Braces; trusses; and artifical legs, arms, and eyes are covered when furnished incident to a physician’s services or on a physician’s order. A brace includes rigid and semirigid devices used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body. Back braces include, but are not limited to, sacroiliac, sacrolumbar, dorsolumbar corsets, and belts. Stump stockings and harnesses (including replacements) are also covered when these appliances are essential to the effective use of an artificial limb. Adjustments to an artificial limb or other appliance required by wear or by a change in the patient’s condition are covered when ordered by a physician. Adjustments, repairs, and replacements are covered so long as the device continues to be medically required.
Kafo, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment
Kafo, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment
Addition to lower extremity fracture orthosis, plastic shoe insert with ankle joints
Addition to lower extremity fracture orthosis, drop lock knee joint
Addition to lower extremity fracture orthosis, limited motion knee joint
Addition to lower extremity fracture orthosis, adjustable motion knee joint, lerman type
Addition to lower extremity fracture orthosis, quadrilateral brim
Addition to lower extremity fracture orthosis, waist belt
Addition to lower extremity fracture orthosis, hip joint, pelvic band, thigh flange, and pelvic belt
Addition to lower extremity, limited ankle motion, each joint
Continued
Addition to lower extremity, dorsiflexion assist (plantar flexion resist), each joint
Addition to lower extremity, dorsiflexion and plantar flexion assist/resist, each joint
Addition to lower extremity orthosis, ankle system, microprocessor-controlled feature plantarflexion and/or dorsiflexion, includes power source
New
Addition to lower extremity, split flat caliper stirrups and plate attachment
Addition to lower extremity orthosis, rocker bottom for total contact ankle foot orthosis, for custom fabricated orthosis only
Addition to lower extremity, round caliper and plate attachment
Addition to lower extremity, foot plate, molded to patient model, stirrup attachment
Addition to lower extremity, reinforced solid stirrup (scott-craig type)
Addition to lower extremity, long tongue stirrup
Addition to lower extremity, varus/valgus correction ('t') strap, padded/lined or malleolus pad
Addition to lower extremity, varus/valgus correction, plastic modification, padded/lined
Addition to lower extremity, molded inner boot
Addition to lower extremity, abduction bar (bilateral hip involvement), jointed, adjustable
Addition to lower extremity, abduction bar-straight
Addition to lower extremity, non-molded lacer, for custom fabricated orthosis only
Addition to lower extremity, lacer molded to patient model, for custom fabricated orthosis only
Addition to lower extremity, anterior swing band
Addition to lower extremity, pre-tibial shell, molded to patient model
Addition to lower extremity, prosthetic type, (bk) socket, molded to patient model, (used for 'ptb' 'afo' orthoses)
Addition to lower extremity, extended steel shank
Continued
Addition to lower extremity, patten bottom
Addition to lower extremity, torsion control, ankle joint and half solid stirrup
Addition to lower extremity, torsion control, straight knee joint, each joint
Addition to lower extremity, straight knee joint, heavy duty, each joint
Addition to lower extremity, polycentric knee joint, for custom fabricated knee ankle foot orthosis, each joint
Addition to lower extremity, offset knee joint, each joint
Addition to lower extremity, offset knee joint, heavy duty, each joint
Addition to lower extremity orthosis, suspension sleeve
Addition to knee joint, drop lock, each
Addition to knee lock with integrated release mechanism (bail, cable, or equal), any material, each joint
Addition to knee joint, disc or dial lock for adjustable knee flexion, each joint
Addition to knee joint, ratchet lock for active and progressive knee extension, each joint
Addition to knee joint, lift loop for drop lock ring
Addition to lower extremity, thigh/weight bearing, gluteal/ ischial weight bearing, ring
Addition to lower extremity, thigh/weight bearing, quadri- lateral brim, molded to patient model
Addition to lower extremity, thigh/weight bearing, quadri- lateral brim, custom fitted
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim molded to patient model
Addition to lower extremity, thigh/weight bearing, ischial containment/narrow m-l brim, custom fitted
Addition to lower extremity, thigh-weight bearing, lacer, non-molded
Addition to lower extremity, thigh/weight bearing, lacer, molded to patient model