|
L3975 |
 |
Shoulder elbow wrist hand finger orthosis, shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Sewhfo cap design w/o jnt cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment | | DME | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
|
|
|
|
L3976 |
|
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Sewhfo airplane w/o jnts cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment | | DME | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
|
|
|
|
L3977 |
|
Shoulder elbow wrist hand finger orthosis, shoulder cap design, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Sewhfo cap desgn w/jnt(s) cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment | | DME | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
|
|
|
|
L3978 |
|
Shoulder elbow wrist hand finger orthosis, abduction positioning (airplane design), thoracic component and support bar, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Sewhfo airplane w/jnt(s) cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment | | DME | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
|
|
|