ModifiedAlliance HealthPolicy 5B

Orthotics & Prosthetics coverage

Defines Medicaid coverage, requirements, and prior authorization processes for orthotic and prosthetic devices provided to North Carolina Medicaid beneficiaries, including EPSDT exceptions for those under 21.

Policy Summary

PayerAlliance Health

PolicyOrthotics & Prosthetics coverage

Policy CodePolicy 5B

Change TypeAttachment B HCPCS, credential, and quantity updates

Effective Date

Next Review Date

Key ActionObtain prior authorization via NCTracks for unlisted items, overrides, and non-warranty repairs and submit CMN/PA with supporting documentation.

SourceLink

POLICY UPDATE CHANGES

Clarified documentation criteria for medical justification of the flex-foot system and removed a brand reference.

Updated ICD-10-CM code lists for diabetic shoes, ankle/foot orthoses, prosthetic shoes, and external breast prostheses, with multiple unspecified codes deleted and diabetes codes added.

Extensive updates to Attachment B: HCPCS code descriptions, provider credential mappings, lifetime expectancies, quantity limitations, and removal/addition of codes and credentials.

Added Doctor of Podiatric Medicine (DPM) as an accepted provider type for many HCPCS codes and updated related provider qualification sections.

Changed lifetime expectancy and quantity limits for specific HCPCS codes (e.g., L2755; multiple prosthetic codes now have '2 per 6 months' rather than '6 months all ages').

Removed references to asterisks and plus signs indicating prior approval requirements from the Orthotics and Prosthetics fee schedule.

Renamed 'Cranial Orthosis for Plagiocephaly' to 'Cranial Remolding Orthosis' and divided Helmets into Cranial Protection and Cranial Remolding Orthosis with updated medical necessity criteria.

Changed lifetime expectancy of HCPCS code S1040 from '0-12 months' to '0-18 months' to align with updated cranial remolding criteria.

Updated multiple HCPCS codes to align with CMS 2024 annual HCPCS code updates (e.g., K1022 replaced with L5926; several A65xx and L18xx/L37xx splits and additions).

Removed several provider certifications from specific HCPCS codes where those certifications fall outside scope of practice (multiple codes listed).

Updated Place of Service list to include specific place codes (12, 04, 13, 14, 33, 34).

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Attachment BAttachment B

Under 21EPSDT

RequiredPrior Approval

Covered w/criteriaCoverage stance

6 monthsFace-to-face

HCPCS 2024HCPCS updates (2024)

Coverage Criteria and Medical Necessity

General Criteria Covered

Covered when ALL of the following are met

General coverage: a. The procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis and not in excess of the beneficiary's needs; b. The procedure, product, or service can be safely furnished and no equally effective, more conservative, or less costly treatment is available statewide; c. The procedure, product, or service is furnished not primarily for the convenience of the beneficiary, caretaker, or provider; d. The device is prescribed by the beneficiary's treating physician, physician assistant, or nurse practitioner and medical necessity is documented.

Sections 3.1 and 1.0

Medical Necessity Definition

Medical necessity: An orthotic or prosthetic device is medically necessary if it is needed to maintain or improve a beneficiary's medical, physical, or functional level.

Section 1.0

General and device-specific medical necessity

Covered when ALL of the following are met

Ordering and encounter: a. Ordered by a physician, physician assistant, or nurse practitioner; b. A documented face-to-face encounter with the ordering clinician related to the primary reason for orthotic or prosthetic need has occurred no more than 6 months prior to initiation; c. The ordering clinician reviews the beneficiary's need at least annually.face-to-face ≤ 6 months; annual review

Section 3.2.1

Device-specific necessity: Orthotic devices: required to correct or prevent skeletal deformities, support or align movable body parts, or preserve/improve physical function. Prosthetic devices: replacement for all or part of function of a permanently inoperative, absent, or malfunctioning body part required for mobility, daily care, or rehabilitation. Devices must be a reasonable, medically necessary part of the treatment plan, consistent with diagnosis and functional limitations, and of high quality with replacement parts available.

