Suggested HCPCS Code: L1830

• Universal sizing will fit most patients
• Elastic velcro straps allow for added compression
• Two movable stays for medial and lateral placement
• Contoured posterior stays for extra rigidity

Underlying Conditions:

• Knee Derangement
• ACL Tear
• Congenital Deformity of Knee Joint
• Chondromalacia of Patella
• Old Bucket Handle of Medial Meniscus
• Pathologic Fracture of Femur/Tibia/Fibula
• Disruption of MCL
• Rheumatoid Arthritis
• Osteoarthritis

Coverage Criteria:

• Recent knee injury or recent surgical procedure on knee

.

Suggested HCPCS Code: L1830

• Easy to fit with “slide to size” straps
• Dual cuffs and popliteal supports for exact immobilization
• Sleeve under brace for patient warmth
• Durable, comfortable and latex free

Underlying Conditions:

• Knee Derangement
• ACL Tear
• Congenital Deformity of Knee Joint
• Chondromalacia of Patella
• Old Bucket Handle of Medial Meniscus
• Pathologic Fracture of Femur/Tibia/Fibula
• Disruption of MCL
• Rheumatoid Arthritis
• Osteoarthritis

Coverage Criteria:

• Recent knee injury or recent surgical procedure on knee

Suggested HCPCS Code: L1831

• Easy to use pull ring and lock mechanism
• Six possible positions
• No additional tools necessary
• Removable, machine washable cover

Underlying Conditions:

• Knee Contracture

Coverage Criteria:

• Patient has flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees

Suggested HCPCS Code: E1810

• Goniometer dial can be set to a range of flexion or extension in 5° increments
• Provides excellent support for flaccid or weak extremities and helps immobilize painful extremities
• Patented malleable splint spine can bend to the desired ROM and the cuffs can adjusted for optimal fit.

Underlying Conditions:

• Knee Contracture

Coverage Criteria:

• Patient has flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees

Suggested HCPCS Code: L1831

• Provides prolonged low load passive stretch and treats hyper extension of the knee
• Adjustable dials allow gradual changes to move the joint toward normal alignment
• Brace provides 3-point leverage similar to manual stretching improving range of motion
• Padding provides comfort and redistributes skin pressure
• High-temperature plastic cuffs can be remolded to custom fit the patient’s upper and lower legs.

Underlying Conditions:

• Knee Contracture

Coverage Criteria:

• Patient has flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees

Suggested HCPCS Code: L1831

• X strap for complete knee range of motion
• Air technology uses 2 air bladders at the back of the leg to redistribute skin pressure
• Bilateral hinged uprights work with the air bladders to continue to move the joint toward normal alignment
• Hinges can be removed for the most severe flexion contracture and added as the range improves
• Soft, breathable fabric helps keep the patient’s leg cool and dry

Underlying Conditions:

• Knee Contracture

Coverage Criteria:

• Patient has flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees

Suggested HCPCS Code: L1831

• X strap for complete knee range of motion
• Adjustable dials lock in to apply mild stretch
• Side bars flex when patient draws inward, then brings the joint back to preset position
• Gradually reset dials to work joint toward normal alignment and re-lengthen shortened tissue

Underlying Conditions:

• Knee Contracture

Coverage Criteria:

• Patient has flexion or extension contractures of the knee with movement on passive range of motion testing of at least 10 degrees

Suggested HCPCS Code: L1845/L1852

• Sleek, low profile design
• Durable, lightweight aluminum construction
• Flexion (45°, 60°, 75°, 90°) and extension (0°, 10°, 20°, 30°, 40°) stops

Underlying Conditions:

• ACL Tear
• Congenital Deformity of Knee Joint
• Chondromalacia of Patella
• Old Bucket Handle of Medial Meniscus
• Pathologic Fracture of Femur/Tibia/Fibula
• Rheumatoid Arthritis
• Osteoarthritis

Coverage Criteria: Patient must meet one of the following criteria)

