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Spine Surgery and Pain Management Procedure Therapy Prior Approval List

See List
CPT/
HCPCS Code
Description Effective Date
A4221 Supplies for maintenance of non-insulin drug infusion catheter, per week (list drugs separately)  
A4224 Supplies for maintenance of insulin infusion catheter, per week  
A4225 Supplies for external insulin infusion pump, syringe type cartridge, sterile, each  
A4290 Sacral nerve stimulation test lead, each  
A4575 Topical hyperbaric oxygen chamber, disposable  
A4604 Tubing with integrated heating element for use with positive airway pressure device. Authorization required on or after 12/1/18 12/1/18
A4606 Oxygen probe for use with oximeter device, replacement  
A4649 Surgical supply; miscellaneous 1/1/18
A5500 For diabetics only, fitting (including follow-up), custom preparation and supply of off-the-shelf depth-inlay shoe manufactured to accommodate multi-density insert(s), per shoe   
A5501 For diabetics only, fitting (including follow-up), custom preparation and supply of shoe molded from cast(s) of patient's foot (custom molded shoe), per shoe   
A5503 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with roller or rigid rocker bottom, per shoe   
A5504 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with wedge(s), per shoe   
A5505 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with metatarsal bar, per shoe   
A5506 For diabetics only, modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe with off-set heel(s), per shoe   
A5507 For diabetics only, not otherwise specified modification (including fitting) of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe   
A5508 For diabetics only, deluxe feature of off-the-shelf depth-inlay shoe or custom molded shoe, per shoe   
A5510 For diabetics only, direct formed, compression molded to patient's foot without external heat source, multiple-density insert(s) prefabricated, per shoe   
A5512 For diabetics only, multiple density insert, direct formed, molded to foot after external heat source of 230 degrees Fahrenheit or higher, total contact with patient's foot, including arch, base layer minimum of 1/4 inch material of shore a 35 durometer or 3/16 inch material of shore a 40 durometer (or higher), prefabricated, each   
A5513 For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer or higher, includes arch filler and other shaping material, custom fabricated, each   
A6261 Wound filler, gel/paste, per fluid ounce, not otherwise specified 1/1/18
A6262 Wound filler, dry form, per gram, not otherwise specified 1/1/18
A6549 Gradient compression stocking/sleeve, not otherwise specified 1/1/18
A6550 Wound care set, for negative pressure wound therapy electrical pump, includes all supplies and accessories  
A7025 High frequency chest wall oscillation system vest, replacement for use with patient owned equipment, each  
A7026 High frequency chest wall oscillation system hose, replacement for use with patient owned equipment, each  
A7027 Combination oral/nasal mask, used with continuous positive airway pressure device, each   
A7028 Oral cushion for combination oral/nasal mask, replacement only, each   
A7029 Nasal pillows for combination oral/nasal mask, replacement only, pair   
A7030 Full face mask used with positive airway pressure device, each   
A7031 Face mask interface, replacement for full face mask, each   
A7032 Cushion for use on nasal mask interface, replacement only, each. Authorization required on or after 12/1/18 12/1/18
A7033 Pillow for use on nasal cannula type interface, replacement only, pair   
A7034 Nasal interface (mask or cannula type) used with positive airway pressure device, with or without head strap. Authorization required on or after 12/1/18 12/1/18
A7035 Headgear used with positive airway pressure device. Authorization required on or after 12/1/18 12/1/18
A7036 Chinstrap used with positive airway pressure device. Authorization required on or after 12/1/18:  12/1/18
A7037 Tubing used with positive airway pressure device. Authorization required on or after 12/1/18 12/1/18
A7038 Filter, disposable, used with positive airway pressure device. Authorization required on or after 12/1/18 12/1/18
A7039 Filter, non disposable, used with positive airway pressure device. Authorization required on or after 12/1/18 12/1/18
A7044 Oral interface used with positive airway pressure device, each   
A7045 Exhalation port with or without swivel used with accessories for positive airway devices, replacement only   
A7046 Water chamber for humidifier, used with positive airway pressure device, replacement, each. Authorization required on or after 12/1/18 12/1/18
A9282 Wig, any type, each   
A9900 Miscellaneous dme supply, accessory, and/or service component of another hcpcs code 1/1/18
A9999 Miscellaneous dme supply or accessory, not otherwise specified 1/1/18
E0159 Brake attachment for wheeled walker, replacement, each 1/1/18
E0181 Powered pressure reducing mattress overlay/pad, alternating, with pump, includes heavy duty  
E0182 Pump for alternating pressure pad, for replacement only  
E0184 Dry pressure mattress  
E0185 Gel or gel-like pressure pad for mattress, standard mattress length and width 1/1/18
E0186 Air pressure mattress  
E0187 Water pressure mattress  
E0189 Lambswool sheepskin pad, any size 1/1/18
E0190 Positioning cushion/pillow/wedge, any shape or size, includes all components and accessories 1/1/18
E0193 Powered air flotation bed (low air loss therapy)  
E0194 Air fluidized bed  
E0196 Gel pressure mattress  
E0197 Air pressure pad for mattress, standard mattress length and width  
E0198 Water pressure pad for mattress, standard mattress length and width 1/1/18
E0200 Heat lamp, without stand (table model), includes bulb, or infrared element 1/1/18
E0203 Therapeutic lightbox, minimum 10,000 lux, table top model 1/1/18
E0205 Heat lamp, with stand, includes bulb, or infrared element 1/1/18
E0210 Electric heat pad, standard 1/1/18
E0217 Water circulating heat pad with pump  
E0218 Water circulating cold pad with pump  
E0221 Infrared heating pad system 1/1/18
E0225 Hydrocollator unit, includes pads 1/1/18
E0235 Paraffin bath unit, portable (see medical supply code a4265 for paraffin) 1/1/18
E0236 Pump for water circulating pad 1/1/18
E0239 Hydrocollator unit, portable 1/1/18
E0250 Hospital bed, fixed height, with any type side rails, with mattress  
E0251 Hospital bed, fixed height, with any type side rails, without mattress  
E0255 Hospital bed, variable height, hi-lo, with any type side rails, with mattress  
E0256 Hospital bed, variable height, hi-lo, with any type side rails, without mattress  
E0260 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, with mattress  
E0261 Hospital bed, semi-electric (head and foot adjustment), with any type side rails, without mattress  
E0265 Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, with mattress  
E0266 Hospital bed, total electric (head, foot, and height adjustments), with any type side rails, without mattress  
E0270 Hospital bed, institutional type includes: oscillating, circulating and stryker frame, with mattress  
E0271 Mattress, innerspring 1/1/18
E0272 Mattress, foam rubber 1/1/18
E0273 Bed board 1/1/18
E0274 Over-bed table 1/1/18
E0277 Powered pressure-reducing air mattress  
E0280 Bed cradle, any type 1/1/18
E0290 Hospital bed, fixed height, without side rails, with mattress  
E0291 Hospital bed, fixed height, without side rails, without mattress  
E0292 Hospital bed, variable height, hi-lo, without side rails, with mattress  
E0293 Hospital bed, variable height, hi-lo, without side rails, without mattress  
E0294 Hospital bed, semi-electric (head and foot adjustment), without side rails, with mattress  
E0295 Hospital bed, semi-electric (head and foot adjustment), without side rails, without mattress  
E0296 Hospital bed, total electric (head, foot, and height adjustments), without side rails, with mattress  
E0297 Hospital bed, total electric (head, foot, and height adjustments), without side rails, without mattress  
E0300 Pediatric crib, hospital grade, fully enclosed, with or without top enclosure  
E0301 Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, without mattress  
E0302 Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, without mattress  
E0303 Hospital bed, heavy-duty, extra wide, with weight capacity greater than 350 pounds, but less than or equal to 600 pounds, with any type side rails, with mattress  
E0304 Hospital bed, extra heavy-duty, extra wide, with weight capacity greater than 600 pounds, with any type side rails, with mattress  
E0305 Bed side rails, half length 1/1/18
E0310 Bed side rails, full length 1/1/18
E0315 Bed accessory: board, table, or support device, any type 1/1/18
E0316 Safety enclosure frame/canopy for use with hospital bed, any type  
E0328 Hospital bed, pediatric, manual, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress  
E0329 Hospital bed, pediatric, electric or semi-electric, 360 degree side enclosures, top of headboard, footboard and side rails up to 24 inches above the spring, includes mattress  
E0371 Nonpowered advanced pressure reducing overlay for mattress, standard mattress length and width  
E0372 Powered air overlay for mattress, standard mattress length and width  
E0373 Nonpowered advanced pressure reducing mattress  
E0424 Stationary compressed gaseous oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing  
E0425 Stationary compressed gas system, purchase; includes regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing  
E0430 Portable gaseous oxygen system, purchase; includes regulator, flowmeter, humidifier, cannula or mask, and tubing  
E0431 Portable gaseous oxygen system, rental; includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing  
E0433 Portable liquid oxygen system, rental; home liquefier used to fill portable liquid oxygen containers, includes portable containers, regulator, flowmeter, humidifier, cannula or mask and tubing, with or without supply reservoir and contents gauge  
E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, contents gauge, cannula or mask, and tubing  
E0435 Portable liquid oxygen system, purchase; includes portable container, supply reservoir, flowmeter, humidifier, contents gauge, cannula or mask, tubing and refill adaptor  
E0439 Stationary liquid oxygen system, rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, & tubing  
E0440 Stationary liquid oxygen system, purchase; includes use of reservoir, contents indicator, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing  
E0441 Stationary oxygen contents, gaseous, 1 month's supply = 1 unit  
E0442 Stationary oxygen contents, liquid, 1 month's supply = 1 unit  
E0443 Portable oxygen contents, gaseous, 1 month's supply = 1 unit  
E0444 Portable oxygen contents, liquid, 1 month's supply = 1 unit  
E0445 Oximeter device for measuring blood oxygen levels noninvasively  
E0446 Topical oxygen delivery system, not otherwise specified, includes all supplies and accessories  
E0455 Oxygen tent, excluding croup or pediatric tents 1/1/18
E0457 Chest shell (cuirass) 1/1/18
E0459 Chest wrap 1/1/18
E0462 Rocking bed with or without side rails 1/1/18
E0465 Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)  
E0466 Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)  
E0470 Respiratory assist device, bi-level pressure capability, without backup rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)   
E0471 Respiratory assist device, bi-level pressure capability, with back-up rate feature, used with noninvasive interface, e.g., nasal or facial mask (intermittent assist device with continuous positive airway pressure device)  
E0472 Respiratory assist device, bi-level pressure capability, with backup rate feature, used with invasive interface, e.g., tracheostomy tube (intermittent assist device with continuous positive airway pressure device)  
E0480 Percussor, electric or pneumatic, home model 1/1/18
E0481 Intrapulmonary percussive ventilation system and related accessories  
E0482 Cough stimulating device, alternating positive and negative airway pressure 1/1/18
E0483 High frequency chest wall oscillation air-pulse generator system, (includes hoses and vest), each  
E0484 Oscillatory positive expiratory pressure device, non-electric, any type, each 1/1/18
E0485 Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, prefabricated, includes fitting and adjustment  
E0486 Oral device/appliance used to reduce upper airway collapsibility, adjustable or nonadjustable, custom fabricated, includes fitting and adjustment  
E0487 Spirometer, electronic, includes all accessories 1/1/18
E0550 Humidifier, durable for extensive supplemental humidification during ippb treatments or oxygen delivery 1/1/18
E0555 Humidifier, durable, glass or autoclavable plastic bottle type, for use with regulator or flowmeter 1/1/18
E0561 Humidifier, non heated, used with positive airway pressure device   
E0562 Humidifier, heated, used with positive airway pressure device   
E0572 Aerosol compressor, adjustable pressure, light duty for intermittent use 1/1/18
E0574 Ultrasonic/electronic aerosol generator with small volume nebulizer 1/1/18
E0575 Nebulizer, ultrasonic, large volume  
E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type, for use with regulator or flowmeter 1/1/18
E0585 Nebulizer, with compressor and heater 1/1/18