Section 3.2.1 a–c

Provider enrollment and certification: To be reimbursed, the provider shall be enrolled and hold the required provider certification for the specific device per Attachment B.

Section 3.2.1.e and Attachment B

Diabetic shoes and inserts

Covered when ALL of the following are met

Diabetes diagnosis: The beneficiary has a diagnosis of diabetes mellitus.

Subsection 5.3.1 a

Associated foot conditions: Beneficiary has one or more: previous amputation of the other foot or part; history of previous foot ulceration; history of pre-ulcerative calluses; peripheral neuropathy with evidence of callus formation; foot deformity; or poor circulation.

Subsection 5.3.1 b

Physician certification and plan of care: The physician managing the beneficiary's diabetes certifies that criteria are met, that the beneficiary is treated under a comprehensive diabetes care plan, and requires diabetic shoes.

Subsection 5.3.1 c

Adult quantity limits (one-year):

Thoracic-lumbar-sacral/lumbar orthoses

Covered when ANY of the following indications are present

TLSO/LSO indications: Ordered to reduce pain by restricting trunk mobility; or to facilitate healing following an injury to the spine or related soft tissues; or to facilitate healing following a surgical procedure on the spine or related soft tissue; or to support weak spinal muscles or a deformed spine.

Subsection 5.3.2

Cranial helmets and remolding orthoses

Covered when ALL of the following are met (context differs by purpose)

Cranial protection helmets: Protective helmets are medically necessary when cranial protection is required due to a documented medical condition that makes the beneficiary susceptible to injury during activities of daily living; helmets are not provided for sports-related activities; prior approval is required for custom molded cranial protection helmets.

Subsection 5.3.3.1

Cranial remolding orthoses (general): Cranial remolding is the use of a custom helmet or band to mold the cranium toward normal limits and is used post-operatively for craniosynostosis or to treat deformational plagiocephaly.

Subsection 5.3.3.2

Synostotic Plagiocephaly (post-operative)

Covered when ALL of the following are met

Post-operative cranial remolding orthosis: a. Clinical documentation from the beneficiary's neurosurgeon or craniofacial surgeon indicates the need for surgical correction of craniosynostosis and postoperative need for a cranial remolding orthosis; and b. Documentation includes the date and type of surgical procedure performed.

Synostotic (post-operative) criteria, chunk 37

Deformational Plagiocephaly (non-synostotic)

Covered when ALL of the following are met

Diagnosis and prescriber: a. Beneficiary has a diagnosis of deformational (non-synostotic) plagiocephaly; and b. A cranial remolding orthosis has been prescribed by the beneficiary's primary care physician (MD, DO) or a neurosurgical/craniofacial specialist (MD, DO, NP, PA).

Subsection 5.3.3.2

Conservative treatment trial: Unless contraindicated, documentation of at least a 2-month trial of failed conservative treatment (repositioning regimen or PT/OT) is required; this requirement is waived if beneficiary is six months of age or greater at presentation.2 months

Subsection 5.3.3.2

Age and severity: Beneficiary is 4 to 18 months of age and one of the following anthropometric measures documents moderate to severe deformity:ages 4–18 months

Orthoses — Cervical, Hip, Knee, Upper Limb

Covered when any of the listed indications are met for the specified orthosis

Cervical orthosis indications: To reduce pain by restricting neck mobility; to facilitate healing after cervical spine injury or related soft tissue injury; to facilitate healing following cervical spine surgery; or to support weak cervical muscles or a deformed cervical spine.

Subsection 5.3.4

Hip orthosis indications: To reduce pain by restricting hip mobility; to facilitate healing following hip injury or surgery; or to support weak hip muscles or hip deformity.

Subsection 5.3.5

Knee orthosis indications: To reduce pain by restricting knee mobility; to facilitate healing following knee injury or surgery; or to support weak knee muscles or knee deformity (not provided solely for sports-related activities).