• Recent knee injury or Recent surgical procedure on knee
• Patient is ambulatory and has knee instability due to diagnosis stabilization

Suggested HCPCS Code: L1843/L1851

• Unique air blatter unloading
• Soft OA that reduces migration
• Single Upright ROM hinge
• Lightweight
• Comfortable
• Easy to use

Underlying Conditions:

• Congenital Deformity of Knee Joint
• Chondromalacia of Patella
• Old Bucket Handle of Medial Meniscus
• Pathologic Fracture of Femur/Tibia/Fibula
• Rheumatoid Arthritis
• Osteoarthritis

Coverage Criteria: Patient must meet one of the following criteria

• Recent knee injury or Recent surgical procedure on knee
• Patient is ambulatory and has knee instability due to diagnosis stabilization

Suggested HCPCS Code: L1843/L1851

• Design with quick release snaps for easy on-off
• Three point knee pressure reduction system
• Varus and Valgus adjustment for perfect alignment
• Easily adjust hinge setting

Underlying Conditions:

• Congenital Deformity of Knee Joint
• Chondromalacia of Patella
• Old Bucket Handle of Medial Meniscus
• Pathologic Fracture of Femur/Tibia/Fibula
• Rheumatoid Arthritis
• Osteoarthritis

Coverage Criteria: Patient must meet one of the following criteria

• Recent knee injury or Recent surgical procedure on knee
• Patient is ambulatory and has knee instability due to diagnosis stabilization

Suggested HCPCS Code: L1843/L1851

• 3-point fixation grasps medially and laterally for optimum off-loading force
• Adjustable flexion/extension control
• Low profile uprights, reduce hitting opposite knee especially for bi-lateral wearers
• Anterior/posterior calf/thigh straps secure uprights for proper alignment along sides of leg and helps prevent migration

Underlying Conditions:

• Osteoarthritis
• Congenital Deformity of Knee Joint
• Chondromalacia of Patella
• Old Bucket Handle of Medial Meniscus
• Pathologic Fracture of Femur/Tibia/Fibula
• Rheumatoid Arthritis

Coverage Criteria: Patient must meet one of the following criteria

• Recent knee injury or Recent surgical procedure on knee
• Patient is ambulatory and has knee instability due to diagnosis stabilization

Suggested HCPCS Code: L1820

• Wrap Design for customized fit
• Bilateral, Lightweight, Breathable
• Universal Sizing for a customized fit
• Available with patella stabilizing donut buttress

Underlying Conditions:

• Chronic Knee Instability
• Rheumatoid Arthritis
• Pathologic Fracture of Femur/Fibia/Fibula
• Congenital Deformity of Knee Joint
• Osteoarthritis
• Patella Fracture
• Derangement of Meniscus due to Tear or Injury

Coverage Criteria:

• Ambulatory patient with weakness or deformity of the knee requiring stabilization

Suggested HCPCS Code: L1820

• Wrap-around straps secure uprights/hinges in position and minimize migration.
• Soft popliteal knit prevents “bunching”
• Perforated, breathable skin-friendly neoprene with polycentric hinges
• Pressure relieving, stabilizing patella shaped silicone buttress

Underlying Conditions:

• Chronic Knee Instability
• Rheumatoid Arthritis
• Pathologic Fracture of Femur/Fibia/Fibula
• Congenital Deformity of Knee Joint
• Osteoarthritis
• Patella Fracture
• Derangement of Meniscus due to Tear or Injury

Coverage Criteria:

• Ambulatory patient with weakness or deformity of the knee requiring stabilization

Suggested HCPCS Code: L1832/L1833

• Wrap Design for customized fit
• Bilateral, Lightweight, Breathable
• Universal Sizing for a customized fit
• Easy to set hinges, no tools needed

Underlying Conditions:

• Congenital Deformity of Knee Joint
• Pathologic Fracture of Femur/Tibia/Fibula
• Patella Fracture
• Rheumatoid Arthritis
• Derangement of Meniscus Due to Tear or Injury
• Chondromalacia of Patella
• Osteoarthritis

