Braces and Supports

Policy ID: O-8-031

Section: Orthotic & Prosthetic Devices

Effective Date: February 01, 2019

Last Reviewed: July 22, 2020

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 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.

Criteria

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 individualis 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 specificindividual 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

L1310

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
L1686

Cast-braces (fracture braces)

Comfort, non-therapeutic cast-braces (Cam Walker) may beconsidered 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

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 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

Rehabilitation bracesmay 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
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 adolescentindividuals 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 thanone(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 leasttwo (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

L1836

L1930

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

A4656

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 beconsidered 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

Not Applicable

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

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.

Section: Orthotic & Prosthetic Devices

Effective Date: February 01, 2019

Revised Date: January 22, 2020

Archived Date: August 07, 2020

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 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.

Criteria

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

L1310

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
L1686

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

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

L1836

L1930

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

A4656

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)

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, 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
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S52.361J	S52.361K	S52.361M	S52.361N	S52.361P	S52.361Q	S52.361R
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S52.372J	S52.372K	S52.372M	S52.372N	S52.372P	S52.372Q	S52.372R
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S52.399J	S52.399K	S52.399M	S52.399N	S52.399P	S52.399Q	S52.399R
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S52.90XN	S52.90XP	S52.90XQ	S52.90XR	S52.90XS	S52.91XA	S52.91XB
S52.91XC	S52.91XD	S52.91XE	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	S62.001A	S62.001B	S62.001D	S62.001G	S62.001K
S62.001P	S62.001S	S62.002A	S62.002B	S62.002D	S62.002G	S62.002K
S62.002P	S62.002S	S62.009A	S62.009B	S62.009D	S62.009G	S62.009K
S62.009P	S62.009S	S62.011A	S62.011B	S62.011D	S62.011G	S62.011K