E0601 Continuous positive airway pressure (CPAP) device  
E0605 Vaporizer, room type 1/1/18
E0610 Pacemaker monitor, self-contained, (checks battery depletion, includes audible and visible check systems) 1/1/18
E0615 Pacemaker monitor, self contained, checks battery depletion and other pacemaker components, includes digital/visible check systems 1/1/18
E0617 External defibrillator with integrated electrocardiogram analysis  
E0618 Apnea monitor, without recording feature 1/1/18
E0619 Apnea monitor, with recording feature 1/1/18
E0620 Skin piercing device for collection of capillary blood, laser, each 1/1/18
E0625 Patient lift, bathroom or toilet, not otherwise classified 1/1/18
E0627 Seat lift mechanism, electric, any type  
E0629 Seat lift mechanism, non-electric, any type  
E0630 Patient lift, hydraulic or mechanical, includes any seat, sling, strap(s) or pad(s) 1/1/18
E0635 Patient lift, electric, with seat or sling  
E0636 Multipositional patient support system, with integrated lift, patient accessible controls  
E0637 Combination sit to stand frame/table system, any size including pediatric, with seat lift feature, with or without wheels  
E0638 Standing frame/table system, one position (e.g., upright, supine or prone stander), any size including pediatric, with or without wheels  
E0639 Patient lift, moveable from room to room with disassembly and reassembly, includes all components/accessories  
E0640 Patient lift, fixed system, includes all components/accessories  
E0641 Standing frame/table system, multi-position (e.g., three-way stander), any size including pediatric, with or without wheels  
E0642 Standing frame/table system, mobile (dynamic stander), any size including pediatric  
E0650 Pneumatic compressor, nonsegmental home model  
E0651 Pneumatic compressor, segmental home model without calibrated gradient pressure  
E0652 Pneumatic compressor, segmental home model with calibrated gradient pressure  
E0655 Nonsegmental pneumatic appliance for use with pneumatic compressor, half arm  
E0656 Segmental pneumatic appliance for use with pneumatic compressor, trunk  
E0657 Segmental pneumatic appliance for use with pneumatic compressor, chest  
E0660 Nonsegmental pneumatic appliance for use with pneumatic compressor, full leg  
E0665 Nonsegmental pneumatic appliance for use with pneumatic compressor, full arm  
E0666 Nonsegmental pneumatic appliance for use with pneumatic compressor, half leg  
E0667 Segmental pneumatic appliance for use with pneumatic compressor, full leg  
E0668 Segmental pneumatic appliance for use with pneumatic compressor, full arm  
E0669 Segmental pneumatic appliance for use with pneumatic compressor, half leg  
E0670 Segmental pneumatic appliance for use with pneumatic compressor, integrated, 2 full legs and trunk  
E0671 Segmental gradient pressure pneumatic appliance, full leg  
E0672 Segmental gradient pressure pneumatic appliance, full arm  
E0673 Segmental gradient pressure pneumatic appliance, half leg  
E0675 Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency (unilateral or bilateral system)  
E0676 Intermittent limb compression device (includes all accessories), not otherwise specified  
E0691 Ultraviolet light therapy system, includes bulbs/lamps, timer and eye protection; treatment area 2 sq ft or less  
E0692 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 4 ft panel  
E0693 Ultraviolet light therapy system panel, includes bulbs/lamps, timer and eye protection, 6 ft panel  
E0700 Safety equipment, device or accessory, any type 1/1/18
E0710 Restraints, any type (body, chest, wrist or ankle) 1/1/18
E0720 Transcutaneous electrical nerve stimulation (tens) device, two lead, localized stimulation 1/1/18
E0730 Transcutaneous electrical nerve stimulation (tens) device, four or more leads, for multiple nerve stimulation 1/1/18
E0740 Non-implanted pelvic floor electrical stimulator, complete system 1/1/18
E0744 Neuromuscular stimulator for scoliosis 1/1/18
E0745 Neuromuscular stimulator, electronic shock unit  
E0746 Electromyography (emg), biofeedback device 1/1/18
E0747 Osteogenesis stimulator, electrical, noninvasive, other than spinal applications  
E0748 Osteogenesis stimulator, electrical, noninvasive, spinal applications  
E0749 Osteogenesis stimulator, electrical, surgically implanted  
E0755 Electronic salivary reflex stimulator (intra-oral/non-invasive) 1/1/18
E0760 Osteogenesis stimulator, low intensity ultrasound, noninvasive  
E0761 Nonthermal pulsed high frequency radiowaves, high peak power electromagnetic energy treatment device  
E0762 Transcutaneous electrical joint stimulation device system, includes all accessories 1/1/18
E0764 Functional neuromuscular stimulation, transcutaneous stimulation of sequential muscle groups of ambulation with computer control, used for walking by spinal cord injured, entire system, after completion of training program  
E0765 FDA approved nerve stimulator, with replaceable batteries, for treatment of nausea and vomiting  
E0766 Electrical stimulation device used for cancer treatment, includes all accessories, any type  
E0769 Electrical stimulation or electromagnetic wound treatment device, not otherwise classified  
E0770 Functional electrical stimulator, transcutaneous stimulation of nerve and/or muscle groups, any type, complete system, not otherwise specified  
E0776 Iv pole 1/1/18
E0779 Ambulatory infusion pump, mechanical, reusable, for infusion 8 hours or greater 1/1/18
E0780 Ambulatory infusion pump, mechanical, reusable, for infusion less than 8 hours 1/1/18
E0781 Ambulatory infusion pump, single or multiple channels, electric or battery operated, with administrative equipment, worn by patient 1/1/18
E0784 External ambulatory infusion pump, insulin  
E0786 Implantable programmable infusion pump, replacement (excludes implantable intraspinal catheter)  
E0791 Parenteral infusion pump, stationary, single or multi-channel 1/1/18
E0920 Fracture frame, attached to bed, includes weights 1/1/18
E0930 Fracture frame, free standing, includes weights 1/1/18
E0935 Continuous passive motion exercise device for use on knee only  
E0936 Continuous passive motion exercise device for use other than knee  
E0940 Trapeze bar, free standing, complete with grab bar 1/1/18
E0941 Gravity assisted traction device, any type 1/1/18
E0946 Fracture, frame, dual with cross bars, attached to bed, (e.g., balken, 4 poster) 1/1/18
E0947 Fracture frame, attachments for complex pelvic traction 1/1/18
E0948 Fracture frame, attachments for complex cervical traction 1/1/18
E0951 Heel loop/holder, any type, with or without ankle strap, each 1/1/18
E0952 Toe loop/holder, any type, each 1/1/18
E0955 Wheelchair accessory, headrest, cushioned, any type, including fixed mounting hardware, each 1/1/18
E0956 Wheelchair accessory, lateral trunk or hip support, any type, including fixed mounting hardware, each 1/1/18
E0957 Wheelchair accessory, medial thigh support, any type, including fixed mounting hardware, each 1/1/18
E0959 Manual wheelchair accessory, adapter for amputee, each 1/1/18
E0960 Wheelchair accessory, shoulder harness/straps or chest strap, including any type mounting hardware 1/1/18
E0961 Manual wheelchair accessory, wheel lock brake extension (handle), each 1/1/18
E0967 Manual wheelchair accessory, hand rim with projections, any type, replacement only, each 1/1/18
E0969 Narrowing device, wheelchair 1/1/18
E0973 Wheelchair accessory, adjustable height, detachable armrest, complete assembly, each 1/1/18
E0974 Manual wheelchair accessory, anti-rollback device, each 1/1/18
E0980 Safety vest, wheelchair 1/1/18
E0981 Wheelchair accessory, seat upholstery, replacement only, each 1/1/18
E0982 Wheelchair accessory, back upholstery, replacement only, each 1/1/18
E0983 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control 1/1/18
E0984 Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, tiller control  
E0985 Wheelchair accessory, seat lift mechanism 1/1/18
E0986 Manual wheelchair accessory, push-rim activated power assist system  
E0988 Manual wheelchair accessory, lever-activated, wheel drive, pair 1/1/18
E0992 Manual wheelchair accessory, solid seat insert 1/1/18
E0994 Arm rest, each 1/1/18
E0995 Wheelchair accessory, calf rest/pad, replacement only, each 1/1/18
E1002 Wheelchair accessory, power seating system, tilt only  
E1003 Wheelchair accessory, power seating system, recline only, without shear reduction  
E1004 Wheelchair accessory, power seating system, recline only, with mechanical shear reduction  
E1005 Wheelchair accessory, power seating system, recline only, with power shear reduction  
E1006 Wheelchair accessory, power seating system, combination tilt and recline, without shear reduction  
E1007 Wheelchair accessory, power seating system, combination tilt and recline, with mechanical shear reduction  
E1008 Wheelchair accessory, power seating system, combination tilt and recline, with power shear reduction  
E1009 Wheelchair accessory, addition to power seating system, mechanically linked leg elevation system, including pushrod and leg rest, each  
E1010 Wheelchair accessory, addition to power seating system, power leg elevation system, including legrest, pair  
E1011 Modification to pediatric size wheelchair, width adjustment package (not to be dispensed with initial chair) 1/1/18
E1012 Wheelchair accessory, addition to power seating system, center mount power elevating leg rest/platform, complete system, any type, each 1/1/18
E1014 Reclining back, addition to pediatric size wheelchair 1/1/18
E1015 Shock absorber for manual wheelchair, each  
E1016 Shock absorber for power wheelchair, each  
E1017 Heavy duty shock absorber for heavy duty or extra heavy duty manual wheelchair, each  
E1018 Heavy duty shock absorber for heavy duty or extra heavy duty power wheelchair, each  
E1028 Wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick, other control interface or positioning accessory 1/1/18
E1029 Wheelchair accessory, ventilator tray, fixed 1/1/18
E1030 Wheelchair accessory, ventilator tray, gimbaled  
E1036 Multi-positional patient transfer system, extra-wide, with integrated seat, operated by caregiver, patient weight capacity greater than 300 lbs 1/1/18
E1050 Fully-reclining wheelchair, fixed full length arms, swing away detachable elevating leg rests  
E1060 Fully-reclining wheelchair, detachable arms, desk or full length, swing away detachable elevating legrests  
E1070 Fully-reclining wheelchair, detachable arms (desk or full length) swing away detachable footrest  
E1161 Manual adult size wheelchair, includes tilt in space  
E1220 Wheelchair; specially sized or constructed, (indicate brand name, model number, if any) and justification  
E1225 Wheelchair accessory, manual semi-reclining back, (recline greater than 15 degrees, but less than 80 degrees), each 1/1/18
E1226 Wheelchair accessory, manual fully reclining back, (recline greater than 80 degrees), each 1/1/18
E1229 Wheelchair, pediatric size, not otherwise specified 1/1/18
E1230 Power operated vehicle (3- or 4-wheel nonhighway), specify brand name and model number  
E1231 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system  
E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system  
E1233 Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system  
E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system  
E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system  
E1236 Wheelchair, pediatric size, folding, adjustable, with seating system  
E1237 Wheelchair, pediatric size, rigid, adjustable, without seating system  
E1238 Wheelchair, pediatric size, folding, adjustable, without seating system  
E1239 Power wheelchair, pediatric size, not otherwise specified  
E1240 Lightweight wheelchair, detachable arms, (desk or full length) swing away detachable, elevating legrest  
E1250 Lightweight wheelchair, fixed full length arms, swing away detachable footrest  
E1260 Lightweight wheelchair, detachable arms (desk or full length) swing away detachable footrest  
E1270 Lightweight wheelchair, fixed full length arms, swing away detachable elevating legrests  
E1280 Heavy duty wheelchair, detachable arms (desk or full length) elevating legrests  
E1285 Heavy duty wheelchair, fixed full length arms, swing away detachable footrest  
E1290 Heavy duty wheelchair, detachable arms (desk or full length) swing away detachable footrest  
E1295 Heavy-duty wheelchair, fixed full-length arms, elevating legrest  
E1296 Special wheelchair seat height from floor  
E1297 Special wheelchair seat depth, by upholstery  
E1298 Special wheelchair seat depth and/or width, by construction  
E1352 Oxygen accessory, flow regulator capable of positive inspiratory pressure 1/1/18
E1355 Stand/rack 1/1/18
E1356 Oxygen accessory, battery pack/cartridge for portable concentrator, any type, replacement only, each 1/1/18
E1357 Oxygen accessory, battery charger for portable concentrator, any type, replacement only, each 1/1/18
E1358 Oxygen accessory, dc power adapter for portable concentrator, any type, replacement only, each 1/1/18
E1372 Immersion external heater for nebulizer 1/1/18
E1390 Oxygen concentrator, single delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate  
E1391 Oxygen concentrator, dual delivery port, capable of delivering 85 percent or greater oxygen concentration at the prescribed flow rate, each  
E1392 Portable oxygen concentrator, rental  
