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L3806 |
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Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom fabricated, includes fitting and adjustment
| short | Whfo w/joint(s) custom fab |
| 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 |
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L3807 |
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Wrist hand finger orthosis, without joint(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
| short | Whfo w/o joints pre cst |
| 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 |
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L3808 |
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Wrist hand finger orthosis, rigid without joints, may include soft interface material; straps, custom fabricated, includes fitting and adjustment
| short | Whfo, rigid w/o joints |
| 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 |
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L3809 |
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Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type
| short | Whfo w/o joints pre ots |
| 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 |
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L3891 |
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Addition to upper extremity joint, wrist or elbow, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each
| short | Torsion mechanism wrist/elbo |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 0.0 | 3 Date of Service Edit: Clinical | Published Contractor Policy |
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L3900 |
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Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom fabricated
| short | Hinge extension/flex wrist/f |
| 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 |
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L3901 |
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Wrist hand finger orthosis, dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, cable driven, custom fabricated
| short | Hinge ext/flex wrist finger |
| 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 |
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L3904 |
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Wrist hand finger orthosis, external powered, electric, custom fabricated
| short | Whfo electric custom fitted |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
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| 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 |
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