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.
Addition to lower extremity, thigh/weight bearing, high roll cuff
Addition to lower extremity, pelvic control, hip joint, clevis type two position joint, each
Addition to lower extremity, pelvic control, pelvic sling
Addition to lower extremity, pelvic control, hip joint, clevis type, or thrust bearing, free, each
Addition to lower extremity, pelvic control, hip joint, clevis or thrust bearing, lock, each
Addition to lower extremity, pelvic control, hip joint, heavy duty, each
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, each
Addition to lower extremity, pelvic control, hip joint, adjustable flexion, extension, abduction control, each
Addition to lower extremity, pelvic control, plastic, molded to patient model, reciprocating hip joint and cables
Addition to lower extremity, pelvic control, metal frame, reciprocating hip joint and cables
Continued
Addition to lower extremity, pelvic control, band and belt, unilateral
Addition to lower extremity, pelvic control, band and belt, bilateral
Addition to lower extremity, pelvic and thoracic control, gluteal pad, each
Addition to lower extremity, thoracic control, thoracic band
Addition to lower extremity, thoracic control, paraspinal uprights
Addition to lower extremity, thoracic control, lateral support uprights
Addition to lower extremity orthosis, plating chrome or nickel, per bar
Addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, per segment, for custom fabricated orthosis only
Addition to lower extremity orthosis, extension, per extension, per bar (for lineal adjustment for growth)
Orthotic side bar disconnect device, per bar
Addition to lower extremity orthosis, non-corrosive finish, per bar
Addition to lower extremity orthosis, drop lock retainer, each
Addition to lower extremity orthosis, knee control, full kneecap
Addition to lower extremity orthosis, knee control, knee cap, medial or lateral pull, for use with custom fabricated orthosis only
Addition to lower extremity orthosis, knee control, condylar pad
Addition to lower extremity orthosis, soft interface for molded plastic, below knee section
Addition to lower extremity orthosis, soft interface for molded plastic, above knee section
Addition to lower extremity orthosis, tibial length sock, fracture or equal, each
Addition to lower extremity orthosis, femoral length sock, fracture or equal, each
Addition to lower extremity joint, knee or ankle, concentric adjustable torsion style mechanism for custom fabricated orthotics only, each
Continued
Lower extremity orthoses, not otherwise specified
Foot, insert, removable, molded to patient model, 'ucb' type, berkeley shell, each
Foot, insert, removable, molded to patient model, spenco, each
Foot, insert, removable, molded to patient model, plastazote or equal, each
Foot, insert, removable, molded to patient model, silicone gel, each
Foot, insert, removable, molded to patient model, longitudinal arch support, each
Foot, insert, removable, molded to patient model, longitudinal/ metatarsal support, each
Foot, insert, removable, formed to patient foot, each
Foot, insert/plate, removable, addition to lower extremity orthosis, high strength, lightweight material, all hybrid lamination/prepreg composite, each
Foot, arch support, removable, premolded, longitudinal, each
Foot, arch support, removable, premolded, metatarsal, each
Foot, arch support, removable, premolded, longitudinal/ metatarsal, each
Foot, arch support, non-removable attached to shoe, longitudinal, each
Foot, arch support, non-removable attached to shoe, metatarsal, each
Foot, arch support, non-removable attached to shoe, longitudinal/metatarsal, each
Hallus-valgus night dynamic splint, prefabricated, off-the-shelf
Foot, abduction rotation bar, including shoes
Foot, abduction rotation bar, without shoes
Foot, adjustable shoe-styled positioning device
Foot, adductus positioning device, adjustable