E1399 Durable medical equipment, miscellaneous  
E1405 Oxygen and water vapor enriching system with heated delivery 1/1/18
E1406 Oxygen and water vapor enriching system without heated delivery 1/1/18
E1800 Dynamic adjustable elbow extension/flexion device, includes soft interface material  
E1801 Static progressive stretch elbow device, extension and/or flexion, with or without range of motion adjustment, includes all components and accessories  
E1802 Dynamic adjustable forearm pronation/supination device, includes soft interface material  
E1805 Dynamic adjustable wrist extension/flexion device, includes soft interface material  
E1806 Static progressive stretch wrist device, flexion and/or extension, with or without range of motion adjustment, includes all components and accessories  
E1825 Dynamic adjustable finger extension/flexion device, includes soft interface material  
E1840 Dynamic adjustable shoulder flexion / abduction / rotation device, includes soft interface material 1/1/18
E1841 Static progressive stretch shoulder device, with or without range of motion adjustment, includes all components and accessories  
E2000 Gastric suction pump, home model, portable or stationary, electric 1/1/18
E2100 Blood glucose monitor with integrated voice synthesizer 1/1/18
E2101 Blood glucose monitor with integrated lancing/blood sample 1/1/18
E2201 Manual wheelchair accessory, nonstandard seat frame, width greater than or equal to 20 inches and less than 24 inches 1/1/18
E2202 Manual wheelchair accessory, nonstandard seat frame width, 24-27 inches 1/1/18
E2203 Manual wheelchair accessory, nonstandard seat frame depth, 20 to less than 22 inches 1/1/18
E2204 Manual wheelchair accessory, nonstandard seat frame depth, 22 to 25 inches 1/1/18
E2205 Manual wheelchair accessory, handrim without projections (includes ergonomic or contoured), any type, replacement only, each 1/1/18
E2206 Manual wheelchair accessory, wheel lock assembly, complete, replacement only, each 1/1/18
E2207 Wheelchair accessory, crutch and cane holder, each 1/1/18
E2208 Wheelchair accessory, cylinder tank carrier, each 1/1/18
E2209 Accessory, arm trough, with or without hand support, each 1/1/18
E2210 Wheelchair accessory, bearings, any type, replacement only, each 1/1/18
E2211 Manual wheelchair accessory, pneumatic propulsion tire, any size, each 1/1/18
E2212 Manual wheelchair accessory, tube for pneumatic propulsion tire, any size, each 1/1/18
E2213 Manual wheelchair accessory, insert for pneumatic propulsion tire (removable), any type, any size, each 1/1/18
E2214 Manual wheelchair accessory, pneumatic caster tire, any size, each 1/1/18
E2215 Manual wheelchair accessory, tube for pneumatic caster tire, any size, each 1/1/18
E2216 Manual wheelchair accessory, foam filled propulsion tire, any size, each 1/1/18
E2217 Manual wheelchair accessory, foam filled caster tire, any size, each 1/1/18
E2218 Manual wheelchair accessory, foam propulsion tire, any size, each 1/1/18
E2219 Manual wheelchair accessory, foam caster tire, any size, each 1/1/18
E2220 Manual wheelchair accessory, solid (rubber/plastic) propulsion tire, any size, replacement only, each 1/1/18
E2221 Manual wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each 1/1/18
E2222 Manual wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each 1/1/18
E2224 Manual wheelchair accessory, propulsion wheel excludes tire, any size, replacement only, each 1/1/18
E2225 Manual wheelchair accessory, caster wheel excludes tire, any size, replacement only, each 1/1/18
E2226 Manual wheelchair accessory, caster fork, any size, replacement only, each 1/1/18
E2227 Manual wheelchair accessory, gear reduction drive wheel, each  
E2228 Manual wheelchair accessory, wheel braking system and lock, complete, each 1/1/18
E2230 Manual wheelchair accessory, manual standing system 1/1/18
E2231 Manual wheelchair accessory, solid seat support base (replaces sling seat), includes any type mounting hardware 1/1/18
E2291 Back, planar, for pediatric size wheelchair including fixed attaching hardware 1/1/18
E2292 Seat, planar, for pediatric size wheelchair including fixed attaching hardware 1/1/18
E2293 Back, contoured, for pediatric size wheelchair including fixed attaching hardware 1/1/18
E2294 Seat, contoured, for pediatric size wheelchair including fixed attaching hardware 1/1/18
E2295 Manual wheelchair accessory, for pediatric size wheelchair, dynamic seating frame, allows coordinated movement of multiple positioning features 1/1/18
E2300 Wheelchair accessory, power seat elevation system, any type  
E2301 Wheelchair accessory, power standing system, any type  
E2310 Power wheelchair accessory, electronic connection between wheelchair controller and one power seating system motor, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware  
E2311 Power wheelchair accessory, electronic connection between wheelchair controller and 2 or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware  
E2312 Power wheelchair accessory, hand or chin control interface, mini-proportional remote joystick, proportional, including fixed mounting hardware  
E2313 Power wheelchair accessory, harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware, each 1/1/18
E2321 Power wheelchair accessory, hand control interface, remote joystick, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware  
E2322 Power wheelchair accessory, hand control interface, multiple mechanical switches, nonproportional, including all related electronics, mechanical stop switch, and fixed mounting hardware  
E2323 Power wheelchair accessory, specialty joystick handle for hand control interface, prefabricated 1/1/18
E2324 Power wheelchair accessory, chin cup for chin control interface 1/1/18
E2325 Power wheelchair accessory, sip and puff interface, nonproportional, including all related electronics, mechanical stop switch, and manual swingaway mounting hardware  
E2326 Power wheelchair accessory, breath tube kit for sip and puff interface 1/1/18
E2327 Power wheelchair accessory, head control interface, mechanical, proportional, including all related electronics, mechanical direction change switch, and fixed mounting hardware  
E2328 Power wheelchair accessory, head control or extremity control interface, electronic, proportional, including all related electronics and fixed mounting hardware  
E2329 Power wheelchair accessory, head control interface, contact switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware  
E2330 Power wheelchair accessory, head control interface, proximity switch mechanism, nonproportional, including all related electronics, mechanical stop switch, mechanical direction change switch, head array, and fixed mounting hardware  
E2331 Power wheelchair accessory, attendant control, proportional, including all related electronics and fixed mounting hardware 1/1/18
E2351 Power wheelchair accessory, electronic interface to operate speech generating device using power wheelchair control interface 1/1/18
E2358 Power wheelchair accessory, group 34 non-sealed lead acid battery, each 1/1/18
E2359 Power wheelchair accessory, group 34 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) 1/1/18
E2360 Power wheelchair accessory, 22nf non-sealed lead acid battery, each 1/1/18
E2361 Power wheelchair accessory, 22nf sealed lead acid battery, each, (e.g., gel cell, absorbed glassmat) 1/1/18
E2362 Power wheelchair accessory, group 24 non-sealed lead acid battery, each 1/1/18
E2363 Power wheelchair accessory, group 24 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) 1/1/18
E2364 Power wheelchair accessory, u-1 non-sealed lead acid battery, each 1/1/18
E2365 Power wheelchair accessory, u-1 sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) 1/1/18
E2366 Power wheelchair accessory, battery charger, single mode, for use with only one battery type, sealed or non-sealed, each 1/1/18
E2367 Power wheelchair accessory, battery charger, dual mode, for use with either battery type, sealed or non-sealed, each 1/1/18
E2368 Power wheelchair component, drive wheel motor, replacement only 1/1/18
E2369 Power wheelchair component, drive wheel gear box, replacement only 1/1/18
E2370 Power wheelchair component, integrated drive wheel motor and gear box combination, replacement only 1/1/18
E2371 Power wheelchair accessory, group 27 sealed lead acid battery, (e.g., gel cell, absorbed glassmat), each 1/1/18
E2372 Power wheelchair accessory, group 27 non-sealed lead acid battery, each 1/1/18
E2373 Power wheelchair accessory, hand or chin control interface, compact remote joystick, proportional, including fixed mounting hardware  
E2374 Power wheelchair accessory, hand or chin control interface, standard remote joystick (not including controller), proportional, including all related electronics and fixed mounting hardware, replacement only 1/1/18
E2375 Power wheelchair accessory, non-expandable controller, including all related electronics and mounting hardware, replacement only 1/1/18
E2376 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, replacement only  
E2377 Power wheelchair accessory, expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue 1/1/18
E2378 Power wheelchair component, actuator, replacement only 1/1/18
E2381 Power wheelchair accessory, pneumatic drive wheel tire, any size, replacement only, each 1/1/18
E2382 Power wheelchair accessory, tube for pneumatic drive wheel tire, any size, replacement only, each 1/1/18
E2383 Power wheelchair accessory, insert for pneumatic drive wheel tire (removable), any type, any size, replacement only, each 1/1/18
E2384 Power wheelchair accessory, pneumatic caster tire, any size, replacement only, each 1/1/18
E2385 Power wheelchair accessory, tube for pneumatic caster tire, any size, replacement only, each 1/1/18
E2386 Power wheelchair accessory, foam filled drive wheel tire, any size, replacement only, each 1/1/18
E2387 Power wheelchair accessory, foam filled caster tire, any size, replacement only, each 1/1/18
E2388 Power wheelchair accessory, foam drive wheel tire, any size, replacement only, each 1/1/18
E2389 Power wheelchair accessory, foam caster tire, any size, replacement only, each 1/1/18
E2390 Power wheelchair accessory, solid (rubber/plastic) drive wheel tire, any size, replacement only, each 1/1/18
E2391 Power wheelchair accessory, solid (rubber/plastic) caster tire (removable), any size, replacement only, each 1/1/18
E2392 Power wheelchair accessory, solid (rubber/plastic) caster tire with integrated wheel, any size, replacement only, each 1/1/18
E2394 Power wheelchair accessory, drive wheel excludes tire, any size, replacement only, each 1/1/18
E2395 Power wheelchair accessory, caster wheel excludes tire, any size, replacement only, each 1/1/18
E2396 Power wheelchair accessory, caster fork, any size, replacement only, each 1/1/18
E2397 Power wheelchair accessory, lithium-based battery, each 1/1/18
E2402 Negative pressure wound therapy electrical pump, stationary or portable    
E2500 Speech generating device, digitized speech, using prerecorded messages, less than or equal to 8 minutes recording time  
E2502 Speech generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time  
E2504 Speech generating device, digitized speech, using prerecorded messages, greater than 20 minutes but less than or equal to 40 minutes recording time  
E2506 Speech generating device, digitized speech, using prerecorded messages, greater than 40 minutes recording time  
E2508 Speech generating device, synthesized speech, requiring message formulation by spelling and access by physical contact with the device  
E2510 Speech generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access  
E2511 Speech generating software program, for personal computer or personal digital assistant  
E2512 Accessory for speech generating device, mounting system  
E2599 Accessory for speech generating device, not otherwise classified  
E2609 Custom fabricated wheelchair seat cushion, any size  
E2610 Wheelchair seat cushion, powered 1/1/18
E2611 General use wheelchair back cushion, width less than 22 inches, any height, including any type mounting hardware 1/1/18
E2612 General use wheelchair back cushion, width 22 inches or greater, any height, including any type mounting hardware 1/1/18
E2613 Positioning wheelchair back cushion, posterior, width less than 22 inches, any height, including any type mounting hardware 1/1/18
E2614 Positioning wheelchair back cushion, posterior, width 22 inches or greater, any height, including any type mounting hardware 1/1/18
E2615 Positioning wheelchair back cushion, posterior-lateral, width less than 22 inches, any height, including any type mounting hardware 1/1/18
E2616 Positioning wheelchair back cushion, posterior-lateral, width 22 inches or greater, any height, including any type mounting hardware 1/1/18
E2617 Custom fabricated wheelchair back cushion, any size, including any type mounting hardware  
E2619 Replacement cover for wheelchair seat cushion or back cushion, each 1/1/18
E2620 Positioning wheelchair back cushion, planar back with lateral supports, width less than 22 inches, any height, including any type mounting hardware 1/1/18
E2621 Positioning wheelchair back cushion, planar back with lateral supports, width 22 inches or greater, any height, including any type mounting hardware 1/1/18
E2622 Skin protection wheelchair seat cushion, adjustable, width less than 22 inches, any depth 1/1/18
