|
L5654 |
 |
Addition to lower extremity, socket insert, symes, (kemblo, pelite, aliplast, plastazote or equal)
| short | Socket insert symes |
| 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 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L5655 |
|
Addition to lower extremity, socket insert, below knee (kemblo, pelite, aliplast, plastazote or equal)
| short | Socket insert below knee |
| 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 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L5656 |
|
Addition to lower extremity, socket insert, knee disarticulation (kemblo, pelite, aliplast, plastazote or equal)
| short | Socket insert knee articulat |
| 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 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L5658 |
|
Addition to lower extremity, socket insert, above knee (kemblo, pelite, aliplast, plastazote or equal)
| short | Socket insert above knee |
| 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 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L5661 |
|
Addition to lower extremity, socket insert, multi-durometer symes
| short | Multi-durometer symes |
| 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 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L5665 |
|
Addition to lower extremity, socket insert, multi-durometer, below knee
| short | Multi-durometer below knee |
| 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 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L5666 |
|
Addition to lower extremity, below knee, cuff suspension
| short | Below knee cuff suspension |
| 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 |
|
|
|
|
L5668 |
|
Addition to lower extremity, below knee, molded distal cushion
| short | Bk molded distal cushion |
| 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 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L5670 |
|
Addition to lower extremity, below knee, molded supracondylar suspension ('pts' or similar)
| short | Bk molded supracondylar susp |
| 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 |
|
|
|
|
L5671 |
|
Addition to lower extremity, below knee / above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert
| short | Bk/ak locking mechanism |
| 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 |
|
|
|
|
L5672 |
|
Addition to lower extremity, below knee, removable medial brim suspension
| short | Bk removable medial brim sus |
| 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 |
|
|
|
|
L5673 |
|
Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism
| short | Socket insert w lock mech |
| 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 | Nature of Equipment | | DME | 4.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
|
|
|
|
L5676 |
|
Additions to lower extremity, below knee, knee joints, single axis, pair
| short | Bk knee joints single axis 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 |
|
|
|
|
L5677 |
|
Additions to lower extremity, below knee, knee joints, polycentric, pair
| short | Bk knee joints polycentric 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 |
|
|
|
|
L5678 |
|
Additions to lower extremity, below knee, joint covers, pair
| short | Bk joint covers pair |
| 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 |
|
|
|
|
L5679 |
|
Addition to lower extremity, below knee/above knee, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism
| short | Socket insert w/o lock mech |
| 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 | Nature of Equipment | | DME | 4.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
|
|
|
|
L5680 |
|
Addition to lower extremity, below knee, thigh lacer, nonmolded
| short | Bk thigh lacer non-molded |
| 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 |
|
|
|
|
L5681 |
|
Addition to lower extremity, below knee/above knee, custom fabricated socket insert for congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code l5673 or l5679)
| short | Intl custm cong/latyp insert |
| 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 |
|
|
|
|
L5682 |
|
Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded
| short | Bk thigh lacer glut/ischia m |
| 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 |
|
|
|
|
L5683 |
|
Addition to lower extremity, below knee/above knee, custom fabricated socket insert for other than congenital or atypical traumatic amputee, silicone gel, elastomeric or equal, for use with or without locking mechanism, initial only (for other than initial, use code l5673 or l5679)
| short | Initial custom socket insert |
| 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 |
|
|
|
|
L5684 |
|
Addition to lower extremity, below knee, fork strap
| short | Bk fork strap |
| 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 |
|
|
|
|
L5685 |
|
Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each
| short | Below knee sus/seal sleeve |
| 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 |
|
|
|
|
L5686 |
|
Addition to lower extremity, below knee, back check (extension control)
| short | Bk back check |
| 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 |
|
|
|
|
L5688 |
|
Addition to lower extremity, below knee, waist belt, webbing
| short | Bk waist belt webbing |
| 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 |
|
|
|
|
L5690 |
|
Addition to lower extremity, below knee, waist belt, padded and lined
| short | Bk waist belt padded and lin |
| 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 |
|
|
|
|
L5692 |
|
Addition to lower extremity, above knee, pelvic control belt, light
| short | Ak pelvic control belt light |
| 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 |
|
|
|
|
L5694 |
|
Addition to lower extremity, above knee, pelvic control belt, padded and lined
| short | Ak pelvic control belt pad/l |
| 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 |
|
|
|
|
L5695 |
|
Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each
| short | Ak sleeve susp neoprene/equa |
| 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 |
|
|
|
|
L5696 |
|
Addition to lower extremity, above knee or knee disarticulation, pelvic joint
| short | Ak/knee disartic pelvic join |
| 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 |
|
|
|
|
L5697 |
|
Addition to lower extremity, above knee or knee disarticulation, pelvic band
| short | Ak/knee disartic pelvic 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 |
|
|
|
|
L5698 |
|
Addition to lower extremity, above knee or knee disarticulation, silesian bandage
| short | Ak/knee disartic silesian ba |
| 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 |
|
|
|
|
L5699 |
|
All lower extremity prostheses, shoulder harness
| short | Shoulder harness |
| 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 |
|
|
|