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.


  • L1220

    Addition to tlso, (low profile), anterior thoracic extension
  • L1230

    Addition to tlso, (low profile), milwaukee type superstructure
  • L1240

    Addition to tlso, (low profile), lumbar derotation pad
  • L1250

    Addition to tlso, (low profile), anterior asis pad
  • L1260

    Addition to tlso, (low profile), anterior thoracic derotation pad
  • L1270

    Addition to tlso, (low profile), abdominal pad
  • L1280

    Addition to tlso, (low profile), rib gusset (elastic), each
  • L1290

    Addition to tlso, (low profile), lateral trochanteric pad
  • L1300

    Other scoliosis procedure, body jacket molded to patient model
  • L1310

    Other scoliosis procedure, post-operative body jacket


  • Continued
  • L1499

    Spinal orthosis, not otherwise specified
  • L1600

    Hip orthosis, abduction control of hip joints, flexible, frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an inidividual with expertise
  • L1610

    Hip orthosis, abduction control of hip joints, flexible, (frejka cover only), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1620

    Hip orthosis, abduction control of hip joints, flexible, (pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1630

    Hip orthosis, abduction control of hip joints, semi-flexible (von rosen type), custom fabricated
  • L1640

    Hip orthosis, abduction control of hip joints, static, pelvic band or spreader bar, thigh cuffs, custom fabricated
  • L1650

    Hip orthosis, abduction control of hip joints, static, adjustable, (ilfled type), prefabricated, includes fitting and adjustment
  • L1652

    Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type
  • L1660

    Hip orthosis, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment
  • L1680

    Hip orthosis, abduction control of hip joints, dynamic, pelvic control, adjustable hip motion control, thigh cuffs (rancho hip action type), custom fabricated
  • L1681

    Hip orthosis, bilateral hip joints and thigh cuffs, adjustable flexion, extension, abduction control of hip joint, postoperative hip abduction type, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1685

    Hip orthosis, abduction control of hip joint, postoperative hip abduction type, custom fabricated
  • L1686

    Hip orthosis, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment
  • L1690

    Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment
  • L1700

    Legg perthes orthosis, (toronto type), custom fabricated
  • L1710

    Legg perthes orthosis, (newington type), custom fabricated
  • L1720

    Legg perthes orthosis, trilateral, (tachdijan type), custom fabricated
  • L1730

    Legg perthes orthosis, (scottish rite type), custom fabricated
  • L1755

    Legg perthes orthosis, (patten bottom type), custom fabricated
  • L1810

    Knee orthosis, elastic with joints, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise


  • Continued
  • L1812

    Knee orthosis, elastic with joints, prefabricated, off-the-shelf
  • L1820

    Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment
  • L1830

    Knee orthosis, immobilizer, canvas longitudinal, prefabricated, off-the-shelf
  • L1831

    Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment
  • L1832

    Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1833

    Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf
  • L1834

    Knee orthosis, without knee joint, rigid, custom fabricated
  • L1836

    Knee orthosis, rigid, without joint(s), includes soft interface material, prefabricated, off-the-shelf
  • L1840

    Knee orthosis, derotation, medial-lateral, anterior cruciate ligament, custom fabricated
  • L1843

    Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1844

    Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
  • L1845

    Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1846

    Knee orthosis, double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, custom fabricated
  • L1847

    Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1848

    Knee orthosis, double upright with adjustable joint, with inflatable air support chamber(s), prefabricated, off-the-shelf
  • L1850

    Knee orthosis, swedish type, prefabricated, off-the-shelf
  • L1851

    Knee orthosis (ko), single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
  • L1852

    Knee orthosis (ko), double upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf
  • L1860

    Knee orthosis, modification of supracondylar prosthetic socket, custom fabricated (sk)
  • L1900

    Ankle foot orthosis, spring wire, dorsiflexion assist calf band, custom fabricated