S62.011P	S62.011S	S62.012A	S62.012B	S62.012D	S62.012G	S62.012K
S62.012P	S62.012S	S62.013A	S62.013B	S62.013D	S62.013G	S62.013K
S62.013P	S62.013S	S62.014A	S62.014B	S62.014D	S62.014G	S62.014K
S62.014P	S62.014S	S62.015A	S62.015B	S62.015D	S62.015G	S62.015K
S62.015P	S62.015S	S62.016A	S62.016B	S62.016D	S62.016G	S62.016K
S62.016P	S62.016S	S62.021A	S62.021B	S62.021D	S62.021G	S62.021K
S62.021P	S62.021S	S62.022A	S62.022B	S62.022D	S62.022G	S62.022K
S62.022P	S62.022S	S62.023A	S62.023B	S62.023D	S62.023G	S62.023K
S62.023P	S62.023S	S62.024A	S62.024B	S62.024D	S62.024G	S62.024K
S62.024P	S62.024S	S62.025A	S62.025B	S62.025D	S62.025G	S62.025K
S62.025P	S62.025S	S62.026A	S62.026B	S62.026D	S62.026G	S62.026K
S62.026P	S62.026S	S62.031A	S62.031B	S62.031D	S62.031G	S62.031K
S62.031P	S62.031S	S62.032A	S62.032B	S62.032D	S62.032G	S62.032K
S62.032P	S62.032S	S62.033A	S62.033B	S62.033D	S62.033G	S62.033K
S62.033P	S62.033S	S62.034A	S62.034B	S62.034D	S62.034G	S62.034K
S62.034P	S62.034S	S62.035A	S62.035B	S62.035D	S62.035G	S62.035K
S62.035P	S62.035S	S62.036A	S62.036B	S62.036D	S62.036G	S62.036K
S62.036P	S62.036S	S62.101A	S62.101B	S62.101D	S62.101G	S62.101K
S62.101P	S62.101S	S62.102A	S62.102B	S62.102D	S62.102G	S62.102K
S62.102P	S62.102S	S62.109A	S62.109B	S62.109D	S62.109G	S62.109K
S62.109P	S62.109S	S62.111A	S62.111B	S62.111D	S62.111G	S62.111K
S62.111P	S62.111S	S62.112A	S62.112B	S62.112D	S62.112G	S62.112K
S62.112P	S62.112S	S62.113A	S62.113B	S62.113D	S62.113G	S62.113K
S62.113P	S62.113S	S62.114A	S62.114B	S62.114D	S62.114G	S62.114K
S62.114P	S62.114S	S62.115A	S62.115B	S62.115D	S62.115G	S62.115K
S62.115P	S62.115S	S62.116A	S62.116B	S62.116D	S62.116G	S62.116K
S62.116P	S62.116S	S62.121A	S62.121B	S62.121D	S62.121G	S62.121K
S62.121P	S62.121S	S62.122A	S62.122B	S62.122D	S62.122G	S62.122K
S62.122P	S62.122S	S62.123A	S62.123B	S62.123D	S62.123G	S62.123K
S62.123P	S62.123S	S62.124A	S62.124B	S62.124D	S62.124G	S62.124K
S62.124P	S62.124S	S62.125A	S62.125B	S62.125D	S62.125G	S62.125K
S62.125P	S62.125S	S62.126A	S62.126B	S62.126D	S62.126G	S62.126K
S62.126P	S62.126S	S62.131A	S62.131B	S62.131D	S62.131G	S62.131K
S62.131P	S62.131S	S62.132A	S62.132B	S62.132D	S62.132G	S62.132K
S62.132P	S62.132S	S62.133A	S62.133B	S62.133D	S62.133G	S62.133K
S62.133P	S62.133S	S62.134A	S62.134B	S62.134D	S62.134G	S62.134K
S62.134P	S62.134S	S62.135A	S62.135B	S62.135D	S62.135G	S62.135K
S62.135P	S62.135S	S62.136A	S62.136B	S62.136D	S62.136G	S62.136K
S62.136P	S62.136S	S62.141A	S62.141B	S62.141D	S62.141G	S62.141K
S62.141P	S62.141S	S62.142A	S62.142B	S62.142D	S62.142G	S62.142K
S62.142P	S62.142S	S62.143A	S62.143B	S62.143D	S62.143G	S62.143K
S62.143P	S62.143S	S62.144A	S62.144B	S62.144D	S62.144G	S62.144K
S62.144P	S62.144S	S62.145A	S62.145B	S62.145D	S62.145G	S62.145K
S62.145P	S62.145S	S62.146A	S62.146B	S62.146D	S62.146G	S62.146K
S62.146P	S62.146S	S62.151A	S62.151B	S62.151D	S62.151G	S62.151K
S62.151P	S62.151S	S62.152A	S62.152B	S62.152D	S62.152G	S62.152K