Subsection 5.3.6

Static Ankle-Foot Orthosis (AFO)

A static AFO is covered when EITHER all of Criteria a–d are met OR Criterion e is met

Criteria a–d (contracture treatment): a. Plantar flexion contracture with dorsiflexion on passive ROM testing of at least 10 degrees; b. Reasonable expectation ability to correct the contracture; c. Contracture interferes or is expected to interfere significantly with functional abilities; d. Used as a component of a therapy program including active stretching; pretreatment goniometer measurement and documentation of stretching program required.≥10° dorsiflexion on passive ROM

Subsection 5.3.7

Criterion e (alternate): e. The beneficiary has a diagnosis of plantar fasciitis.

Subsection 5.3.7

AFOs and KAFOs for Ambulation

Covered for ambulatory beneficiaries when ALL basic criteria met and possibly custom fabricated if one of additional criteria met

Basic coverage for ambulation: Ambulatory beneficiaries with weakness or deformity of the foot/ankle requiring stabilization for medical reasons and with potential for functional benefit are covered for AFO; KAFO covered when additional knee stability is required.

Subsection 'AFOs and KAFOs Used During Ambulation'

Custom fabrication criteria: Custom-fabricated AFO/KAFO covered when one of: (a) beneficiary cannot be fit with a prefabricated AFO; (b) condition expected to be permanent or >6 months; (c) need to control knee/ankle/foot in more than one plane; (d) documented neurological, circulatory, or orthopedic status requiring custom fabrication to prevent tissue injury; (e) healing fracture lacking normal anatomical integrity.>6 months for permanence criterion

Subsection 5.3.7

Orthopedic Shoes and Footwear

Covered when ALL of the following conditions are met

Orthopedic shoe coverage: Shoe is an integral part of a covered leg brace and medically necessary for proper functioning of the brace; heel/sole replacements, inserts, and shoe transfers are covered when integral to a covered brace; a matching shoe not attached to a brace is non-covered.

Subsection 5.3.8

Lower Limb Prostheses and Component Additions

Lower Limb Prosthesis covered when ALL of the following are met

Basic lower limb prosthesis criteria: a. Beneficiary reaches or maintains a defined functional state within a reasonable period; b. Beneficiary is motivated to ambulate; c. Able to perform unipedal sit-to-stand with upper extremity support; d. Able to bear weight on the residual extremity with upper extremity support.

Subsection 5.3.10

Additions—functional justification: Additions to prosthesis are covered when medically necessary based on beneficiary's potential functional abilities and documented justification (e.g., K-level requirements, duration of prosthetic use, volume change criteria for vacuum systems, specific functional activities for flex-foot, multiaxial ankle with active dorsiflexion). Prior approval and detailed medical justification required for many additions.see per-addition criteria (e.g., K3/K4, 18 months use)

Subsection 5.3.10 and Attachment D/Attachment B

Documentation and PA: Medical documentation must show all criteria are met and a completed CMN/PA form and supporting medical documentation must be submitted to NC Medicaid's fiscal agent; prior approval forms available online for specific components.

Upper Limb Prostheses

Covered when ALL of the following are met

Upper limb prosthesis coverage: Device replaces all or part of function of a permanently inoperative, absent, or malfunctioning upper limb; beneficiary requires the prosthesis for activities of daily living or rehabilitation; treating clinician documents beneficiary motivation to use the device and signs a written rehabilitation plan with goals; accessories essential to effective use are covered.

Subsection 5.3.11

Elastic Supports

Covered when ordered for one of the following indications

Elastic support indications: Severe or incapacitating vascular problems (acute thrombophlebitis, massive venous stasis, pulmonary embolism); venous insufficiency; varicose veins; edema of lower extremities; edema of pregnancy; or lymphedema.

Subsection 5.3.12

Upper Limb Prostheses

Upper limb prosthesis covered when ALL of the following are met

Upper limb prosthesis requirements: 1) Device replaces all or part of the function of a permanently inoperative, absent, or malfunctioning upper limb; 2) Beneficiary requires the prosthesis for ADLs or rehabilitation; 3) Treating clinician documents beneficiary motivation to use the device; 4) Treating clinician signs a written rehabilitation plan with expected goals. Accessories essential to effective use (e.g., stump stockings, harness) are covered.