E2623 Skin protection wheelchair seat cushion, adjustable, width 22 inches or greater, any depth 1/1/18
E2624 Skin protection and positioning wheelchair seat cushion, adjustable, width less than 22 inches, any depth 1/1/18
E2625 Skin protection and positioning wheelchair seat cushion, adjustable, width 22 inches or greater, any depth 1/1/18
E2626 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable 1/1/18
E2627 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable rancho type 1/1/18
E2628 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining 1/1/18
E2629 Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints) 1/1/18
E2630 Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke type suspension support 1/1/18
E2631 Wheelchair accessory, addition to mobile arm support, elevating proximal arm 1/1/18
E2632 Wheelchair accessory, addition to mobile arm support, offset or lateral rocker arm with elastic balance control 1/1/18
E2633 Wheelchair accessory, addition to mobile arm support, supinator 1/1/18
E8000 Gait trainer, pediatric size, posterior support, includes all accessories and components  
E8001 Gait trainer, pediatric size, upright support, includes all accessories and components  
E8002 Gait trainer, pediatric size, anterior support, includes all accessories and components  
K0001 Standard wheelchair 1/1/18
K0002 Standard hemi (low seat) wheelchair 1/1/18
K0003 Lightweight wheelchair  
K0004 High strength, lightweight wheelchair  
K0005 Ultralightweight wheelchair  
K0006 Heavy duty wheelchair  
K0007 Extra heavy duty wheelchair  
K0008 Custom manual wheelchair/base  
K0009 Other manual wheelchair/base  
K0010 Standard - weight frame motorized/power wheelchair  
K0011 Standard - weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking  
K0012 Lightweight portable motorized/power wheelchair  
K0013 Custom motorized/power wheelchair base  
K0014 Other motorized/power wheelchair base  
K0015 Detachable, non-adjustable height armrest, replacement only, each 1/1/18
K0017 Detachable, adjustable height armrest, base, replacement only, each 1/1/18
K0018 Detachable, adjustable height armrest, upper portion, replacement only, each 1/1/18
K0019 Arm pad, replacement only, each 1/1/18
K0020 Fixed, adjustable height armrest, pair 1/1/18
K0037 High mount flip-up footrest, replacement only, each 1/1/18
K0038 Leg strap, each 1/1/18
K0039 Leg strap, h style, each 1/1/18
K0040 Adjustable angle footplate, each 1/1/18
K0041 Large size footplate, each 1/1/18
K0042 Standard size footplate, replacement only, each 1/1/18
K0043 Footrest, lower extension tube, replacement only, each 1/1/18
K0044 Footrest, upper hanger bracket, replacement only, each 1/1/18
K0045 Footrest, complete assembly, replacement only, each 1/1/18
K0046 Elevating legrest, lower extension tube, replacement only, each 1/1/18
K0047 Elevating legrest, upper hanger bracket, replacement only, each 1/1/18
K0050 Ratchet assembly, replacement only 1/1/18
K0051 Cam release assembly, footrest or legrest, replacement only, each 1/1/18
K0052 Swingaway, detachable footrests, replacement only, each 1/1/18
K0053 Elevating footrests, articulating (telescoping), each 1/1/18
K0056 Seat height less than 17" or equal to or greater than 21" for a high strength, lightweight, or ultralightweight wheelchair 1/1/18
K0065 Spoke protectors, each 1/1/18
K0069 Rear wheel assembly, complete, with solid tire, spokes or molded, replacement only, each 1/1/18
K0070 Rear wheel assembly, complete, with pneumatic tire, spokes or molded, replacement only, each 1/1/18
K0071 Front caster assembly, complete, with pneumatic tire, replacement only, each 1/1/18
K0072 Front caster assembly, complete, with semi-pneumatic tire, replacement only, each 1/1/18
K0073 Caster pin lock, each 1/1/18
K0077 Front caster assembly, complete, with solid tire, replacement only, each 1/1/18
K0098 Drive belt for power wheelchair, replacement only 1/1/18
K0105 Iv hanger, each 1/1/18
K0108 Wheelchair component or accessory, not otherwise specified  
K0195 Elevating leg rests, pair (for use with capped rental wheelchair base) 1/1/18
K0455 Infusion pump used for uninterrupted parenteral administration of medication, (e.g., epoprostenol or treprostinol) 1/1/18
K0601 Replacement battery for external infusion pump owned by patient, silver oxide, 1.5 volt, each 1/1/18
K0602 Replacement battery for external infusion pump owned by patient, silver oxide, 3 volt, each 1/1/18
K0603 Replacement battery for external infusion pump owned by patient, alkaline, 1.5 volt, each 1/1/18
K0604 Replacement battery for external infusion pump owned by patient, lithium, 3.6 volt, each 1/1/18
K0605 Replacement battery for external infusion pump owned by patient, lithium, 4.5 volt, each 1/1/18
K0606 Automatic external defibrillator, with integrated electrocardiogram analysis, garment type  
K0607 Replacement battery for automated external defibrillator, garment type only, each  
K0608 Replacement garment for use with automated external defibrillator, each  
K0609 Replacement electrodes for use with automated external defibrillator, garment type only, each  
K0672 Addition to lower extremity orthosis, removable soft interface, all components, replacement only, each 1/1/18
K0730 Controlled dose inhalation drug delivery system  
K0733 Power wheelchair accessory, 12 to 24 amp hour sealed lead acid battery, each (e.g., gel cell, absorbed glassmat) 1/1/18
K0738 Portable gaseous oxygen system, rental; home compressor used to fill portable oxygen cylinders; includes portable containers, regulator, flowmeter, humidifier, cannula or mask, and tubing 1/1/18
K0800 Power operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds  
K0801 Power operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds  
K0802 Power operated vehicle, group 1 very heavy-duty, patient weight capacity 451 to 600 pounds  
K0806 Power operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds  
K0807 Power operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds  
K0808 Power operated vehicle, group 2 very heavy-duty, patient weight capacity 451 to 600 pounds  
K0812 Power operated vehicle, not otherwise classified  
K0813 Power wheelchair, group 1 standard, portable, sling/solid seat and back, patient weight capacity up to and including 300 pounds  
K0814 Power wheelchair, group 1 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds  
K0815 Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds  
K0816 Power wheelchair, group 1 standard, captain's chair, patient weight capacity up to and including 300 pounds  
K0820 Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0821 Power wheelchair, group 2 standard, portable, captain's chair, patient weight capacity up to and including 300 pounds  
K0822 Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0823 Power wheelchair, group 2 standard, captain's chair, patient weight capacity up to and including 300 pounds  
K0824 Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds  
K0825 Power wheelchair, group 2 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds  
K0826 Power wheelchair, group 2 very heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds  
K0827 Power wheelchair, group 2 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds  
K0828 Power wheelchair, group 2 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more  
K0829 Power wheelchair, group 2 extra heavy-duty, captain's chair, patient weight 601 pounds or more  
K0830 Power wheelchair, group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0831 Power wheelchair, group 2 standard, seat elevator, captains chair, patient weight capacity up to and including 300 pounds  
K0835 Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0836 Power wheelchair, group 2 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds  
K0837 Power wheelchair, group 2 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds  
K0838 Power wheelchair, group 2 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds  
K0839 Power wheelchair, group 2 very heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds  
K0840 Power wheelchair, group 2 extra heavy-duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more  
K0841 Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0842 Power wheelchair, group 2 standard, multiple power option, captain's chair, patient weight capacity up to and including 300 pounds  
K0843 Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds  
K0848 Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0849 Power wheelchair, group 3 standard, captain's chair, patient weight capacity up to and including 300 pounds  
K0850 Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds  
K0851 Power wheelchair, group 3 heavy-duty, captain's chair, patient weight capacity 301 to 450 pounds  
K0852 Power wheelchair, group 3 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds  
K0853 Power wheelchair, group 3 very heavy-duty, captain's chair, patient weight capacity 451 to 600 pounds  
K0854 Power wheelchair, group 3 extra heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more  
K0855 Power wheelchair, group 3 extra heavy-duty, captain's chair, patient weight capacity 601 pounds or more  
K0856 Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0857 Power wheelchair, group 3 standard, single power option, captain's chair, patient weight capacity up to and including 300 pounds  
K0858 Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds  
K0859 Power wheelchair, group 3 heavy-duty, single power option, captain's chair, patient weight capacity 301 to 450 pounds  
K0860 Power wheelchair, group 3 very heavy-duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds  
K0861 Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0862 Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds  
K0863 Power wheelchair, group 3 very heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds  
K0864 Power wheelchair, group 3 extra heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 601 pounds or more  
K0868 Power wheelchair, group 4 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0869 Power wheelchair, group 4 standard, captains chair, patient weight capacity up to and including 300 pounds  
K0870 Power wheelchair, group 4 heavy duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds  
K0871 Power wheelchair, group 4 very heavy duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds  
K0877 Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0878 Power wheelchair, group 4 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds  
K0879 Power wheelchair, group 4 heavy duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds  
K0880 Power wheelchair, group 4 very heavy duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds  
K0884 Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds  
K0885 Power wheelchair, group 4 standard, multiple power option, captains chair, patient weight capacity up to and including 300 pounds  
K0886 Power wheelchair, group 4 heavy duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds  
K0890 Power wheelchair, group 5 pediatric, single power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds  
K0891 Power wheelchair, group 5 pediatric, multiple power option, sling/solid seat/back, patient weight capacity up to and including 125 pounds  
K0898 Power wheelchair, not otherwise classified  
K0899 Power mobility device, not coded by dme pdac or does not meet criteria  
K0900 Customized durable medical equipment, other than wheelchair 1/1/18
L0113 Cranial cervical orthosis, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment 1/1/18
L0454 Tlso flexible, provides trunk support, extends from sacrococcygeal junction to above t-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0455 Tlso, flexible, provides trunk support, extends from sacrococcygeal junction to above t-9 vertebra, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks with rigid stays or panel(s), includes shoulder straps and closures, prefabricated, off-the-shelf 1/1/18
L0457 Tlso, flexible, provides trunk support, thoracic region, rigid posterior panel and soft anterior apron, extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, restricts gross trunk motion in the sagittal plane, produces intracavitary pressure to reduce load on the intervertebral disks, includes straps and closures, prefabricated, off-the-shelf 1/1/18
L0458 Tlso, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment 1/1/18
L0460 Tlso, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0462 Tlso, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment 1/1/18
L0464 Tlso, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment 1/1/18
L0466 Tlso, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0467 Tlso, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, restricts gross trunk motion in sagittal plane, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf  
L0468 Tlso, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal, and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0469 Tlso, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction over scapulae, lateral strength provided by pelvic, thoracic, and lateral frame pieces, restricts gross trunk motion in sagittal and coronal planes, produces intracavitary pressure to reduce load on intervertebral disks, prefabricated, off-the-shelf  
