q76.414

Q76.415

Q76.419

S11.90XA

S12.9XXA

S12.01 XA

S12.01XB

S12.02XA

S12.02XB

S12.14XA

S12.14XB

S12.24XA

S12.24XB

S12.34XA

S12.34XB

S12.44XA

S12.44XB

S12.54XA

S12.54XB

S12.64XA

S12.64XB

S12.000A

S12.000B

S12.001A

S12.001B

S12.030A

S12.030B

S1 2.031A

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

S12.150A

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

S12.250A

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

S12.350A

S12.350B

S12.351A

S12.351B

S12.390A

S12.390B

S12.391A

S12.391B

S12.400A

S12.400B

S1 2.401A

S12.401B

S12.430A

S12.430B

S1 2.431A

S12.431 B

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

S1 2.531 B

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

S12.650A

S12.650B

S12.651A

S12.651B

S12.690A

S12.690B

S12.691A

S12.691B

S13.0XXA

S13.4XXA

S13.8XXA

S13.20XA

S13.29XA

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

S14.0XXA

S14.2XXA

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

S16.1XXA

S22.009A

S22.009B

S24.109A

S32.2XXA

S32.2XXB

S32.10XA

S32.10XB

S32.009A

S32.009B

S34.109A

S34.139A

Covered Diagnosis Codes for Procedure Code L1499 (Chest Orthotic)