Coverage Criteria: Patient must meet one of the following criteria

• Recent knee injury or recent surgical procedure on knee
• Patient is ambulatory and has knee instability due to diagnosis

Suggested HCPCS Code: L1832/L1833

• Snap-in flexion and extension stops included
• Soft popliteal knit prevents “bunching”
• Perforated, breathable skin-friendly neoprene with polycentric hinges
• Pressure relieving, stabilizing patella shaped silicone buttress

Underlying Conditions:

• Congenital Deformity of Knee Joint
• Pathologic Fracture of Femur/Tibia/Fibula
• Patella Fracture
• Rheumatoid Arthritis
• Derangement of Meniscus Due to Tear or Injury
• Chondromalacia of Patella
• Osteoarthritis

Coverage Criteria: Patient must meet one of the following criteria

• Recent knee injury or recent surgical procedure on knee
• Patient is ambulatory and has knee instability due to diagnosis

Post Op Hip Brace

Suggested HCPCS Code: L1686

• Designed to allow controlled hip flexion in 15 degree increments from -30 to 105 degrees
• Can be locking in any position from -30 degrees to 60 degrees
• Malleable arms bend for abduction purposes.
• Low profile design.
• Malleable waist and leg cuffs.

Underlying Conditions:

• Osteoarthritis of the hip
• Osteoarthritis Resulting from Hip Dysplasia
• Post Traumatic Osteoarthritis of Hip

Coverage Criteria: Item is for treatment of illness or injury or to improve function of hip. (Not preventative.)  

OA Unloader Hip Brace

Suggested HCPCS Code: L1690

• Comfortable Lycra, discreet under clothes
• Unique pulley system delivers compression where
• Control external hip rotation with rotation control strap

Underlying Conditions:

• Osteoarthritis of the hip
• Osteoarthritis Resulting from Hip Dysplasia
• Post Traumatic Osteoarthritis of Hip

Coverage Criteria: Item is for treatment of illness or injury or to improve function of hip. (Not preventative.)

Hip Knee Air Orthosis

Suggested HCPCS Code: L1652

• 4 air bladders (2 on each side) to redistribute skin pressure and gradually increase the hip’s range of motion
• Wide cuff straps provide comfort, increasing likelihood of patient compliance
• Spreader Bar Assembly with 3 choices of abductor-bar length provides greater hip abduction when needed
• Hand bulb air pump (included)
• Can be used in bed or in a wheelchair

Underlying Conditions:

• Osteoarthritis of the hip
• Hip contracture
• Hip adbuction
• Stress fracture of the hip

Coverage Criteria: Item is for treatment of illness or injury or to improve function of hip. (Not preventative.) 

 

Hyperextension ROM Elbow Brace

Suggested HCPCS Code: L3760/L3761

• Provides prolonged low load passive stretch and treats hyper extension of the elbow
• Adjustable dials allow gradual changes to move the joint toward normal alignment
• Brace provides 3-point leverage similar to manual stretching, improving range of motion
• Padding provides comfort and redistributes skin pressure

Underlying Conditions:

• Elbow Contracture
• Rheumatoid Arthritis
• Hemarthrosis of Elbow
• Felty’s Syndrome of Elbow

Coverage Criteria: 

• Item is for treatment of illness or injury or to improve function of elbow. (Not preventative.)  

 

ROM Padded Air Elbow Brace

Suggested HCPCS Code: L3760/L3761

• Air technology uses an air bladder at the inside of the elbow, positioned parallel to the arm to redistribute skin pressure
• Bilateral hinged uprights work with the air bladders to continue to move the joint toward normal alignment
• Hinges can be removed for the most severe flexion and added as the range improves

Underlying Conditions:

• Elbow Contracture
• Rheumatoid Arthritis
• Hemarthrosis of Elbow
• Felty’s Syndrome of Elbow

Coverage Criteria: 

• Item is for treatment of illness or injury or to improve function of elbow. (Not preventative.)  

