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L3905 |
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Wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Who w/nontorsion jnt(s) cf |
| 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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L3906 |
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Wrist hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Who w/o joints cf |
| 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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L3908 |
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Wrist hand orthosis, wrist extension control cock-up, non molded, prefabricated, off-the-shelf
| short | Who cock-up nonmolde 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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L3912 |
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Hand finger orthosis (hfo), flexion glove with elastic finger control, prefabricated, off-the-shelf
| short | Hfo flexion glove pre ots |
| 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 |
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L3913 |
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Hand finger orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Hfo w/o joints cf |
| 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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L3915 |
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Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
| short | Who nontorsion jnts 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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L3916 |
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Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf
| short | Who nontorsion jnts pre ots |
| 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 |
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L3917 |
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Hand orthosis, metacarpal fracture orthosis, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
| short | Metacarp fx orthosis 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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L3918 |
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Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf
| short | Metacarp fx orthosis 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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L3919 |
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Hand orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Ho w/o joints cf |
| 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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L3921 |
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Hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Hfo w/joint(s) cf |
| 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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L3923 |
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Hand finger orthosis, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
| short | Hfo without 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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L3924 |
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Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-the-shelf
| short | Hfo without 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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L3925 |
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Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), non torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, off-the-shelf
| short | Fo pip dip jnt/sprng pre ots |
| 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 | Code Descriptor / CPT Instruction | | DME | 4.0 | 3 Date of Service Edit: Clinical | Code Descriptor / CPT Instruction |
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L3927 |
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Finger orthosis, proximal interphalangeal (pip)/distal interphalangeal (dip), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, off-the-shelf
| short | Fo pip dip no jt spr pre ots |
| 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 | Clinical: Data | | DME | 4.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L3929 |
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Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
| short | Hfo nontorsion jnts 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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L3930 |
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Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, off-the-shelf
| short | Hfo nontorsion jnts 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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L3931 |
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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, prefabricated, includes fitting and adjustment
| short | Whfo nontorsion joint prefab |
| 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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L3933 |
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Finger orthosis, without joints, may include soft interface, custom fabricated, includes fitting and adjustment
| short | Fo w/o joints cf |
| 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 | Clinical: Data | | DME | 3.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L3935 |
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Finger orthosis, nontorsion joint, may include soft interface, custom fabricated, includes fitting and adjustment
| short | Fo nontorsion joint cf |
| 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 | Clinical: Data | | DME | 3.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L3956 |
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Addition of joint to upper extremity orthosis, any material; per joint
| short | Add joint upper ext orthosis |
| 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 | Clinical: CMS Workgroup | | DME | 4.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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