Q67.7

A18.01

G90.1

M08. 1

M25.78

M40.00

M40.03

M40.04

M40.35

M40.36

M40.37

M40.40

M40.45

M40.46

M40.47

M40.50

M40.55

M40.56

M40.57

M40.202

M40.203

M40.204

M40.205

M40.209

M40.292

M40.293

M40.294

M40.295

M40.299

M41.9

M41.00

M41.02

M41.03

M41.04

M41.05

M41.06

M41.07

M41.08

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

M41.112

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

M43.6

M43.8X1

M43.8X2

M43.8X3

M43.8X4

M43.8X5

M43.8X6

M43.8X7

M43.8X8

M43.8X9

M43.9

M43.20

M43.21

M43.22

M43.23

M43.24

M43.25

M43.26

M43.27

M43.28

M45.0

M45.1

M45.2

M45.3

M45.4

M45.5

M45.6

M45.7

M45.8

M45.9

M46.1

M46.00

M46.01

M46.02

M46.03

M46.04

M46.05

M46.06

M46.07

M46.08

M46.09

M46.40

M46.41

M46.42

M46.43

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

M47.9

M47.10

M47.11

M47.12

M47.13

M47.14

M47.15

M47.16

M47.17

M47.18

M47.20

M47.21

M47.22

M47.23

M47.24

M47.25

M47.26

M47.27

M47.28

M47.011

M47.012

M47.013

M47.014

M47.015

M47.016

M47.019

M47.021

M47.022

M47.029

M47.811

M47.812

M47.813

M47.814

M47.815

M47.816

M47.817

M47.818

M47.819

M47.891

M47.892

M47.893

M47.894

M47.895

M47.896

M47.897

M47.898

M47.899

M48.8X1

M48.8X2

M48.8X3

M48.8X4

M48.8X5

M48.8X6

M48.8X7

M48.8X8

M48.8X9

M48.9

M48.00

M48.01

M48.02

M48.03

M48.04

M48.05

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

M48.061

M48.062

M49.80

M49.81

M49.82

M49.83

M49.84

M49.85

M49.86

M49.87

M49.88

M49.89

M50.00

M50.01

M50.03

M50.10

M50.11

M50.13

M50.20

M50.21

M50.23

M50.30

M50.31

M50.33

M50.80

M50.81

M50.83

M50.90

M50.91

M50.93

M50.020

M50.021

M50.022

M50.023

M50.120

M50.121

M50.122

M50.123

M50.220

M50.221

M50.222

M50.223

M50.320

M50.321

M50.322

M50.323

M50.820

M50.821

M50.822

M50.823

M50.920

M50.921

M50.922

M50.923

M51.9

M51.04

M51.05

M51.06

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

M53.0

M53.1

M53.2X7

M53.2X8

M53.3

M53.9

M53.80

M53.81

M53.82

M53.83

M53.84

M53.85

M53.86

M53.87

M53.88

M54.2

M54.50

M54.51

M54.59

M54.6

M54.9

M54.03

M54.04

M54.05

M54.06

M54.07

M54.08

M54.09

M54.11

M54.12

M54.13

M54.14

M54.15

M54.16

M54.17

M54.30

M54.31

M54.32

M54.40

M54.41

M54.42

M54.81

M54.89

M62.830

M67.88

M81.0

M81.6

M81.8

M96.1

M96.2

M96.3

M96.4

M96.5

M99.10

M99.11

M99.12

M99.13

M99.14

M99.15

M99.20

M99.21

M99.22

M99.23

M99.24

M99.25

M99.26

M99.27

M99.28

M99.29

M99.30

M99.31

M99.32

M99.33

M99.34

M99.35

M99.36

M99.37

M99.38

M99.39

M99.40

M99.41

M99.42

M99.43

M99.44

M99.45

M99.46

M99.47

M99.48

M99.49

M99.50

M99.51

M99.52

M99.53

M99.54

M99.55

M99.56

M99.57

M99.58

M99.59

M99.60

M99.61

M99.62

M99.63

M99.64

M99.65

M99.66

M99.67

M99.68

M99.69

M99.70

M99.71

M99.72

M99.73

M99.74

M99.75

M99.76

M99.77

M99.78

M99.79

M99.83

M99.84

Q04.9

Q05.0

Q05.1

Q05.2

Q05.3

Q05.4

Q05.5

Q05.6

Q05.7

Q05.8

Q05.9

Q06.0

Q06.1

Q06.2

Q06.3

Q06.4

Q06.8

Q06.9

Q07.8

Q07.9

Q07.00

Q07.01

Q07.02

Q07.03

Q76.0

Q76.1

Q76.2

Q76.49

Q76.411

Q76.412

Q76.413

Q76.414

Q76.415

Q76.419

S11.90XA

S12.9XXA

S12.01XA

S12.01XB

S12.02XA

S12.02XB

S12.14XA

S12.14XB

S12.24XA

S12.24XB

S12.34XA

S12.34XB

S12.44XA

S12.44XB

S12.54XA

S12.54XB

S12.64XA

S12.64XB

S12.000A

S12.000B

S12.001A

S12.001B

S12.030A

S12.030B

S12.031A

S12.031B

S12.040A

S12.040B

S12.041A

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

S12.150A

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

S12.250A

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

S12.350A

S12.400A

S12.400B

S12.401A

S12.401B

S12.430A

S12.430B

S12.431A

S12.431B

S12.450A

S12.450B

S1 2.451A

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

S12.550A

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

S12.650A

S12.650B

S12.651A

S12.651B

S12.690A

S12.690B

S12.691A

S12.691B

S13.0XXA

S13.4XXA

S13.8XXA

S13.9XXA

S13.20XA

S13.29XA

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

S14.0XXA

S14.2XXA

S14.3XXA

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

S14.119A

S14.121A

S14.122A

S14.123A

S14.124A

S14.125A

S14.126A

S14.127A

S14.128A

S14.129A

S14.131A

S14.132A

S14.133A

S14.134A

S14.135A

S14.136A

S14.137A

S14.138A

S14.139A

S14.141A

S14.142A

S14.143A

S14.144A

S14.145A

S14.146A

S14.147A

S14.148A

S14.149A

S14.151A

S14.152A

S14.153A

S14.154A

S14.155A

S14.156A

S14.157A

S14.158A

S14.159A

S16.1XXA

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

S23.3XXA

S23.8XXA

S23.9XXA

S23.20XA

S23.29XA

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

S24.0XXA

S24.2XXA

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

S31.000A

S32.2XXA

S32.2XXB

S32.10XA

S32.10XB

S32.14XA

S32.14XB

S32.15XA

S32.15XB

S32.16XA

S32.16XB

S32.17XA

S32.17XB

S32.19XA

S32.19XB

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

S32.110A

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

S33.0XXA

S33.2XXA

S33.5XXA

S33.6XXA

S33.8XXA

S33.9XXA

S33.39XA

S33.100A

S33.101A

S33.110A

S33.111A

S33.120A

S33.121A

S33.130A

S33.131A

S33.140A

S33.141A

S34.3XXA

S34.4XXA

S34.01XA

S34.02XA

S34.21XA

S34.22XA

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

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

M12.551

M12.552

M16.0

M16.11

M16.12

M24.151

M24.152

M24.851

M24.852

M25.251

M25.252

M25.351

M25.352

M25.451

M25.452

M25.551

M25.552

M87.051

M87.052

M87.150

M87.151

M87.152

M87.251

M87.252

M87.350

M87.351

M87.352

M87.850

M87.851

M87.852

M90.551

M90.552

Q65.1

Q65.4

Q65.6

Q65.01

Q65.02

Q65.31

Q65.32

Q65.89

R29.4

S72.001A

S72.002A

S72.141A

S72.142A

S72.144A

S72.145A

T84.010A

T84.011A

T84.012A

T84.013A

T84.018A

T84.019A

A18.01

M40.00

M40.03

M40.04

M40.05

M40.10

M40.12

M40.13

M40.14

M40.15

M40.30

M40.35

M40.36

M40.37

M40.40

M40.45

M40.46

M40.47

M40.50

M40.55

M40.56

M40.57

M40.202

M40.203

M40.204

M40.205

M40.209

M40.292

M40.293

M40.294

M40.295

M40.299

M41.9

M41.00

M41.02

M41.03

M41.04

M41.05

M41.06

M41.07

M41.08

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

M41.112

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

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)