S62.152P	S62.152S	S62.153A	S62.153B	S62.153D	S62.153G	S62.153K
S62.153P	S62.153S	S62.154A	S62.154B	S62.154D	S62.154G	S62.154K
S62.154P	S62.154S	S62.155A	S62.155B	S62.155D	S62.155G	S62.155K
S62.155P	S62.155S	S62.156A	S62.156B	S62.156D	S62.156G	S62.156K
S62.156P	S62.156S	S62.161A	S62.161B	S62.161D	S62.161G	S62.161K
S62.161P	S62.161S	S62.162A	S62.162B	S62.162D	S62.162G	S62.162K
S62.162P	S62.162S	S62.163A	S62.163B	S62.163D	S62.163G	S62.163K
S62.163P	S62.163S	S62.164A	S62.164B	S62.164D	S62.164G	S62.164K
S62.164P	S62.164S	S62.165A	S62.165B	S62.165D	S62.165G	S62.165K
S62.165P	S62.165S	S62.166A	S62.166B	S62.166D	S62.166G	S62.166K
S62.166P	S62.166S	S62.171A	S62.171B	S62.171D	S62.171G	S62.171K
S62.171P	S62.171S	S62.172A	S62.172B	S62.172D	S62.172G	S62.172K
S62.172P	S62.172S	S62.173A	S62.173B	S62.173D	S62.173G	S62.173K
S62.173P	S62.173S	S62.174A	S62.174B	S62.174D	S62.174G	S62.174K
S62.174P	S62.174S	S62.175A	S62.175B	S62.175D	S62.175G	S62.175K
S62.175P	S62.175S	S62.176A	S62.176B	S62.176D	S62.176G	S62.176K
S62.176P	S62.176S	S62.181A	S62.181B	S62.181D	S62.181G	S62.181K
S62.181P	S62.181S	S62.182A	S62.182B	S62.182D	S62.182G	S62.182K
S62.182P	S62.182S	S62.183A	S62.183B	S62.183D	S62.183G	S62.183K
S62.183P	S62.183S	S62.184A	S62.184B	S62.184D	S62.184G	S62.184K
S62.184P	S62.184S	S62.185A	S62.185B	S62.185D	S62.185G	S62.185K
S62.185P	S62.185S	S62.186A	S62.186B	S62.186D	S62.186G	S62.186K
S62.186P	S62.186S	S62.201A	S62.201B	S62.201D	S62.201G	S62.201K
S62.201P	S62.201S	S62.202A	S62.202B	S62.202D	S62.202G	S62.202K
S62.202P	S62.202S	S62.209A	S62.209B	S62.209D	S62.209G	S62.209K
S62.209P	S62.209S	S62.211A	S62.211B	S62.211D	S62.211G	S62.211K
S62.211P	S62.211S	S62.212A	S62.212B	S62.212D	S62.212G	S62.212K
S62.212P	S62.212S	S62.213A	S62.213B	S62.213D	S62.213G	S62.213K
S62.213P	S62.213S	S62.221A	S62.221B	S62.221D	S62.221G	S62.221K
S62.221P	S62.221S	S62.222A	S62.222B	S62.222D	S62.222G	S62.222K
S62.222P	S62.222S	S62.223A	S62.223B	S62.223D	S62.223G	S62.223K
S62.223P	S62.223S	S62.224A	S62.224B	S62.224D	S62.224G	S62.224K
S62.224P	S62.224S	S62.225A	S62.225B	S62.225D	S62.225G	S62.225K
S62.225P	S62.225S	S62.226A	S62.226B	S62.226D	S62.226G	S62.226K
S62.226P	S62.226S	S62.231A	S62.231B	S62.231D	S62.231G	S62.231K
S62.231P	S62.231S	S62.232A	S62.232B	S62.232D	S62.232G	S62.232K
S62.232P	S62.232S	S62.233A	S62.233B	S62.233D	S62.233G	S62.233K
S62.233P	S62.233S	S62.234A	S62.234B	S62.234D	S62.234G	S62.234K
S62.234P	S62.234S	S62.235A	S62.235B	S62.235D	S62.235G	S62.235K
S62.235P	S62.235S	S62.236A	S62.236B	S62.236D	S62.236G	S62.236K
S62.236P	S62.236S	S62.241A	S62.241B	S62.241D	S62.241G	S62.241K
S62.241P	S62.241S	S62.242A	S62.242B	S62.242D	S62.242G	S62.242K
S62.242P	S62.242S	S62.243A	S62.243B	S62.243D	S62.243G	S62.243K
S62.243P	S62.243S	S62.244A	S62.244B	S62.244D	S62.244G	S62.244K
S62.244P	S62.244S	S62.245A	S62.245B	S62.245D	S62.245G	S62.245K
S62.245P	S62.245S	S62.246A	S62.246B	S62.246D	S62.246G	S62.246K
S62.246P	S62.246S	S62.251A	S62.251B	S62.251D	S62.251G	S62.251K
