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L3201 |
 |
Orthopedic shoe, oxford with supinator or pronator, infant
| short | Oxford w supinat/pronat inf |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3202 |
|
Orthopedic shoe, oxford with supinator or pronator, child
| short | Oxford w/ supinat/pronator c |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3203 |
|
Orthopedic shoe, oxford with supinator or pronator, junior
| short | Oxford w/ supinator/pronator |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3204 |
|
Orthopedic shoe, hightop with supinator or pronator, infant
| short | Hightop w/ supp/pronator inf |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3206 |
|
Orthopedic shoe, hightop with supinator or pronator, child
| short | Hightop w/ supp/pronator chi |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3207 |
|
Orthopedic shoe, hightop with supinator or pronator, junior
| short | Hightop w/ supp/pronator jun |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3208 |
|
Surgical boot, each, infant
| short | Surgical boot each infant |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3209 |
|
Surgical boot, each, child
| short | Surgical boot each child |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3211 |
|
Surgical boot, each, junior
| short | Surgical boot each junior |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3212 |
|
Benesch boot, pair, infant
| short | Benesch boot pair infant |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3213 |
|
Benesch boot, pair, child
| short | Benesch boot pair child |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3214 |
|
Benesch boot, pair, junior
| short | Benesch boot pair junior |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3215 |
|
Orthopedic footwear, ladies shoe, oxford, each
| short | Orthopedic ftwear ladies oxf |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 0.0 | 3 Date of Service Edit: Clinical | Published Contractor Policy |
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L3216 |
|
Orthopedic footwear, ladies shoe, depth inlay, each
| short | Orthoped ladies shoes dpth i |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3217 |
|
Orthopedic footwear, ladies shoe, hightop, depth inlay, each
| short | Ladies shoes hightop depth i |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3219 |
|
Orthopedic footwear, mens shoe, oxford, each
| short | Orthopedic mens shoes oxford |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 0.0 | 3 Date of Service Edit: Clinical | Published Contractor Policy |
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L3221 |
|
Orthopedic footwear, mens shoe, depth inlay, each
| short | Orthopedic mens shoes dpth i |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3222 |
|
Orthopedic footwear, mens shoe, hightop, depth inlay, each
| short | Mens shoes hightop depth inl |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 2.0 | 2 Date of Service Edit: Policy | Anatomic Consideration |
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L3224 |
|
Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis)
| short | Woman's shoe oxford brace |
| 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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L3225 |
|
Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)
| short | Man's shoe oxford brace |
| 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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L3230 |
|
Orthopedic footwear, custom shoe, depth inlay, each
| short | Custom shoes depth inlay |
| 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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L3250 |
|
Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
| short | Custom mold shoe remov prost |
| 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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L3251 |
|
Foot, shoe molded to patient model, silicone shoe, each
| short | Shoe molded to pt silicone s |
| 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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L3252 |
|
Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each
| short | Shoe molded plastazote cust |
| 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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L3253 |
|
Foot, molded shoe plastazote (or similar) custom fitted, each
| short | Shoe molded plastazote cust |
| 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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|
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L3254 |
|
Non-standard size or width
| short | Orth foot non-stndard size/w |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
|
|
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L3255 |
|
Non-standard size or length
| short | Orth foot non-standard size/ |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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L3257 |
|
Orthopedic footwear, additional charge for split size
| short | Orth foot add charge split s |
| 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: CMS Workgroup | | DME | 1.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
|
|
|
|
L3260 |
|
Surgical boot/shoe, each
| short | Ambulatory surgical boot eac |
| MUE | | Location | Value | Ajudication Indicator | Rationale |
|---|
| PRA | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | OPH | 0.0 | 3 Date of Service Edit: Clinical | CMS Policy | | DME | 0.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
|
|
|
|
L3265 |
|
Plastazote sandal, each
| short | Plastazote sandal each |
| 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 | 0.0 | 3 Date of Service Edit: Clinical | Clinical: CMS Workgroup |
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