Padded Elbow Brace

Suggested HCPCS Code: L3760/L3761

• Adjustable dials allow gradual changes to move joint toward normal alignment
• High-temperature plastic cuffs can be remolded to custom fit patient’s upper and lower arms
• Flex Technology splint moves with the patient’s abnormal muscle tone/spasticity
• Padding provides comfort and redistributes skin pressure
• Brace provides 3-point leverage similar to manual stretching, improving range of motion
• Lower cuff swivels to allow for varying degrees of flexion

*Available in more sizes as well as custom sizing. 

Underlying Conditions:

• Elbow Contracture
• Rheumatoid Arthritis
• Hemarthrosis of Elbow
• Felty’s Syndrome of Elbow

Coverage Criteria: 

• Item is for treatment of illness or injury or to improve function of elbow. (Not preventative.) 

Contracture Locking Elbow Orthosis

Suggested HCPCS Code: L3760/L3761

• Assists with elbow extension Easy to use pull ring and lock mechanism Six possible positions No additional tools necessary.

Underlying Conditions:

• Elbow Contracture
• Rheumatoid Arthritis
• Hemarthrosis of Elbow
• Felty’s Syndrome of Elbow

Coverage Criteria: 

• Item is for treatment of illness or injury or to improve function of elbow. (Not preventative.)  

Humeral Fracture Shoulder Brace

Suggested HCPCS Code: L3980

• Lightweight, durable, and cannot absorb moisture
• Trimmable polyethylene and lined with closed-cell foam
• Allows a range of motion at the shoulder and elbow

Underlying Conditions:

• Fracture of the shaft of the Humerus
• Fracture of the surgical neck of Humerus
• Displaced fracture of the tuberosity of Humerus

Coverage Criteria: 

• Item is for treatment of illness or injury or to improve function of upper body. (Not preventative.)

Shoulder Abduction Brace

Suggested HCPCS Code: L3960

• Aluminum waistband is moldable to patient torso and prevents anterior migration
• Brace positions include gunslinger, neutral plane and external rotation
• One-hand buckles ease patient reapplication
• Universal sling design to fit every patient with one brace
• Unique pistol grip adjusts with quick-pull tabs and keeps the arm from migrating forward out of the sling

Underlying Conditions:

• Frozen Shoulder
• Primary Osteoarthritis
• Shoulder Bicipital Tendinitis
• Shoulder Post Traumatic Osteoarthritis
• Impingement Syndrome
• Arthritis of Shoulder

Coverage Criteria: 

• Item is for treatment of illness or injury or to improve function of upper body. (Not preventative.)

GivMohr Sling

Suggested HCPCS Code: L3670

• Sling is available in 2 styles. One arm or bilateral
• Improves gait and balance
• Supports arm(s) in a functional position
• Reduced shoulder subluxation and shoulder pain
• Allows controlled arm swing

Underlying Conditions:

• Frozen Shoulder
• Primary Osteoarthritis
• Shoulder Subluxation
• Impingement Syndrome
• Arthritis of Shoulder
• Brachial Plexis Injury
• Post Polio Syndrome
• Transverse Myelitis
• Central Cord Syndrome

Coverage Criteria: 

• Item is for treatment of illness or injury or to improve function of upper body. (Not preventative.) 

Shoulder Immobilizer with Waist Strap

Suggested HCPCS Code: L3670

• Soft cotton/poly blend for increased comfort
• Removable foam waist strap
• D-ring on strap for easy adjustment
• Fits right or left arm

Underlying Conditions:

• Fracture of Shaft of Clavicle
• Fracture of Sternal End of Clavicle
• Sprain of the Shoulder or Elbow
• Stiffness of Shoulder not Elsewhere Classified
• Elbow Fracture
• Ulna Fracture

Coverage Criteria: 

• Item is for treatment of illness or injury or to improve function of upper body. (Not preventative.)