L0470 Tlso, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment 1/1/18
L0472 Tlso, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment 1/1/18
L0480 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated  
L0482 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 1 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated  
L0484 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell without interface liner, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated  
L0486 Thoracic-lumbar-sacral orthotic (TLSO), triplanar control, 2 piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, lateral strength is enhanced by overlapping plastic, restricts gross trunk motion in the sagittal, coronal, and transverse planes, includes a carved plaster or CAD-CAM model, custom fabricated  
L0488 Tlso, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment 1/1/18
L0490 Tlso, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the t-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment 1/1/18
L0491 Tlso, sagittal-coronal control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment 1/1/18
L0492 Tlso, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment 1/1/18
L0624 Sacroiliac orthosis, provides pelvic-sacral support, with rigid or semi-rigid panels placed over the sacrum and abdomen, reduces motion about the sacroiliac joint, includes straps, closures, may include pendulous abdomen design, custom fabricated 1/1/18
L0625 Lumbar orthosis, flexible, provides lumbar support, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include pendulous abdomen design, shoulder straps, stays, prefabricated, off-the-shelf 1/1/18
L0626 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0627 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0628 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf 1/1/18
L0629 Lumbar-sacral orthosis, flexible, provides lumbo-sacral support, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include stays, shoulder straps, pendulous abdomen design, custom fabricated 1/1/18
L0630 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0631 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0632 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated 1/1/18
L0633 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0634 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, custom fabricated 1/1/18
L0635 Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment 1/1/18
L0636 Lumbar-sacral orthotic (LSO), sagittal-coronal control, lumbar flexion, rigid posterior frame/panels, lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, custom fabricated  
L0637 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0638 Lumbar-sacral orthotic (LSO), sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, custom fabricated  
L0639 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L0640 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, custom fabricated 1/1/18
L0641 Lumbar orthosis, sagittal control, with rigid posterior panel(s), posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf  
L0642 Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf  
L0643 Lumbar-sacral orthosis, sagittal control, with rigid posterior panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf  
L0648 Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf  
L0649 Lumbar-sacral orthosis, sagittal-coronal control, with rigid posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, stays, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf  
L0650 Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf  
L0651 Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated, off-the-shelf  
L0980 Peroneal straps, prefabricated, off-the-shelf, pair 1/1/18
L0982 Stocking supporter grips, prefabricated, off-the-shelf, set of four (4) 1/1/18
L1200 Thoracic-lumbar-sacral-orthosis (tlso), inclusive of furnishing initial orthosis only 1/1/18
L1300 Other scoliosis procedure, body jacket molded to patient model  
L1310 Other scoliosis procedure, postoperative body jacket  
L1499 Spinal orthosis, not otherwise specified  
L1812 Knee orthosis, elastic with joints, prefabricated, off-the-shelf  
L1820 Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment 1/1/18
L1830 Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf 1/1/18
L1831 Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment 1/1/18
L1832 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L1833 Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf  
L1834 Knee orthosis, without knee joint, rigid, custom fabricated 1/1/18
L1836 Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf 1/1/18
L1840 Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated  
L1843 Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L1844 Knee orthotic (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated  
L1845 Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L1846 Knee orthotic, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated  
L1847 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L1848 Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf  
L1850 Knee orthosis, swedish type, prefabricated, off-the-shelf 1/1/18
L1851 Knee orthosis (KO), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf  
L1852 Knee orthosis (KO), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf  
L1860 Knee orthotic (KO), modification of supracondylar prosthetic socket, custom fabricated (SK)  
L1900 Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom fabricated 1/1/18
L1902 Ankle orthosis, ankle gauntlet or similar, with or without joints, prefabricated, off-the-shelf 1/1/18
L1904 Ankle orthosis, ankle gauntlet or similar, with or without joints, custom fabricated 1/1/18
L1906 Ankle foot orthosis, multiligamentous ankle support, prefabricated, off-the-shelf 1/1/18
L1907 Ankle orthosis, supramalleolar with straps, with or without interface/pads, custom fabricated 1/1/18
L1910 Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment 1/1/18
L1920 Ankle foot orthosis, single upright with static or adjustable stop (phelps or perlstein type), custom fabricated 1/1/18
L1930 Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment 1/1/18
L1932 Afo, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment 1/1/18
L1940 Ankle foot orthosis, plastic or other material, custom fabricated 1/1/18
L1945 Ankle foot orthosis, plastic, rigid anterior tibial section (floor reaction), custom fabricated 1/1/18
L1950 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic, custom fabricated 1/1/18
L1951 Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment 1/1/18
L1960 Ankle foot orthosis, posterior solid ankle, plastic, custom fabricated 1/1/18
L1970 Ankle foot orthosis, plastic with ankle joint, custom fabricated 1/1/18
L1971 Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment 1/1/18
L1980 Ankle foot orthosis, single upright free plantar dorsiflexion, solid stirrup, calf band/cuff (single bar 'bk' orthosis), custom fabricated 1/1/18
L1990 Ankle foot orthosis, double upright free plantar dorsiflexion, solid stirrup, calf band/cuff (double bar 'bk' orthosis), custom fabricated  
L2000 Knee ankle foot orthosis, single upright, free knee, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'ak' orthosis), custom fabricated 1/1/18
L2005 Knee-ankle-foot orthotic (KAFO), any material, single or double upright, stance control, automatic lock and swing phase release, any type activation, includes ankle joint, any type, custom fabricated  
L2010 Knee-ankle-foot orthotic (KAFO), single upright, free ankle, solid stirrup, thigh and calf bands/cuffs (single bar 'AK' orthotic), without knee joint, custom fabricated  
L2020 Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs (double bar 'AK' orthotic), custom fabricated  
L2030 Knee-ankle-foot orthotic (KAFO), double upright, free ankle, solid stirrup, thigh and calf bands/cuffs, (double bar 'AK' orthotic), without knee joint, custom fabricated  
L2034 Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion knee, medial-lateral rotation control, with or without free motion ankle, custom fabricated  
L2035 Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment 1/1/18
L2036 Knee-ankle-foot orthotic (KAFO), full plastic, double upright, with or without free motion knee, with or without free motion ankle, custom fabricated  
L2037 Knee-ankle-foot orthotic (KAFO), full plastic, single upright, with or without free motion knee, with or without free motion ankle, custom fabricated  
L2038 Knee-ankle-foot orthotic (KAFO), full plastic, with or without free motion knee, multi-axis ankle, custom fabricated  
L2106 Ankle foot orthosis, fracture orthosis, tibial fracture cast orthosis, thermoplastic type casting material, custom fabricated 1/1/18
L2108 Ankle-foot orthotic (AFO), fracture orthotic, tibial fracture cast orthotic, custom fabricated  
L2112 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment 1/1/18
L2114 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment 1/1/18
L2116 Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment 1/1/18
L2126 Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, thermoplastic type casting material, custom fabricated  
L2128 Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, custom fabricated  
L2132 Kafo, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment 1/1/18
L2134 Kafo, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment 1/1/18
L2136 Knee-ankle-foot orthotic (KAFO), fracture orthotic, femoral fracture cast orthotic, rigid, prefabricated, includes fitting and adjustment  
L2192 Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt 1/1/18
L2750 Addition to lower extremity orthosis, plating chrome or nickel, per bar 1/1/18
L2755 Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only 1/1/18
L2760 Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth) 1/1/18
L2768 Orthotic side bar disconnect device, per bar 1/1/18
L2780 Addition to lower extremity orthosis, non-corrosive finish, per bar 1/1/18
L2999 Lower extremity orthoses, not otherwise specified  
L3000 Foot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each  
L3001 Foot, insert, removable, molded to patient model, spenco, each  
L3002 Foot, insert, removable, molded to patient model, plastazote or equal, each 1/1/18
L3003 Foot, insert, removable, molded to patient model, silicone gel, each  
L3010 Foot, insert, removable, molded to patient model, longitudinal arch support, each  
L3020 Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each  
L3030 Foot, insert, removable, formed to patient foot, each  
L3031 Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each  
L3040 Foot, arch support, removable, premolded, longitudinal, each 1/1/18
L3050 Foot, arch support, removable, premolded, metatarsal, each 1/1/18
L3060 Foot, arch support, removable, premolded, longitudinal/ metatarsal, each 1/1/18
L3070 Foot, arch support, non-removable attached to shoe, longitudinal, each 1/1/18
L3080 Foot, arch support, non-removable attached to shoe, metatarsal, each 1/1/18
L3090 Foot, arch support, non-removable attached to shoe, longitudinal/metatarsal, each 1/1/18
L3100 Hallus-valgus night dynamic splint, prefabricated, off-the-shelf 1/1/18
L3201 Orthopedic shoe, oxford with supinator or pronator, infant 1/1/18
L3203 Orthopedic shoe, oxford with supinator or pronator, junior 1/1/18
L3204 Orthopedic shoe, hightop with supinator or pronator, infant 1/1/18
L3206 Orthopedic shoe, hightop with supinator or pronator, child 1/1/18
L3207 Orthopedic shoe, hightop with supinator or pronator, junior 1/1/18
L3215 Orthopedic footwear, ladies shoe, oxford, each 1/1/18
L3216 Orthopedic footwear, ladies shoe, depth inlay, each 1/1/18
L3217 Orthopedic footwear, ladies shoe, hightop, depth inlay, each 1/1/18
L3219 Orthopedic footwear, mens shoe, oxford, each 1/1/18
L3221 Orthopedic footwear, mens shoe, depth inlay, each 1/1/18
L3222 Orthopedic footwear, mens shoe, hightop, depth inlay, each 1/1/18
L3230 Orthopedic footwear, custom shoe, depth inlay, each 1/1/18
L3250 Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each 1/1/18
L3251 Foot, shoe molded to patient model, silicone shoe, each 1/1/18
L3252 Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each 1/1/18
L3253 Foot, molded shoe plastazote (or similar) custom fitted, each 1/1/18
L3254 Non-standard size or width 1/1/18
L3255 Non-standard size or length 1/1/18
L3257 Orthopedic footwear, additional charge for split size 1/1/18
L3330 Lift, elevation, metal extension (skate) 1/1/18
L3674 Shoulder orthosis, abduction positioning (airplane design), thoracic component and support bar, with or without nontorsion joint/turnbuckle, may include soft interface, straps, custom fabricated, includes fitting and adjustment 1/1/18
L3678 Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated, off-the-shelf 1/1/18
L3702 Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment  
L3720 Elbow orthosis, double upright with forearm/arm cuffs, free motion, custom fabricated 1/1/18
L3730 Elbow orthosis, double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated  
L3740 Elbow orthotic (EO), double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated  
L3763 Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment 1/1/18
L3764 Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment 1/1/18
L3765 Elbow-wrist-hand-finger orthotic (EWHFO), rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment  
