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.


  • L3170

    Foot, plastic, silicone or equal, heel stabilizer, prefabricated, off-the-shelf, each
  • L3201

    Orthopedic shoe, oxford with supinator or pronator, infant
  • L3202

    Orthopedic shoe, oxford with supinator or pronator, child
  • L3203

    Orthopedic shoe, oxford with supinator or pronator, junior
  • L3204

    Orthopedic shoe, hightop with supinator or pronator, infant
  • L3206

    Orthopedic shoe, hightop with supinator or pronator, child
  • L3207

    Orthopedic shoe, hightop with supinator or pronator, junior
  • L3208

    Surgical boot, each, infant
  • L3209

    Surgical boot, each, child
  • L3211

    Surgical boot, each, junior


  • Continued
  • L3212

    Benesch boot, pair, infant
  • L3213

    Benesch boot, pair, child
  • L3214

    Benesch boot, pair, junior
  • L3215

    Orthopedic footwear, ladies shoe, oxford, each
  • L3216

    Orthopedic footwear, ladies shoe, depth inlay, each
  • L3217

    Orthopedic footwear, ladies shoe, hightop, depth inlay, each
  • L3219

    Orthopedic footwear, mens shoe, oxford, each
  • L3221

    Orthopedic footwear, mens shoe, depth inlay, each
  • L3222

    Orthopedic footwear, mens shoe, hightop, depth inlay, each
  • L3224

    Orthopedic footwear, woman's shoe, oxford, used as an integral part of a brace (orthosis)
  • L3225

    Orthopedic footwear, man's shoe, oxford, used as an integral part of a brace (orthosis)
  • L3230

    Orthopedic footwear, custom shoe, depth inlay, each
  • L3250

    Orthopedic footwear, custom molded shoe, removable inner mold, prosthetic shoe, each
  • L3251

    Foot, shoe molded to patient model, silicone shoe, each
  • L3252

    Foot, shoe molded to patient model, plastazote (or similar), custom fabricated, each
  • L3253

    Foot, molded shoe plastazote (or similar) custom fitted, each
  • L3254

    Non-standard size or width
  • L3255

    Non-standard size or length
  • L3257

    Orthopedic footwear, additional charge for split size
  • L3260

    Surgical boot/shoe, each


  • Continued
  • L3265

    Plastazote sandal, each
  • L3300

    Lift, elevation, heel, tapered to metatarsals, per inch
  • L3310

    Lift, elevation, heel and sole, neoprene, per inch
  • L3320

    Lift, elevation, heel and sole, cork, per inch
  • L3330

    Lift, elevation, metal extension (skate)
  • L3332

    Lift, elevation, inside shoe, tapered, up to one-half inch
  • L3334

    Lift, elevation, heel, per inch
  • L3340

    Heel wedge, sach
  • L3350

    Heel wedge
  • L3360

    Sole wedge, outside sole
  • L3370

    Sole wedge, between sole
  • L3380

    Clubfoot wedge
  • L3390

    Outflare wedge
  • L3400

    Metatarsal bar wedge, rocker
  • L3410

    Metatarsal bar wedge, between sole
  • L3420

    Full sole and heel wedge, between sole
  • L3430

    Heel, counter, plastic reinforced
  • L3440

    Heel, counter, leather reinforced
  • L3450

    Heel, sach cushion type
  • L3455

    Heel, new leather, standard