Subsection 5.3.11

Elastic Supports

Elastic supports are covered when ANY of the listed clinical indications apply

Elastic supports indications (restated): Severe/incapacitating vascular problems (acute thrombophlebitis, massive venous stasis, pulmonary embolism), venous insufficiency, varicose veins, edema of lower extremities, edema of pregnancy, or lymphedema.

Subsection 5.3.12

Trusses

Trusses are covered when the following condition is met

Truss coverage condition: A hernia is reducible with the application of a truss.

Subsection 5.3.13

Related Supplies

Orthotic and prosthetic-related supplies are covered when ALL of the following are met

Related supplies coverage: The primary orthotic or prosthetic device with which the supply is used is covered, and the supply is necessary for the function of that orthotic or prosthetic device.

Subsection 5.3.14

External Breast Prostheses

External breast prostheses covered when the following condition is met

External breast prosthesis: Beneficiary has had a mastectomy. External breast prosthesis garments with mastectomy form are covered for postoperative use prior to a permanent prosthesis or as an alternative to a mastectomy bra and prosthesis.

Subsection 5.3.15

Ocular Prostheses

Ocular prostheses covered when ANY of the following apply

Ocular prosthesis indications: Absence or shrinkage of an eye due to birth defect, trauma, or surgical removal; a scleral cover shell ordered as artificial support to a shrunken sightless eye or as a barrier in severe dry eye treatment.

Subsection 5.3.16

Cast Boot / Post-Operative Shoe

Cast boots/post-operative shoes are covered when ANY of the following clinical indications apply

Cast boot/post-op shoe indications: To protect a cast during weight-bearing after injury or surgery; to provide support/weight-bearing surface following surgery; to promote wound care and healing via appropriate weight distribution and protection; or when beneficiary is receiving lymphedema treatment and cannot fit conventional footwear. Prior approval is not required for these indications.

Subsection 5.3.17

Service Limits and Overrides

Amount of service and limitation rules

Service limits and overrides: Amount of service is limited to that which is medically necessary as determined by NC Medicaid clinical coverage policies; refer to Attachment B for HCPCS, lifetime expectancies, and quantity limits. Overrides of quantity limits or lifetime expectancies require prior authorization with usual PA documentation plus an explanation of medical necessity for the override.

Subsections 5.4 and 5.5

General coverage conditions

Policy covers orthotic and prosthetic devices when documentation, provider certification, lifetime expectancy, and prior approval (when required) are met

General coverage conditions: Device has documentation of medical necessity on the CMN/PA form or attached medical documentation; the rendering/dispensing provider holds the required certification for the specific HCPCS code listed in Attachment B; HCPCS code in Attachment B has applicable lifetime expectancy/quantity limits; and prior approval is obtained when required.

Sections 1.0, 3.2.1.e, Attachment B

General coverage conditions

Covered when devices are prescribed and dispensed by providers with required credentials listed in Attachment B and when documentation supports medical necessity

Provider and documentation requirements: Device is medically necessary and documented on the CMN/PA form or attached documentation; the furnishing/dispensing provider holds the required credential listed for the HCPCS code in Attachment B (e.g., CO, BOCO, CPO, C.Ped., BOCPD, DPM, MD, DO, PA, NP where specified); and prior approval is obtained when required per Attachment B/fee schedule.

Attachment B and Subsection 3.2.1.e

General Coverage Requirements

Covered when provider complies with all of the following billing and coding requirements:

Billing and coding compliance: Provider shall comply with NCTracks Provider Claims and Billing Assistance Guide, Medicaid bulletins, fee schedules, and use the most specific CPT/HCPCS/ICD-10 codes that accurately describe the service or device; if no specific code exists, use appropriate unlisted code and follow instructions.

Attachment A and Section C (Code(s))

Unit reporting and payment: Report billing units as one per device for purchased equipment; payment is the lower of billed charge or Medicaid maximum and includes delivery, fitting, and assembly (no separate payment for travel/shipping).