L3766 Elbow-wrist-hand-finger orthotic (EWHFO), includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment  
L3809 Wrist hand finger orthosis, without joint(s), prefabricated, off-the-shelf, any type 1/1/18
L3900 Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, wrist or finger driven, custom fabricated  
L3901 Wrist-hand-finger orthotic (WHFO), dynamic flexor hinge, reciprocal wrist extension/ flexion, finger flexion/extension, cable driven, custom fabricated  
L3912 Hand finger orthosis (hfo), flexion glove with elastic finger control, prefabricated, off-the-shelf 1/1/18
L3916 Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, off-the-shelf 1/1/18
L3918 Hand orthosis, metacarpal fracture orthosis, prefabricated, off-the-shelf 1/1/18
L3924 Hand finger orthosis, without joints, may include soft interface, straps, prefabricated, off-the-shelf 1/1/18
L3930 Hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, off-the-shelf 1/1/18
L3975 Shoulder-elbow-wrist-hand-finger orthotic (SEWHO), shoulder cap design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment  
L3981 Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments 1/1/18
L3999 Upper limb orthosis, not otherwise specified 1/1/18
L4002 Replacement strap, any orthosis, includes all components, any length, any type 1/1/18
L4010 Replace trilateral socket brim 1/1/18
L4020 Replace quadrilateral socket brim, molded to patient model 1/1/18
L4030 Replace quadrilateral socket brim, custom fitted 1/1/18
L4040 Replace molded thigh lacer, for custom fabricated orthosis only 1/1/18
L4361 Walking boot, pneumatic and/or vacuum, with or without joints, with or without interface material, prefabricated, off-the-shelf 1/1/18
L4387 Walking boot, non-pneumatic, with or without joints, with or without interface material, prefabricated, off-the-shelf 1/1/18
L4396 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise 1/1/18
L4397 Static or dynamic ankle foot orthosis, including soft interface material, adjustable for fit, for positioning, may be used for minimal ambulation, prefabricated, off-the-shelf  
L4631 Ankle-foot orthotic, walking boot type, varus/valgus correction, rocker bottom, anterior tibial shell, soft interface, custom arch support, plastic or other material, includes straps and closures, custom fabricated  
L5050 Ankle, Symes, molded socket, SACH foot  
L5060 Ankle, Symes, metal frame, molded leather socket, articulated ankle/foot  
L5100 Below knee, molded socket, shin, SACH foot  
L5105 Below knee, plastic socket, joints and thigh lacer, SACH foot  
L5150 Knee disarticulation (or through knee), molded socket, external knee joints, shin, SACH foot  
L5160 Knee disarticulation (or through knee), molded socket, bent knee configuration, external knee joints, shin, SACH foot  
L5200 Above knee, molded socket, single axis constant friction knee, shin, SACH foot  
L5210 Above knee, short prosthesis, no knee joint (stubbies), with foot blocks, no ankle joints, each  
L5220 Above knee, short prosthesis, no knee joint (stubbies), with articulated ankle/foot, dynamically aligned, each  
L5230 Above knee, for proximal femoral focal deficiency, constant friction knee, shin, SACH foot  
L5250 Hip disarticulation, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot  
L5270 Hip disarticulation, tilt table type; molded socket, locking hip joint, single axis constant friction knee, shin, SACH foot  
L5280 Hemipelvectomy, Canadian type; molded socket, hip joint, single axis constant friction knee, shin, SACH foot  
L5301 Below knee, molded socket, shin, SACH foot, endoskeletal system  
L5312 Knee disarticulation (or through knee), molded socket, single axis knee, pylon, sach foot, endoskeletal system  
L5321 Above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee  
L5331 Hip disarticulation, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot  
L5341 Hemipelvectomy, Canadian type, molded socket, endoskeletal system, hip joint, single axis knee, SACH foot  
L5400 Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment, suspension, and one cast change, below knee 1/1/18
L5410 Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension, below knee, each additional cast change and realignment 1/1/18
L5420 Immediate post surgical or early fitting, application of initial rigid dressing, including fitting, alignment and suspension and one cast change 'ak' or knee disarticulation 1/1/18
L5430 Immediate post surgical or early fitting, application of initial rigid dressing, incl. fitting, alignment and supension, 'ak' or knee disarticulation, each additional cast change and realignment 1/1/18
L5450 Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, below knee 1/1/18
L5460 Immediate post surgical or early fitting, application of non-weight bearing rigid dressing, above knee 1/1/18
L5500 Initial, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed  
L5505 Initial, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, direct formed  
L5510 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model  
L5520 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed  
L5530 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model  
L5535 Preparatory, below knee PTB type socket, nonalignable system, no cover, SACH foot, prefabricated, adjustable open end socket  
L5540 Preparatory, below knee PTB type socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model  
L5560 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, plaster socket, molded to model  
L5570 Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, direct formed  
L5580 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, thermoplastic or equal, molded to model  
L5585 Preparatory, above knee - knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, prefabricated adjustable open end socket  
L5590 Preparatory, above knee, knee disarticulation, ischial level socket, nonalignable system, pylon, no cover, SACH foot, laminated socket, molded to model  
L5595 Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover, SACH foot, thermoplastic or equal, molded to patient model  
L5600 Preparatory, hip disarticulation/hemipelvectomy, pylon, no cover, SACH foot, laminated socket, molded to patient model  
L5610 Addition to lower extremity, endoskeletal system, above knee, hydracadence system  
L5611 Addition to lower extremity, endoskeletal system, above knee, knee disarticulation, 4-bar linkage, with friction swing phase control  
L5613 Addition to lower extremity, endoskeletal system, above knee, knee disarticulation, 4-bar linkage, with hydraulic swing phase control  
L5614 Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control  
L5616 Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control  
L5617 Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each 1/1/18
L5618 Addition to lower extremity, test socket, symes  
L5620 Addition to lower extremity, test socket, below knee  
L5622 Addition to lower extremity, test socket, knee disarticulation  
L5624 Addition to lower extremity, test socket, above knee  
L5626 Addition to lower extremity, test socket, hip disarticulation  
L5628 Addition to lower extremity, test socket, hemipelvectomy  
L5629 Addition to lower extremity, below knee, acrylic socket 1/1/18
L5630 Addition to lower extremity, symes type, expandable wall socket 1/1/18
L5631 Addition to lower extremity, above knee or knee disarticulation, acrylic socket 1/1/18
L5632 Addition to lower extremity, symes type, 'ptb' brim design socket 1/1/18
L5634 Addition to lower extremity, symes type, posterior opening (canadian) socket 1/1/18
L5636 Addition to lower extremity, symes type, medial opening socket 1/1/18
L5637 Addition to lower extremity, below knee, total contact 1/1/18
L5638 Addition to lower extremity, below knee, leather socket 1/1/18
L5639 Addition to lower extremity, below knee, wood socket  
L5640 Addition to lower extremity, knee disarticulation, leather socket 1/1/18
L5642 Addition to lower extremity, above knee, leather socket 1/1/18
L5643 Addition to lower extremity, hip disarticulation, flexible inner socket, external frame  
L5644 Addition to lower extremity, above knee, wood socket 1/1/18
L5645 Addition to lower extremity, below knee, flexible inner socket, external frame 1/1/18
L5646 Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket 1/1/18
L5647 Addition to lower extremity, below knee suction socket 1/1/18
L5648 Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket 1/1/18
L5649 Addition to lower extremity, ischial containment/narrow M-L socket  
L5650 Additions to lower extremity, total contact, above knee or knee disarticulation socket 1/1/18
L5651 Addition to lower extremity, above knee, flexible inner socket, external frame  
L5652 Addition to lower extremity, suction suspension, above knee or knee disarticulation socket 1/1/18
L5653 Addition to lower extremity, knee disarticulation, expandable wall socket 1/1/18
L5654 Addition to lower extremity, socket insert, symes, (kemblo, pelite, aliplast, plastazote or equal) 1/1/18
L5655 Addition to lower extremity, socket insert, below knee (kemblo, pelite, aliplast, plastazote or equal) 1/1/18
L5656 Addition to lower extremity, socket insert, knee disarticulation (kemblo, pelite, aliplast, plastazote or equal) 1/1/18
L5658 Addition to lower extremity, socket insert, above knee (kemblo, pelite, aliplast, plastazote or equal) 1/1/18
L5661 Addition to lower extremity, socket insert, multi-durometer symes 1/1/18
L5665 Addition to lower extremity, socket insert, multi-durometer, below knee 1/1/18
L5666 Addition to lower extremity, below knee, cuff suspension 1/1/18
L5668 Addition  to lower extremity, below knee, molded distal cushion 1/1/18
L5670 Addition to lower extremity, below knee, molded supracondylar suspension ('pts' or similar) 1/1/18
L5671 Addition to lower extremity, below knee / above knee suspension locking mechanism (shuttle, lanyard or equal), excludes socket insert 1/1/18
L5672 Addition to lower extremity, below knee, removable medial brim suspension 1/1/18
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 1/1/18
L5676 Additions to lower extremity, below knee, knee joints, single axis, pair 1/1/18
L5677 Additions to lower extremity, below knee, knee joints, polycentric, pair 1/1/18
L5678 Additions to lower extremity, below knee, joint covers, pair 1/1/18
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  
L5680 Addition to lower extremity, below knee, thigh lacer, nonmolded 1/1/18
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)  
L5682 Addition to lower extremity, below knee, thigh lacer, gluteal/ischial, molded 1/1/18
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)  
L5684 Addition to lower extremity, below knee, fork strap 1/1/18
L5685 Addition to lower extremity prosthesis, below knee, suspension/sealing sleeve, with or without valve, any material, each 1/1/18
L5686 Addition to lower extremity, below knee, back check (extension control) 1/1/18
L5688 Addition to lower extremity, below knee, waist belt, webbing 1/1/18
L5690 Addition to lower extremity, below knee, waist belt, padded and lined 1/1/18
L5692 Addition to lower extremity, above knee, pelvic control belt, light 1/1/18
L5694 Addition to lower extremity, above knee, pelvic control belt, padded and lined 1/1/18
L5695 Addition to lower extremity, above knee, pelvic control, sleeve suspension, neoprene or equal, each 1/1/18
L5696 Addition to lower extremity, above knee or knee disarticulation, pelvic joint 1/1/18
L5697 Addition to lower extremity, above knee or knee disarticulation, pelvic band 1/1/18
L5698 Addition to lower extremity, above knee or knee disarticulation, silesian bandage 1/1/18
L5699 All lower extremity prostheses, shoulder harness 1/1/18
L5700 Replacement, socket, below knee, molded to patient model  
L5701 Replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model  
L5702 Replacement, socket, hip disarticulation, including hip joint, molded to patient model  
L5703 Ankle, Symes, molded to patient model, socket without solid ankle cushion heel (SACH) foot, replacement only  
L5704 Custom shaped protective cover, below knee 1/1/18
L5705 Custom shaped protective cover, above knee 1/1/18
L5706 Custom shaped protective cover, knee disarticulation 1/1/18
L5707 Custom shaped protective cover, hip disarticulation  
L5710 Addition, exoskeletal knee-shin system, single axis, manual lock 1/1/18
L5711 Additions exoskeletal knee-shin system, single axis, manual lock, ultra-light material 1/1/18
L5712 Addition, exoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) 1/1/18
L5714 Addition, exoskeletal knee-shin system, single axis, variable friction swing phase control 1/1/18
L5716 Addition, exoskeletal knee-shin system, polycentric, mechanical stance phase lock 1/1/18
L5718 Addition, exoskeletal knee-shin system, polycentric, friction swing and stance phase control 1/1/18
L5722 Addition, exoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control 1/1/18
L5724 Addition, exoskeletal knee-shin system, single axis, fluid swing phase control  
L5726 Addition, exoskeletal knee-shin system, single axis, external joints, fluid swing phase control  
L5728 Addition, exoskeletal knee-shin system, single axis, fluid swing and stance phase control  
L5780 Addition, exoskeletal knee-shin system, single axis, pneumatic/hydra pneumatic swing phase control  
