|
L2200 |
 |
Addition to lower extremity, limited ankle motion, each joint
| short | Limited ankle motion ea jnt |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2210 |
|
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
| short | Dorsiflexion assist each joi |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2220 |
|
Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
| short | Dorsi & plantar flex ass/res |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2230 |
|
Addition to lower extremity, split flat caliper stirrups and plate attachment
| short | Split flat caliper stirr & p |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2232 |
|
Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only
| short | Rocker bottom, contact afo |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2240 |
|
Addition to lower extremity, round caliper and plate attachment
| short | Round caliper and plate atta |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2250 |
|
Addition to lower extremity, foot plate, molded to patient model, stirrup attachment
| short | Foot plate molded stirrup at |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2260 |
|
Addition to lower extremity, reinforced solid stirrup (scott-craig type)
| short | Reinforced solid stirrup |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2265 |
|
Addition to lower extremity, long tongue stirrup
| short | Long tongue stirrup |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2270 |
|
Addition to lower extremity, varus/valgus correction ('t') strap, padded/lined or malleolus pad
| short | Varus/valgus strap padded/li |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L2275 |
|
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
| short | Plastic mod low ext pad/line |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L2280 |
|
Addition to lower extremity, molded inner boot
| short | Molded inner boot |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2300 |
|
Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
| short | Abduction bar jointed adjust |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment | | DME | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
|
|
|
|
L2310 |
|
Addition to lower extremity, abduction bar-straight
| short | Abduction bar-straight |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment | | DME | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
|
|
|
|
L2320 |
|
Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only
| short | Non-molded lacer |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L2330 |
|
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
| short | Lacer molded to patient mode |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L2335 |
|
Addition to lower extremity, anterior swing band
| short | Anterior swing band |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2340 |
|
Addition to lower extremity, pre-tibial shell, molded to patient model
| short | Pre-tibial shell molded to p |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2350 |
|
Addition to lower extremity, prosthetic type, (bk) socket, molded to patient model, (used for 'ptb' 'afo' orthoses)
| short | Prosthetic type socket molde |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2360 |
|
Addition to lower extremity, extended steel shank
| short | Extended steel shank |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2370 |
|
Addition to lower extremity, patten bottom
| short | Patten bottom |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2375 |
|
Addition to lower extremity, torsion control, ankle joint and half solid stirrup
| short | Torsion ank & half solid sti |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2380 |
|
Addition to lower extremity, torsion control, straight knee joint, each joint
| short | Torsion straight knee joint |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 2.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L2385 |
|
Addition to lower extremity, straight knee joint, heavy duty, each joint
| short | Straight knee joint heavy du |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2387 |
|
Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint
| short | Add le poly knee custom kafo |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2390 |
|
Addition to lower extremity, offset knee joint, each joint
| short | Offset knee joint each |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2395 |
|
Addition to lower extremity, offset knee joint, heavy duty, each joint
| short | Offset knee joint heavy duty |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 4.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
|
|
|
|
L2397 |
|
Addition to lower extremity orthosis, suspension sleeve
| short | Suspension sleeve lower ext |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 4.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration | | DME | 4.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|