Section H Reimbursement

Diabetic Shoes/Inserts — Covered with criteria

Covered when the following code-specific requirements are met:

Diabetic shoes/inserts (code-specific): Codes A5500–A5513 are covered when beneficiary meets diabetic criteria and when provided by required certified providers; quantity and frequency limits apply per Attachment B (e.g., A5500/A5501: 1 left & 1 right per 6 months for ages 0–20; 1 per year for ages 21+; A5512/A5513 inserts up to 3 pairs per year per Attachment B).see Attachment B per-code limits

Subsection 5.3.1 and Attachment B

Helmets — Covered with criteria

Covered when provided by listed certified providers and within lifetime limits:

Helmets—protection and remolding: Protective helmets (A8000–A8004) and cranial remolding orthoses (S1040) are covered when furnished by required certified providers and within the listed lifetime/quantity limits in Attachment B (e.g., A8000–A8003: 1 per 6 months ages 0–20; 1 per 3 years ages 21+; S1040: 1 per beneficiary ages 0–18 months). Prior approval required for cranial remolding orthoses and some custom helmets per policy.see Attachment B (S1040: 0–18 months)

Subsection 5.3.3 and Attachment B

Spinal Orthoses — Covered with criteria

Covered when furnished by the required certified provider and within stated lifetime/quantity limits:

Spinal orthoses—code-specific coverage: Spinal orthoses L0112–L0480 (and related L-codes) are covered when furnished by the required certified provider listed for each code and when requested frequency does not exceed the listed lifetime/quantity limitations (commonly 1 per 6 months for ages 0–20; for ages 21+ limits vary by code, commonly 1 per year or 1 per 3 years as specified in Attachment B).see Attachment B per-code limits

Subsection 5.3.2 and Attachment B

General coverage requirement

Covered when listed provider certification is met and quantity limits are not exceeded

Standard coverage conditions: Device matches the HCPCS description AND the furnishing provider holds the 'Required Provider Certification' listed for that HCPCS code AND the requested frequency does not exceed the listed lifetime/quantity limitation for the member's age group.see per-code limits in Attachment B

Applies across listed code sections

Covered when billed properly with required provider certification and within quantity limits

Per-code billing and provider requirement: Item is covered when billed with the specified L-code, furnished by a provider type listed as required for that code, and provided within the lifetime/quantity limits applicable to the beneficiary's age group.see per-code quantity/age limits in Attachment B

Sections E (Lower Limb Orthoses) and Attachment B

Per-code coverage with provider certification and quantity limits

Per-code coverage rule: Device billed with the exact HCPCS L-code AND the provider holds one of the required certifications listed for that code in Attachment B; quantity/frequency limits and lifetime expectancies listed per code must not be exceeded (pediatric and adult limits may differ).See Attachment B per-code rules

See Attachment B Sections D–G and F

General coverage rule for listed orthotic and footwear L-codes

Listed L-code rule: Provider meets the 'Required Provider Certification' listed for the specific L-code AND the item is provided within the stated quantity/frequency limits (age-stratified as specified). Custom fabricated vs prefabricated distinctions apply per code in Attachment B.See per-code frequency/age limits in Attachment B

Attachment B Sections E–G and F

Under the Medicaid EPSDT special provision, beneficiaries under 21 years may be eligible for services, products, or procedures that exceed standard policy limits when the item is medically necessary to correct or ameliorate a health condition. EPSDT coverage still excludes items that are unsafe, ineffective, experimental/investigational, or not medical in nature; providers must document how the requested device meets EPSDT criteria and why less intensive or less costly statewide options would not be equally effective.

Devices or supplies provided primarily for the comfort or convenience of the beneficiary or caregiver, or intended as backups/duplicates to keep at multiple locations, are not covered. Similarly, items that duplicate another provider’s services or are otherwise not individualized to medical need will be denied. For orthoses specifically, replacement interfaces or additions beyond stated frequency limits (for example, >1 replacement AFO interface per six months) are not covered and will be considered not medically necessary.

