|
L1020 |
 |
Addition to ctlso or scoliosis orthosis, kyphosis pad
| short | Kyphosis pad |
| 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 | Nature of Equipment | | DME | 2.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
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L1025 |
|
Addition to ctlso or scoliosis orthosis, kyphosis pad, floating
| short | Kyphosis pad floating |
| 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 |
|
|
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L1030 |
|
Addition to ctlso or scoliosis orthosis, lumbar bolster pad
| short | Lumbar bolster pad |
| 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 |
|
|
|
|
L1040 |
|
Addition to ctlso or scoliosis orthosis, lumbar or lumbar rib pad
| short | Lumbar or lumbar rib pad |
| 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 |
|
|
|
|
L1050 |
|
Addition to ctlso or scoliosis orthosis, sternal pad
| short | Sternal pad |
| 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 |
|
|
|
|
L1060 |
|
Addition to ctlso or scoliosis orthosis, thoracic pad
| short | Thoracic pad |
| 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 |
|
|
|
|
L1070 |
|
Addition to ctlso or scoliosis orthosis, trapezius sling
| short | Trapezius sling |
| 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 | Nature of Equipment | | DME | 2.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
|
|
|
|
L1080 |
|
Addition to ctlso or scoliosis orthosis, outrigger
| short | Outrigger |
| 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 | Nature of Equipment | | DME | 2.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
|
|
|
|
L1085 |
|
Addition to ctlso or scoliosis orthosis, outrigger, bilateral with vertical extensions
| short | Outrigger bil w/ vert extens |
| 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 | Code Descriptor / CPT Instruction | | DME | 1.0 | 2 Date of Service Edit: Policy | Code Descriptor / CPT Instruction |
|
|
|
|
L1090 |
|
Addition to ctlso or scoliosis orthosis, lumbar sling
| short | Lumbar sling |
| 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 | Anatomic Consideration | | DME | 1.0 | 3 Date of Service Edit: Clinical | Anatomic Consideration |
|
|
|
|
L1100 |
|
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather
| short | Ring flange plastic/leather |
| 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 | Nature of Equipment | | DME | 2.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
|
|
|
|
L1110 |
|
Addition to ctlso or scoliosis orthosis, ring flange, plastic or leather, molded to patient model
| short | Ring flange plas/leather mol |
| 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 | Nature of Equipment | | DME | 2.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
|
|
|
|
L1120 |
|
Addition to ctlso, scoliosis orthosis, cover for upright, each
| short | Covers for upright each |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 3.0 | 3 Date of Service Edit: Clinical | Nature of Equipment | | DME | 3.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
|
|
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