L5781 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system  
L5782 Addition to lower limb prosthesis, vacuum pump, residual limb volume management and moisture evacuation system, heavy-duty  
L5785 Addition, exoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) 1/1/18
L5790 Addition, exoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) 1/1/18
L5795 Addition, exoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal) 1/1/18
L5810 Addition, endoskeletal knee-shin system, single axis, manual lock 1/1/18
L5811 Addition, endoskeletal knee-shin system, single axis, manual lock, ultra-light material 1/1/18
L5812 Addition, endoskeletal knee-shin system, single axis, friction swing and stance phase control (safety knee) 1/1/18
L5814 Addition, endoskeletal knee-shin system, polycentric, hydraulic swing phase control, mechanical stance phase lock  
L5816 Addition, endoskeletal knee-shin system, polycentric, mechanical stance phase lock 1/1/18
L5818 Addition, endoskeletal knee-shin system, polycentric, friction swing, and stance phase control 1/1/18
L5822 Addition, endoskeletal knee-shin system, single axis, pneumatic swing, friction stance phase control  
L5824 Addition, endoskeletal knee-shin system, single axis, fluid swing phase control  
L5826 Addition, endoskeletal knee-shin system, single axis, hydraulic swing phase control, with miniature high activity frame  
L5828 Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control  
L5830 Addition, endoskeletal knee-shin system, single axis, pneumatic/swing phase control  
L5840 Addition, endoskeletal knee-shin system, 4-bar linkage or multiaxial, pneumatic swing phase control  
L5845 Addition, endoskeletal knee-shin system, stance flexion feature, adjustable  
L5848 Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability 1/1/18
L5850 Addition, endoskeletal system, above knee or hip disarticulation, knee extension assist 1/1/18
L5855 Addition, endoskeletal system, hip disarticulation, mechanical hip extension assist 1/1/18
L5856 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type  
L5857 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type  
L5858 Addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type  
L5859 Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)  
L5910 Addition, endoskeletal system, below knee, alignable system 1/1/18
L5920 Addition, endoskeletal system, above knee or hip disarticulation, alignable system 1/1/18
L5925 Addition, endoskeletal system, above knee, knee disarticulation or hip disarticulation, manual lock 1/1/18
L5930 Addition, endoskeletal system, high activity knee control frame  
L5940 Addition, endoskeletal system, below knee, ultra-light material (titanium, carbon fiber or equal) 1/1/18
L5950 Addition, endoskeletal system, above knee, ultra-light material (titanium, carbon fiber or equal) 1/1/18
L5960 Addition, endoskeletal system, hip disarticulation, ultra-light material (titanium, carbon fiber or equal)  
L5961 Addition, endoskeletal system, polycentric hip joint, pneumatic or hydraulic control, rotation control, with or without flexion and/or extension control  
L5962 Addition, endoskeletal system, below knee, flexible protective outer surface covering system  
L5964 Addition, endoskeletal system, above knee, flexible protective outer surface covering system  
L5966 Addition, endoskeletal system, hip disarticulation, flexible protective outer surface covering system  
L5968 Addition to lower limb prosthesis, multiaxial ankle with swing phase active dorsiflexion feature  
L5969 Addition, endoskeletal ankle-foot or ankle system, power assist, includes any type motor(s) 1/1/18
L5970 All lower extremity prostheses, foot, external keel, sach foot 1/1/18
L5971 All lower extremity prosthesis, solid ankle cushion heel (sach) foot, replacement only 1/1/18
L5972 All lower extremity prostheses, foot, flexible keel 1/1/18
L5973 Endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source  
L5974 All lower extremity prostheses, foot, single axis ankle/foot 1/1/18
L5975 All lower extremity prosthesis, combination single axis ankle and flexible keel foot 1/1/18
L5976 All lower extremity prostheses, energy storing foot (seattle carbon copy ii or equal) 1/1/18
L5978 All lower extremity prostheses, foot, multiaxial ankle/foot  
L5979 All lower extremity prostheses, multiaxial ankle, dynamic response foot, one piece system  
L5980 All lower extremity prostheses, flex-foot system  
L5981 All lower extremity prostheses, flex-walk system or equal  
L5982 All exoskeletal lower extremity prostheses, axial rotation unit 1/1/18
L5984 All endoskeletal lower extremity prosthesis, axial rotation unit, with or without adjustability 1/1/18
L5985 All endoskeletal lower extremity prostheses, dynamic prosthetic pylon 1/1/18
L5986 All lower extremity prostheses, multi-axial rotation unit ('mcp' or equal) 1/1/18
L5987 All lower extremity prostheses, shank foot system with vertical loading pylon  
L5988 Addition to lower limb prosthesis, vertical shock reducing pylon feature  
L5990 Addition to lower extremity prosthesis, user adjustable heel height  
L5999 Lower extremity prosthesis, not otherwise specified  
L6611 Addition to upper extremity prosthesis, external powered, additional switch, any type 1/1/18
L6621 Upper extremity prosthesis addition, flexion/extension wrist with or without friction, for use with external powered terminal device  
L6629 Upper extremity addition, quick disconnect lamination collar with coupling piece, otto bock or equal 1/1/18
L6632 Upper extremity addition, latex suspension sleeve, each 1/1/18
L6677 Upper extremity addition, harness, triple control, simultaneous operation of terminal device and elbow 1/1/18
L6680 Upper extremity addition, test socket, wrist disarticulation or below elbow 1/1/18
L6682 Upper extremity addition, test socket, elbow disarticulation or above elbow 1/1/18
L6686 Upper extremity addition, suction socket 1/1/18
L6687 Upper extremity addition, frame type socket, below elbow or wrist disarticulation 1/1/18
L6688 Upper extremity addition, frame type socket, above elbow or elbow disarticulation 1/1/18
L6694 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, for use with locking mechanism 1/1/18
L6695 Addition to upper extremity prosthesis, below elbow/above elbow, custom fabricated from existing mold or prefabricated, socket insert, silicone gel, elastomeric or equal, not for use with locking mechanism 1/1/18
L6696 Addition to upper extremity prosthesis, below elbow/above elbow, 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 L6694 or L6695)  
L6697 Addition to upper extremity prosthesis, below elbow/above elbow, 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 L6694 or L6695)  
L6698 Addition to upper extremity prosthesis, below elbow/above elbow, lock mechanism, excludes socket insert 1/1/18
L6880 Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s)  
L6881 Automatic grasp feature, addition to upper limb electric prosthetic terminal device  
L6882 Microprocessor control feature, addition to upper limb prosthetic terminal device  
L6883 Replacement socket, below elbow/wrist disarticulation, molded to patient model, for use with or without external power  
L6884 Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power  
L6890 Addition to upper extremity prosthesis, glove for terminal device, any material, prefabricated, includes fitting and adjustment 1/1/18
L6925 Wrist disarticulation, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device  
L6935 Below elbow, external power, self-suspended inner socket, removable forearm shell, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device  
L6945 Elbow disarticulation, external power, molded inner socket, removable humeral shell, outside locking hinges, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device  
L6955 Above elbow, external power, molded inner socket, removable humeral shell, internal locking elbow, forearm, Otto Bock or equal electrodes, cables, 2 batteries and one charger, myoelectronic control of terminal device  
L7007 Electric hand, switch or myoelectric controlled, adult  
L7008 Electric hand, switch or myoelectric, controlled, pediatric  
L7009 Electric hook, switch or myoelectric controlled, adult  
L7040 Prehensile actuator, switch controlled  
L7045 Electric hook, switch or myoelectric controlled, pediatric  
L7170 Electronic elbow, Hosmer or equal, switch controlled  
L7180 Electronic elbow, microprocessor sequential control of elbow and terminal device  
L7181 Electronic elbow, microprocessor simultaneous control of elbow and terminal device  
L7185 Electronic elbow, adolescent, Variety Village or equal, switch controlled  
L7186 Electronic elbow, child, Variety Village or equal, switch controlled  
L7190 Electronic elbow, adolescent, Variety Village or equal, myoelectronically controlled  
L7191 Electronic elbow, child, Variety Village or equal, myoelectronically controlled  
L7259 Electronic wrist rotator, any type  
L7360 Six volt battery, each 1/1/18
L7364 Twelve volt battery, each 1/1/18
L7366 Battery charger, twelve volt, each 1/1/18
L7367 Lithium ion battery, rechargeable, replacement 1/1/18
L7368 Lithium ion battery charger, replacement only 1/1/18
L7400 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, ultralight material (titanium, carbon fiber or equal) 1/1/18
L7401 Addition to upper extremity prosthesis, above elbow disarticulation, ultralight material (titanium, carbon fiber or equal) 1/1/18
L7403 Addition to upper extremity prosthesis, below elbow/wrist disarticulation, acrylic material 1/1/18
L7404 Addition to upper extremity prosthesis, above elbow disarticulation, acrylic material 1/1/18
L7499 Upper extremity prosthesis, not otherwise specified  
L7510 Repair of prosthetic device, repair or replace minor parts 1/1/18
L7520 Repair prosthetic device, labor component, per 15 minutes 1/1/18
L7600 Prosthetic donning sleeve, any material, each 1/1/18
L7900 Male vacuum erection system  
L7902 Tension ring, for vacuum erection device, any type, replacement only, each 1/1/18
L8002 Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type 1/1/18
L8035 Custom breast prosthesis, post mastectomy, molded to patient model  
L8040 Nasal prosthesis, provided by a nonphysician  
L8041 Midfacial prosthesis, provided by a nonphysician  
L8042 Orbital prosthesis, provided by a nonphysician  
L8043 Upper facial prosthesis, provided by a nonphysician  
L8044 Hemi-facial prosthesis, provided by a nonphysician  
L8045 Auricular prosthesis, provided by a nonphysician  
L8046 Partial facial prosthesis, provided by a nonphysician  
L8047 Nasal septal prosthesis, provided by a non-physician 1/1/18
L8048 Unspecified maxillofacial prosthesis, by report, provided by a non-physician 1/1/18
L8049 Repair or modification of maxillofacial prosthesis, labor component, 15 minute increments, provided by a non-physician 1/1/18
L8400 Prosthetic sheath, below knee, each 1/1/18
L8410 Prosthetic sheath, above knee, each 1/1/18
L8417 Prosthetic sheath/sock, including a gel cushion layer, below knee or above knee, each 1/1/18
L8430 Prosthetic sock, multiple ply, above knee, each 1/1/18
L8465 Prosthetic shrinker, upper limb, each 1/1/18
L8480 Prosthetic sock, single ply, fitting, above knee, each 1/1/18
L8603 Injectable bulking agent, collagen implant, urinary tract, 2.5 ml syringe, includes shipping and necessary supplies  
L8604 Injectable bulking agent, dextranomer/hyaluronic acid copolymer implant, urinary tract, 1 ml, includes shipping and necessary supplies  
L8606 Injectable bulking agent, synthetic implant, urinary tract, 1 ml syringe, includes shipping and necessary supplies  
L8614 Cochlear device, includes all internal and external components  
L8619 Cochlear implant, external speech processor and controller, integrated system, replacement  
L8627 Cochlear implant, external speech processor, component, replacement  
L8628 Cochlear implant, external controller component, replacement  
L8679 Implantable neurostimulator, pulse generator, any type 1/1/18
L8680 Implantable neurostimulator electrode, each. Revised Code  
L8681 Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only  
L8682 Implantable neurostimulator radiofrequency receiver  
L8683 Radiofrequency transmitter (external) for use with implantable neurostimulator radiofrequency receiver  
L8684 Radiofrequency transmitter (external) for use with implantable sacral root neurostimulator receiver for bowel and bladder management, replacement  
L8685 Implantable neurostimulator pulse generator, single array, rechargeable, includes extension  
L8686 Implantable neurostimulator pulse generator, single array, non-rechargeable, includes extension  
L8687 Implantable neurostimulator pulse generator, dual array, rechargeable, includes extension  
L8688 Implantable neurostimulator pulse generator, dual array, non-rechargeable, includes extension  
L8689 External recharging system for battery (internal) for use with implantable neurostimulator, replacement only  
L8690 Auditory osseointegrated device, includes all internal and external components  
L8691 Auditory osseointegrated device, external sound processor, replacement  
L8692 Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment  
L9900 Orthotic and prosthetic supply, accessory, and/or service component of another hcpcs "l" code 1/1/18
S1040 Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s) 1/1/18