Examples and common limits: a matching shoe that is not attached to a brace is non‑covered. Foot‑drop splints and replacement interfaces are not covered for non‑ambulatory beneficiaries. AFO/KAFO additions or component L‑codes are denied if the base orthosis is not medically necessary. AFOs/KAFOs are covered for ambulatory beneficiaries who meet basic functional criteria, and custom fabrication is allowed only when one of the specific conditions is met (e.g., cannot be fit with a prefabricated AFO; condition expected >6 months; need to control motion in more than one plane). Refer to Attachment B for code‑level required provider certifications and quantity limits for footwear and AFO/KAFO related codes.

Certain professional services and routine device work are included in the device reimbursement and are not billed separately. For prostheses and many orthoses this includes evaluation, fitting, cost of base components and labor, and repairs for normal wear within 90 calendar days of delivery, as well as adjustments made during fitting or within 90 days where not due to changes in the residual limb or functional ability. These services are considered part of the packaged payment for the device.

Hospice rules limit billing for orthotic and prosthetic items: if an item is related to the beneficiary’s terminal illness and the hospice agency is being reimbursed by Medicaid, the hospice agency must supply those orthotic and prosthetic devices and supplies and the orthotics/prosthetics supplier shall not bill Medicaid for items related to the terminal illness. Only devices unrelated to the terminal illness may be billed separately by an enrolled O&P provider.

The policy records prior administrative updates to the HCPCS and diagnosis code listings. Several HCPCS codes have historically been end‑dated, revised, or replaced and unspecified/deleted ICD‑10 'unspecified' diagnosis codes were removed from relevant sections; providers should reference the current Attachment B and the information history for exact code changes and effective dates.

Attachment B was updated to align HCPCS rows with appropriate provider credentials; as part of housekeeping, credentials that fall outside the scope of practice for specific codes (for example, removal of CP from certain shoe and insert codes) were removed. Providers must follow the Attachment B ‘Required Provider Certification’ entries for each HCPCS code when furnishing and billing items.

Medicaid restricts payment for hospice‑related services: a Medicaid‑reimbursed hospice agency is required to supply all orthotic and prosthetic equipment and supplies related to the terminal illness. Only items unrelated to the terminal diagnosis may be billed by external O&P suppliers; providers should confirm hospice responsibility before billing Medicaid.

Some HCPCS entries include 'not otherwise specified' (NOS) or A‑series/NOS codes (for example, A5507) on Attachment B but are subject to the same limits and required provider certifications as specified code rows. Providers should apply the same documentation, credential, and quantity/frequency rules to NOS entries as to other listed HCPCS codes.

This excerpt does not list every possible coverage exception. Not covered categories explicitly include devices provided solely for convenience, backup/duplicate devices, devices and supplies for nursing facility residents when excluded by policy, and items related to hospice care. Additionally, items that duplicate services, are experimental/investigational, or are not individualized to medical necessity are excluded. For specific code exceptions or other exclusions not shown here, refer to the full policy and Attachment B.

Exclusions not present in the excerpt include standard non‑coverage for comfort/convenience items, duplicate/back‑up devices, and items covered by other agencies. For orthoses and prostheses, services incorporated into the bundled device payment (evaluation, fitting, base components, repairs within 90 days, and initial adjustments) are not separately payable. For comprehensive exclusion language and any additional, code‑specific exclusions, consult the complete policy and Attachment B.

HCPCS and Diagnosis Codes (Attachments)

Covered HCPCS Codes - Spinal Orthoses (selected)HCPCSCovered

L0460	TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, prefabricated, includes fitting and adjustment.
L0462	TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, prefabricated, includes fitting and adjustment.
L0464	TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, prefabricated, includes fitting and adjustment.
L0467	TLSO, sagittal control, rigid posterior frame and flexible soft anterior apron with straps, prefabricated, off-the-shelf.
L0469	TLSO, sagittal-coronal control, rigid posterior frame and flexible soft anterior apron with straps, prefabricated, off-the-shelf.

Covered HCPCS Codes - Spinal Orthoses (additional)HCPCSCovered

L0460	TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, prefabricated, includes fitting and adjustment.
L0462	TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, prefabricated, includes fitting and adjustment.
L0464	TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, prefabricated, includes fitting and adjustment.

