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L3702 |
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Elbow orthosis, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Eo w/o joints cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3710 |
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Elbow orthosis, elastic with metal joints, prefabricated, off-the-shelf
| short | Eo elas w/metal jnts pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3720 |
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Elbow orthosis, double upright with forearm/arm cuffs, free motion, custom fabricated
| short | Forearm/arm cuffs free motio |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3730 |
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Elbow orthosis, double upright with forearm/arm cuffs, extension/ flexion assist, custom fabricated
| short | Forearm/arm cuffs ext/flex a |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3740 |
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Elbow orthosis, double upright with forearm/arm cuffs, adjustable position lock with active control, custom fabricated
| short | Cuffs adj lock w/ active con |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3760 |
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Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
| short | Eo adj jt prefab custom fit |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3761 |
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Elbow orthosis (eo), with adjustable position locking joint(s), prefabricated, off-the-shelf
| short | Eo, adj lock joint prefab ot |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3762 |
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Elbow orthosis, rigid, without joints, includes soft interface material, prefabricated, off-the-shelf
| short | Eo rigid w/o joints pre ots |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3763 |
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Elbow wrist hand orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Ewho rigid w/o jnts cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3764 |
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Elbow wrist hand orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Ewho w/joint(s) cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3765 |
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Elbow wrist hand finger orthosis, rigid, without joints, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Ewhfo rigid w/o jnts cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3766 |
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Elbow wrist hand finger orthosis, includes one or more nontorsion joints, elastic bands, turnbuckles, may include soft interface, straps, custom fabricated, includes fitting and adjustment
| short | Ewhfo w/joint(s) cf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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