 

Dorsal Night Splint

Suggested HCPCS Code: L4396/L4397

• Soft, flexible brace
• Easily fasten and adjust with Velcro closures
• Gentle stretch provided through simple dorsiflexion strap
• Fits either left or right foot

Underlying Conditions:

• Plantar Fascial Fibromatosis
• Contracture of Ankle
• Contracture of Foot
• Cervical Disc Disorder with Radiculopathy/Myelopathy

Coverage Criteria: (Patient must meet one of the following criteria)

• Plantar Fasciitis

Or all of the following:

• Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees.
• Reasonable expectation of the ability to correct the contracture
• Contracture is interfering/expected to interfere significantly with functional abilities
• Splint is used as part of therapy program including active stretching of the involved muscles/tendons

 

Posterior Night Splint

Suggested HCPCS Code: L4396/L4397

• Essential treatment for alleviation of night time plantar fasciitis pain
• Three padded straps with buckles to ensure immobilization
• Dual tension straps allow for increased flexion and foot angle for the optimum pain-relieving stretch
• Lightweight night splint, low profile shell is sturdy
• and breathable for proper plantar fasciitis treatment

Underlying Conditions:

• Plantar Fascial Fibromatosis
• Contracture of Ankle
• Contracture of Foot

Coverage Criteria: (Patient must meet one of the following criteria)

• Plantar Fasciitis

Or all of the following:

• Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees.
• Reasonable expectation of the ability to correct the contracture
• Contracture is interfering/expected to interfere significantly with functional abilities
• Splint is used as part of therapy program including active stretching of the involved muscles/tendons

 

Multi PODUS Boot

Suggested HCPCS Code: L4396/L4397

• Flex Technology splint moves with the patient’s abnormal muscle tone and spasticity for comfort and helps to relax the abnormal muscle tone
• Anti-rotation bar prevents rolling of the patient’s leg
• Non-slip sole allows brief standing and walking
• Dorsiflexion assist (flex) straps (aid in proper alignment of the foot and adjustable tension helps to control plantar flexion
• Toe support has “toe off” angle to assist in gait training and short ambulation
• Available in fleece lining
• Available with Flo Form

Underlying Conditions:

• Plantar Fascial Fibromatosis
• Contracture of Ankle
• Contracture of Foot

Coverage Criteria: (Patient must meet one of the following criteria)

• Plantar Fasciitis

Or all of the following:

• Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees.
• Reasonable expectation of the ability to correct the contracture
• Contracture is interfering/expected to interfere significantly with functional abilities
• Splint is used as part of therapy program including active stretching of the involved muscles/tendons

Equinus Brace

Suggested HCPCS Code: L4396 & L2210x2

• Only dorsiflexion brace that fully extends the leg
• Ensures gastric-soleus stretch
• Controls ankle joint placement
• Engages windlass mechanism

Underlying Conditions:

• Plantar Fascial Fibromatosis
• Contracture of Ankle
• Contracture of Foot

Coverage Criteria: (Patient must meet one of the following criteria)

• Plantar Fasciitis

Or all of the following:

• Plantar flexion contracture of the ankle with dorsiflexion on passive range of motion testing (using Goniometer) of at least 10 degrees.
• Reasonable expectation of the ability to correct the contracture
• Contracture is interfering/expected to interfere significantly with functional abilities
• Splint is used as part of therapy program including active stretching of the involved muscles/tendons

 

Air Cam Walker (High or Low)

Suggested HCPCS Code: L4360/L4361

• Air bladders for customized compression
• Hook and fastening straps for quick, easy fitting and adjustments
• Velcro straps and padded insole for comfort and fit
• Fits either left or right foot

Underlying Conditions:

• Ankle Sprain
• Ankle Fracture
• Foot Fracture
• Tendinitis
• Flexion Deformity
• Plantar Fascitis
• Ankle Instability

Coverage Criteria: 

• Patient is ambulatory with weakness or deformity of the foot and ankle requiring stabilization for medical reasons and has the potential to benefit functionally from the boot