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.
Preparatory, below knee 'ptb' type socket, non-alignable system, pylon, no cover, sach foot, laminated socket, molded to model
Preparatory, above knee- knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, plaster socket, molded to model
Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, direct formed
Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon, no cover, sach foot, thermoplastic or equal, molded to model
Preparatory, above knee - knee disarticulation, ischial level socket, non-alignable system, pylon, no cover, sach foot, prefabricated adjustable open end socket
Preparatory, above knee - knee disarticulation ischial level socket, non-alignable system, pylon no cover, sach foot, laminated socket, molded to model
Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, thermoplastic or equal, molded to patient model
Preparatory, hip disarticulation-hemipelvectomy, pylon, no cover, sach foot, laminated socket, molded to patient model
Addition to lower extremity, endoskeletal system, above knee, hydracadence system
Addition to lower extremity, endoskeletal system, above knee - knee disarticulation, 4 bar linkage, with friction swing phase control
Continued
Addition to lower extremity, endoskeletal system, above knee-knee disarticulation, 4 bar linkage, with hydraulic swing phase control
Addition to lower extremity, exoskeletal system, above knee-knee disarticulation, 4 bar linkage, with pneumatic swing phase control
Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control
Addition to lower extremity, endoskeletal system, above knee, universal multiplex system, friction swing phase control
Addition to lower extremity, quick change self-aligning unit, above knee or below knee, each
Addition to lower extremity, test socket, symes
Addition to lower extremity, test socket, below knee
Addition to lower extremity, test socket, knee disarticulation
Addition to lower extremity, test socket, above knee
Addition to lower extremity, test socket, hip disarticulation
Addition to lower extremity, test socket, hemipelvectomy
Addition to lower extremity, below knee, acrylic socket
Addition to lower extremity, symes type, expandable wall socket
Addition to lower extremity, above knee or knee disarticulation, acrylic socket
Addition to lower extremity, symes type, 'ptb' brim design socket
Addition to lower extremity, symes type, posterior opening (canadian) socket
Addition to lower extremity, symes type, medial opening socket
Addition to lower extremity, below knee, total contact
Addition to lower extremity, below knee, leather socket
Addition to lower extremity, below knee, wood socket
Continued
Addition to lower extremity, knee disarticulation, leather socket
Addition to lower extremity, above knee, leather socket
Addition to lower extremity, hip disarticulation, flexible inner socket, external frame
Addition to lower extremity, above knee, wood socket
Addition to lower extremity, below knee, flexible inner socket, external frame
Addition to lower extremity, below knee, air, fluid, gel or equal, cushion socket
Addition to lower extremity, below knee suction socket
Addition to lower extremity, above knee, air, fluid, gel or equal, cushion socket
Addition to lower extremity, ischial containment/narrow m-l socket
Additions to lower extremity, total contact, above knee or knee disarticulation socket
Addition to lower extremity, above knee, flexible inner socket, external frame
Addition to lower extremity, suction suspension, above knee or knee disarticulation socket
Addition to lower extremity, knee disarticulation, expandable wall socket
Addition to lower extremity, socket insert, symes, (kemblo, pelite, aliplast, plastazote or equal)
Addition to lower extremity, socket insert, below knee (kemblo, pelite, aliplast, plastazote or equal)
Addition to lower extremity, socket insert, knee disarticulation (kemblo, pelite, aliplast, plastazote or equal)
Addition to lower extremity prosthesis, manual/automated adjustable air, fluid, gel or equal socket insert for limb volume management, any materials
Addition to lower extremity, socket insert, above knee (kemblo, pelite, aliplast, plastazote or equal)
Addition to lower extremity, socket insert, multi-durometer symes
Addition to lower extremity, socket insert, multi-durometer, below knee