S62.251P	S62.251S	S62.252A	S62.252B	S62.252D	S62.252G	S62.252K
S62.252P	S62.252S	S62.253A	S62.253B	S62.253D	S62.253G	S62.253K
S62.253P	S62.253S	S62.254A	S62.254B	S62.254D	S62.254G	S62.254K
S62.254P	S62.254S	S62.255A	S62.255B	S62.255D	S62.255G	S62.255K
S62.255P	S62.255S	S62.256A	S62.256B	S62.256D	S62.256G	S62.256K
S62.256P	S62.256S	S62.291A	S62.291B	S62.291D	S62.291G	S62.291K
S62.291P	S62.291S	S62.292A	S62.292B	S62.292D	S62.292G	S62.292K
S62.292P	S62.292S	S62.299A	S62.299B	S62.299D	S62.299G	S62.299K
S62.299P	S62.299S	S62.300A	S62.300B	S62.300D	S62.300G	S62.300K
S62.300P	S62.300S	S62.301A	S62.301B	S62.301D	S62.301G	S62.301K
S62.301P	S62.301S	S62.302A	S62.302B	S62.302D	S62.302G	S62.302K
S62.302P	S62.302S	S62.303A	S62.303B	S62.303D	S62.303G	S62.303K
S62.303P	S62.303S	S62.304A	S62.304B	S62.304D	S62.304G	S62.304K
S62.304P	S62.304S	S62.305A	S62.305B	S62.305D	S62.305G	S62.305K
S62.305P	S62.305S	S62.306A	S62.306B	S62.306D	S62.306G	S62.306K
S62.306P	S62.306S	S62.307A	S62.307B	S62.307D	S62.307G	S62.307K
S62.307P	S62.307S	S62.308A	S62.308B	S62.308D	S62.308G	S62.308K
S62.308P	S62.308S	S62.309A	S62.309B	S62.309D	S62.309G	S62.309K
S62.309P	S62.309S	S62.310A	S62.310B	S62.310D	S62.310G	S62.310K
S62.310P	S62.310S	S62.311A	S62.311B	S62.311D	S62.311G	S62.311K
S62.311P	S62.311S	S62.312A	S62.312B	S62.312D	S62.312G	S62.312K
S62.312P	S62.312S	S62.313A	S62.313B	S62.313D	S62.313G	S62.313K
S62.313P	S62.313S	S62.314A	S62.314B	S62.314D	S62.314G	S62.314K
S62.314P	S62.314S	S62.315A	S62.315B	S62.315D	S62.315G	S62.315K
S62.315P	S62.315S	S62.316A	S62.316B	S62.316D	S62.316G	S62.316K
S62.316P	S62.316S	S62.317A	S62.317B	S62.317D	S62.317G	S62.317K
S62.317P	S62.317S	S62.318A	S62.318B	S62.318D	S62.318G	S62.318K
S62.318P	S62.318S	S62.319A	S62.319B	S62.319D	S62.319G	S62.319K
S62.319P	S62.319S	S62.320A	S62.320B	S62.320D	S62.320G	S62.320K
S62.320P	S62.320S	S62.321A	S62.321B	S62.321D	S62.321G	S62.321K
S62.321P	S62.321S	S62.322A	S62.322B	S62.322D	S62.322G	S62.322K
S62.322P	S62.322S	S62.323A	S62.323B	S62.323D	S62.323G	S62.323K
S62.323P	S62.323S	S62.324A	S62.324B	S62.324D	S62.324G	S62.324K
S62.324P	S62.324S	S62.325A	S62.325B	S62.325D	S62.325G	S62.325K
S62.325P	S62.325S	S62.326A	S62.326B	S62.326D	S62.326G	S62.326K
S62.326P	S62.326S	S62.327A	S62.327B	S62.327D	S62.327G	S62.327K
S62.327P	S62.327S	S62.328A	S62.328B	S62.328D	S62.328G	S62.328K
S62.328P	S62.328S	S62.329A	S62.329B	S62.329D	S62.329G	S62.329K
S62.329P	S62.329S	S62.330A	S62.330B	S62.330D	S62.330G	S62.330K
S62.330P	S62.330S	S62.331A	S62.331B	S62.331D	S62.331G	S62.331K
S62.331P	S62.331S	S62.332A	S62.332B	S62.332D	S62.332G	S62.332K
S62.332P	S62.332S	S62.333A	S62.333B	S62.333D	S62.333G	S62.333K
S62.333P	S62.333S	S62.334A	S62.334B	S62.334D	S62.334G	S62.334K
S62.334P	S62.334S	S62.335A	S62.335B	S62.335D	S62.335G	S62.335K
S62.335P	S62.335S	S62.336A	S62.336B	S62.336D	S62.336G	S62.336K
S62.336P	S62.336S	S62.337A	S62.337B	S62.337D	S62.337G	S62.337K