As EmblemHealth continues to upgrade its technology in the coming months, you will see new numbering formats for our referral and preauthorization transactions.

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EmblemHealth is simplifying our utilization management (UM) rules. We are reducing your need to seek pre-authorization (PA) based on the member’s type of plan (Commercial, Medicaid and Medicare) and the selected site of service.

The current PA list will be updated with 99 additional codes that have a site of service requirement on September 1, 2019 for HIP and HIPIC products. PA changes will be applied for GHI products starting on January 1, 2020 and monthly thereafter upon renewal.

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This is a complete list of all services requiring a Prior Approval for HIP members or a Pre-Certification for GHI members* (jointly referred to as "pre-authorization") subject to their benefit plan's coverage for all places of service, including Office (POS 11). The list accounts for EmblemHealth's medical policies, medical technology database, provider manual, and special utilization management programs. Pre-authorization is not a guarantee of payment. Payment is subject to a member's eligibility for benefits on the date of service. Emergency services do not require a pre-authorization

*GHI PPO City of New York employees and non-Medicare eligible retirees with GHI PPO benefits will be managed by Empire BCBS for inpatient and outpatient services. To see what needs authorization, use their look-up tool: https://www.empireblue.com/wps/portal/ehpprovider.

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Caring for your patients with behavioral health issues is important to their overall health. We are here to help you understand and address their health care needs.

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View Clinical Practice Guidelines, evidence-based recommendations to assist practitioners in determining what is covered in medical care under our health benefit plans. Providers will be notified of changes to the Clinical Practice Guidelines in the quarterly provider newsletter News&Notes and in the eNewsFlash. We recommend that network providers check this site monthly to stay current with any updates that are made.

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Drug Safety Communications for Q1 2017

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Drug Safety Communications for Q2 & Q3 of 2017

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View EmblemHealth's Medical Policies.
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A comprehensive listing of medical technologies reviewed by the Medical Policy Committee for coverage consideration. See the Medical Technologies Database.

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The EmblemHealth Commercial and Medicare formularies are compilations of brand and generic pharmaceuticals that have been identified as providing optimal results for plan members while controlling the cost of drug therapy. These formularies are updated regularly through formulary updates.
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EviCore is our vendor for the management of radiology and cardiac imaging procedures. EviCore works to improve utilization and enhance quality by integrating administrative management of patient-centered care.

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2016 Primary Care Physician incentive program for fee-for-service and ACPNY providers.

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EmblemHealth continues to partner with the provider community to continuously improve our members' quality of care and the overall patient experience.

EmblemHealth partners with Express Scripts to manage electronic prescriptions for our members.

E-prescribing is convenient, fast and secure and is mandated by the New York State Department of Health.

It helps you as the provider by eliminating the need to handwrite most prescriptions. It also reduces paperwork, faxes and follow-up phone calls. For more information about e-prescribing, contact Express Scripts at:

Phone: 800-411-1665
Web: Express-Scripts.com/physicians