|
L6890 |
 |
Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment
| short | Prefab glove for term device |
| 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 |
|
|
|
|
L6895 |
|
Addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated
| short | Custom glove for term device |
| 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 |
|
|
|
|
L6900 |
|
Hand restoration (casts, shading and measurements included), partial hand, with glove, thumb or one finger remaining
| short | Hand restorat thumb/1 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 |
|
|
|
|
L6905 |
|
Hand restoration (casts, shading and measurements included), partial hand, with glove, multiple fingers remaining
| short | Hand restoration multiple fi |
| 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 |
|
|
|
|
L6910 |
|
Hand restoration (casts, shading and measurements included), partial hand, with glove, no fingers remaining
| short | Hand restoration no fingers |
| 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 |
|
|
|
|
L6915 |
|
Hand restoration (shading, and measurements included), replacement glove for above
| short | Hand restoration replacmnt g |
| 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 |
|
|
|