S62.337P	S62.337S	S62.338A	S62.338B	S62.338D	S62.338G	S62.338K
S62.338P	S62.338S	S62.339A	S62.339B	S62.339D	S62.339G	S62.339K
S62.339P	S62.339S	S62.340A	S62.340B	S62.340D	S62.340G	S62.340K
S62.340P	S62.340S	S62.341A	S62.341B	S62.341D	S62.341G	S62.341K
S62.341P	S62.341S	S62.342A	S62.342B	S62.342D	S62.342G	S62.342K
S62.342P	S62.342S	S62.343A	S62.343B	S62.343D	S62.343G	S62.343K
S62.343P	S62.343S	S62.344A	S62.344B	S62.344D	S62.344G	S62.344K
S62.344P	S62.344S	S62.345A	S62.345B	S62.345D	S62.345G	S62.345K
S62.345P	S62.345S	S62.346A	S62.346B	S62.346D	S62.346G	S62.346K
S62.346P	S62.346S	S62.347A	S62.347B	S62.347D	S62.347G	S62.347K
S62.347P	S62.347S	S62.348A	S62.348B	S62.348D	S62.348G	S62.348K
S62.348P	S62.348S	S62.349A	S62.349B	S62.349D	S62.349G	S62.349K
S62.349P	S62.349S	S62.350A	S62.350B	S62.350D	S62.350G	S62.350K
S62.350P	S62.350S	S62.351A	S62.351B	S62.351D	S62.351G	S62.351K
S62.351P	S62.351S	S62.352A	S62.352B	S62.352D	S62.352G	S62.352K
S62.352P	S62.352S	S62.353A	S62.353B	S62.353D	S62.353G	S62.353K
S62.353P	S62.353S	S62.354A	S62.354B	S62.354D	S62.354G	S62.354K
S62.354P	S62.354S	S62.355A	S62.355B	S62.355D	S62.355G	S62.355K
S62.355P	S62.355S	S62.356A	S62.356B	S62.356D	S62.356G	S62.356K
S62.356P	S62.356S	S62.357A	S62.357B	S62.357D	S62.357G	S62.357K
S62.357P	S62.357S	S62.358A	S62.358B	S62.358D	S62.358G	S62.358K
S62.358P	S62.358S	S62.359A	S62.359B	S62.359D	S62.359G	S62.359K
S62.359P	S62.359S	S62.360A	S62.360B	S62.360D	S62.360G	S62.360K
S62.360P	S62.360S	S62.361A	S62.361B	S62.361D	S62.361G	S62.361K
S62.361P	S62.361S	S62.362A	S62.362B	S62.362D	S62.362G	S62.362K
S62.362P	S62.362S	S62.363A	S62.363B	S62.363D	S62.363G	S62.363K
S62.363P	S62.363S	S62.364A	S62.364B	S62.364D	S62.364G	S62.364K
S62.364P	S62.364S	S62.365A	S62.365B	S62.365D	S62.365G	S62.365K
S62.365P	S62.365S	S62.366A	S62.366B	S62.366D	S62.366G	S62.366K
S62.366P	S62.366S	S62.367A	S62.367B	S62.367D	S62.367G	S62.367K
S62.367P	S62.367S	S62.368A	S62.368B	S62.368D	S62.368G	S62.368K
S62.368P	S62.368S	S62.369A	S62.369B	S62.369D	S62.369G	S62.369K
S62.369P	S62.369S	S62.390A	S62.390B	S62.390D	S62.390G	S62.390K
S62.390P	S62.390S	S62.391A	S62.391B	S62.391D	S62.391G	S62.391K
S62.391P	S62.391S	S62.392A	S62.392B	S62.392D	S62.392G	S62.392K
S62.392P	S62.392S	S62.393A	S62.393B	S62.393D	S62.393G	S62.393K
S62.393P	S62.393S	S62.394A	S62.394B	S62.394D	S62.394G	S62.394K
S62.394P	S62.394S	S62.395A	S62.395B	S62.395D	S62.395G	S62.395K
S62.395P	S62.395S	S62.396A	S62.396B	S62.396D	S62.396G	S62.396K
S62.396P	S62.396S	S62.397A	S62.397B	S62.397D	S62.397G	S62.397K
S62.397P	S62.397S	S62.398A	S62.398B	S62.398D	S62.398G	S62.398K
S62.398P	S62.398S	S62.399A	S62.399B	S62.399D	S62.399G	S62.399K
S62.399P	S62.399S	S62.90XA	S62.90XB	S62.90XD	S62.90XG	S62.90XK
S62.90XP	S62.90XS	S62.91XA	S62.91XB	S62.91XD	S62.91XG	S62.91XK
S62.91XP	S62.91XS	S62.92XA	S62.92XB	S62.92XD	S62.92XG	S62.92XK
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

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