Covered HCPCS Codes - Diabetic Shoes / Inserts and RelatedHCPCSCovered

L1660	(See Attachment B) Specific lower limb orthosis/related footwear codes — referenced in Attachment B.
L2126	(See Attachment B) Lower limb orthosis additions — referenced in Attachment B.
L2128	(See Attachment B) Lower limb orthosis additions — referenced in Attachment B.
L2132	(See Attachment B) Lower limb orthosis additions — referenced in Attachment B.
L2134	(See Attachment B) Lower limb orthosis additions — referenced in Attachment B.
L2136	(See Attachment B) Lower limb orthosis additions — referenced in Attachment B.
L2180	(See Attachment B) Lower extremity orthosis additions — referenced in Attachment B.
L2182	(See Attachment B) Lower extremity orthosis additions — referenced in Attachment B.
L3332	Orthopedic shoes/footwear related HCPCS in Attachment B.
L3334	Orthopedic shoes/footwear related HCPCS in Attachment B.

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Covered ICD-10 Codes - Diabetes and Related (Diabetic Shoes/Inserts)ICD-10Covered

E08.00 - E09.9	Diabetes mellitus codes (as listed for diabetic shoes, inserts, and modifications).
E10.10 - E10.9	Type 1 diabetes mellitus codes (refer to Attachment B for applicable ranges).
E11.00 - E11.9	Type 2 diabetes mellitus codes (refer to Attachment B for applicable ranges).
E13.0 - E13.9	Other specified diabetes mellitus codes (refer to Attachment B for applicable ranges).

HCPCS Historical and Update Notes (selected)mixed

L3332	Listed in Attachment B; provider credential updates occurred 07/15/2024 (see amended notes).
L3334	Listed in Attachment B; provider credential updates occurred 07/15/2024 (see amended notes).
L3340	Listed in Attachment B; referenced in Orthotics and Prosthetics fee schedule.

Prior Authorization, Documentation, and Billing Actions

Prior Authorization

Prior Approval for Select HCPCS Codes

Prior authorization is required for certain orthotic and prosthetic HCPCS codes as identified on the NC Medicaid Orthotics and Prosthetics Fee Schedule. Providers must obtain prior approval before furnishing devices listed on the fee schedule; PA is valid for the time period shown on the CMN/PA and a new CMN/PA must be submitted if the device is needed for a different or extended period.

Devices requiring PA are identified on the Orthotics and Prosthetics fee schedule at https://medicaid.ncdhhs.gov/providers
PA requests for adults must be submitted through NCTracks per Attachment E procedures
PA validity: as stated on Certificate of Medical Necessity/Prior Approval (CMN/PA)

Note

Prior Approval Symbols Removed

The fee schedule no longer uses prior approval symbols (asterisk or plus) or bolding to indicate PA requirements. Providers must follow the current Orthotics and Prosthetics fee schedule and PA instructions on the Medicaid website to determine which HCPCS codes require prior approval.

Policy Definitions and Abbreviations

Orthotic device definition

Orthotic deviceMedically necessary when required to correct or prevent skeletal deformities, to support or align movable body parts, or to preserve or improve physical function.

Coverage conditionsOrthotic devices must be reasonable and medically necessary part of treatment, consistent with diagnosis and functional limitations, and of high quality with replacement parts available.

Provider rolesMD, DO, DPM, PA, and NP may provide certain orthotic devices when part of current care and as indicated in Attachment B.

Prosthetic device definition

Prosthetic deviceA medically necessary replacement for all or part of the function of a permanently inoperative, absent, or malfunctioning body part; required for mobility, daily care, or rehabilitation.

Coverage conditions

Background

Orthotic and prosthetic devices are intended to maintain or improve a beneficiary's medical, physical, or functional level. Covered devices must be medically necessary, documented on the CMN/PA form or supporting medical records, and furnished by providers holding the credentials required for the specific HCPCS code listed in Attachment B. For beneficiaries under 21 years, the EPSDT special provision may require coverage beyond routine limits when documentation shows the item is necessary to correct or ameliorate a health condition.