G56.01

G56.02

G56.03

G56.1 1

G56.12

G56.13

G56.21

G56.22

G56.23

G56.31

G56.32

G56.33

G56.41

G56.42

G56.43

G56.81

G56.82

G56.83

G56.91

G56.92

G56.93

M24.131

M24.132

M25.531

M25.532

M67.431

M67.432

M77.11

M77.12

S52.91XA

S52.91XB

S52.91XC

S52.91XD

S52.91E

S52.91XF

S52.91XG

S52.91XH

S52.91XJ

S52.91XK

S52.91XM

S52.91XN

S52.91XP

S52.91XQ

S52.91XR

S52.91XS

S52.92XA

S52.92XB

S52.92XC

S52.92XD

S52.92XE

S52.92XF

S52.92XG

S52.92XH

S52.92XJ

S52.92XK

S52.92XM

S52.92XN

S52.92XP

S52.92XQ

S52.92XR

S52.92XS

S52.001A

S52.001B

S52.001C

S52.001D

S52.001E

S52.001F

S52.001G

S52.001 H

S52.001J

S52.001K

S52.001 M

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

S52.011A

S52.011D

S52.011G

S52.011K

S52.011P

S52.011S

S52.012A

S52.012D

S52.012G

S52.012K

S52.012P

S52.012S

S52.021A

S52.021B

S52.021C

S52.021D

S52.021E

S52.021 F

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

S52.024A

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

S52.031A

S52.031B

S52.031C

S52.031D

S52.031E

S52.031 F

S52.031G

S52.031H

S52.031J

S52.031K

S52.031M

S52.031N

S52.031P

S52.031G

S52.031H

S52.031J

S52.031K

S52.031M

S52.031N

S52.031P

S52.031Q

S52.031 R

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

S52.034A

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

S52.041A

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

S52.044A

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

S52.091A

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

S52.101A

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

S52.111A

S52.111D

S52.111G

S52.111K

S52.111P

S52.111S

S52.112A

S52.112D

S52.112G

S52.112K

S52.112P

S52.112S

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

S52.124A

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

S52.131A

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

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S63.8X2A

S63.8X2D

S63.8X2S

S63.91XA

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S63.92XS

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Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 1-22-2020 Annual Review

Internal Medical Policy Committee 7-22-2020 No changes in criteria. Processing change only.

Internal Medical Policy Committee 3-17-2021 Coding update

Added procedure code L9900

Internal Medical Policy Committee 7-22-2021 Coding update

Added procedure code A6456.

Internal Medical Policy Committee 7-21-2022 Annual Review-no changes in criteria

Internal Medical Policy Committee 7-16-2024 Revision with Coding - Effective September 02, 2024

Removed procedure codes 27125; 27130; 27132; 27134; 27137; 27138; 27140; 29861; 29862; 29863; 29914; 29915; & 29916 from Postoperative Hip Braces section; and
Removed Unna Boots section including procedure codes A6456 and L9900; and
Added procedure code L1681 to Postoperative Hip Braces section; and
Added Policy Applications; and
Added Diagnosis codes.

Internal Medical Policy Committee 9-14-2024 Coding - Effective October 01, 2024

Added procedure codes L1006 and L1653

Medical Policies Quick Search

Braces and Supports

Description

Policy Application

Criteria

General Criteria

Hernia supports

Policy Application

Procedure Codes

Supportive back braces

Policy Application

Procedure Codes

Custom-fitted and custom-fabricated back braces

Policy Application

Procedure Codes

Postoperative back braces

Policy Application

Procedure Codes

Quantity Level Limits (QLL) for all back braces

Policy Application

Procedure Codes

Postoperative Hip Braces

Policy Application

Procedure Codes

Cast-Braces-Splints

Policy Application

Procedure Codes

Functional cast-braces

Policy Application

Procedure Codes

Rehabilitation braces

Policy Application

Procedure Codes

Cervical (neck) braces

Policy Application

Procedure Codes

Childhood hip braces

Policy Application

Procedure Codes

Braces for congenital defects or advanced neuromuscular conditions

Policy Application

Procedure Codes

Cervical-thoracic-lumbar-sacral or thoracic-lumbar-sacral orthoses

Policy Application

Procedure Codes

Wheaton braces

Policy Application

Procedure Codes

Splints and immobilizers

Policy Application

Procedure Codes

Policy Application

Miscellaneous covered services

Policy Application

Procedure Codes

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

General Criteria

Hernia supports

Policy Application

Procedure Codes

Supportive back braces

Policy Application

Procedure Codes

Custom-fitted and custom-fabricated back braces

Policy Application

Procedure Codes

Postoperative back braces

Policy Application

Procedure Codes

Quantity Level Limits (QLL) for all back braces

Policy Application

Procedure Codes

Postoperative Hip Braces