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L3650 |
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Shoulder orthosis, figure of eight design abduction restrainer, prefabricated, off-the-shelf
| short | So 8 abd restraint pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment | | DME | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
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L3660 |
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Shoulder orthosis, figure of eight design abduction restrainer, canvas and webbing, prefabricated, off-the-shelf
| short | So 8 ab rstr can/web pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment | | DME | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
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L3670 |
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Shoulder orthosis, acromio/clavicular (canvas and webbing type), prefabricated, off-the-shelf
| short | So acro/clav can web pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment | | DME | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
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L3671 |
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Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | So cap design w/o jnts cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment | | DME | 1.0 | 3 Date of Service Edit: Clinical | Nature of Equipment |
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L3674 |
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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
| short | So airplane w/wo joint cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 3 Date of Service Edit: Clinical | Clinical: Data | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: Data |
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L3675 |
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Shoulder orthosis, vest type abduction restrainer, canvas webbing type or equal, prefabricated, off-the-shelf
| short | So vest canvas/web pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment | | DME | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
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L3677 |
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Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
| short | So hard plas stabili pre cst |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment | | DME | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
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L3678 |
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Shoulder orthosis, shoulder joint design, without joints, may include soft interface, straps, prefabricated, off-the-shelf
| short | So hard plas stabili pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment | | DME | 1.0 | 2 Date of Service Edit: Policy | Nature of Equipment |
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