Policy Revision History

07/11/2005amendment

Instructions for completing the CMN/PA form were revised and policy expanded to include coverage through age 115; provider certification updates included.

01/01/2006HCPCS update

Multiple HCPCS code end-dates and replacements implemented (e.g., K0628/K0629 → A5512/A5513; K0630–K0649 → L0621–L0640; L2039 replaced with L2034 and L2387).

04/01/2007coverage addition

Policy Summary

PayerAlliance Health

PolicyOrthotics & Prosthetics coverage

Policy CodePolicy 5B

Change TypeAttachment B HCPCS, credential, and quantity updates

Effective Date

Next Review Date

Key ActionObtain prior authorization via NCTracks for unlisted items, overrides, and non-warranty repairs and submit CMN/PA with supporting documentation.

SourceLink

On This Page

Within one year coverage limited to either: (a) one pair custom molded shoes (includes inserts) plus 2 additional pairs of inserts; OR (b) one pair depth shoes plus 3 pairs of inserts.

Subsection 5.3.1 coverage limits and Attachment B (A5500–A5513)

Measurements generally obtained by cranial orthosis provider

Anthropometric thresholds: (1) Cranial vault asymmetry index (CVAI) ≥ 6.25; OR (2) Cephalic index (CI) > 90% for brachycephaly; OR (3) CI ≤ 75% for dolichocephaly.CVAI >= 6.25; CI >90% or <=75%

Subsection 5.3.3.2 and chunk 39

Upper limb orthosis indications:

To reduce pain by restricting joint mobility; to facilitate healing after joint injury or surgery; or to support weak skeletal muscles or musculoskeletal deformities.

Removed symbols: asterisks (*) and plus signs (+) previously indicated PA requirements
Use the updated fee schedule and NCTracks PA instructions to determine PA status

Documentation Required

Provider Certification and Quantity Documentation Required

Many HCPCS L-codes list a 'Required Provider Certification' and specific lifetime expectancies or quantity limits. Providers must document and maintain credentials on file that meet the 'Required Provider Certification' for each HCPCS code billed and include documentation of lifetime/quantity limits in the medical record and PA request.

Examples of required certifications include CO, BOCO, CPO, C.Ped., BOCPD, DPM, MD, DO, PA, NP depending on code
Claims must reflect the provider certification associated with the HCPCS L-code

Prior Authorization

Provider Certification and Authorization Expectations

Prior authorization requirements are implied where Attachment B lists a 'Required Provider Certification' and lifetime/quantity limits. Providers should ensure required credentials and any PA approvals are on file prior to billing.

If a code lists a required certification, the furnishing or ordering provider must hold that credential
Having the credential does not remove any PA requirement shown on the fee schedule

Billing Rule

Prior Authorization / Billing Requirement

Prior authorization may also be a billing requirement: services must be billed using the specified HCPCS L-code and performed by the certified provider listed for that code on Attachment B. Failure to bill with the specified L-code or to have the required provider certification on the claim may result in denial.

Bill using the most specific HCPCS/ICD-10 codes that support medical necessity
Claims for HCPCS L-codes must document the required provider certification

Prior Authorization

Prior Authorization for Listed L-codes

Prior authorization is implied for listed L-codes by Attachment B when quantity limits and provider certification are specified. Providers should obtain PA for those L-codes as required by the fee schedule.

Attachment B lists lifetime expectancies and quantity limitations per code
Obtain PA via NCTracks when limits are exceeded or PA is indicated

Prior Authorization

Authorization When Exceeding Frequency Limits

Requests that exceed stated frequency or quantity limits require prior authorization. The PA request must clearly indicate the override type (quantity or lifetime expectancy) and include an explanation of medical necessity from the prescriber.

Override PA must: mark the item on the CMN/PA, state type of override, and include explanation from physician/PA/NP/therapist
Override requests are reviewed under usual PA timelines; outcomes are communicated in standard fashion

Denial Risk

General Denial Triggers

Services or devices may be denied when they are not individualized, inconsistent with the diagnosis, excessive, unsafe, primarily for convenience, duplicate another provider's service, or lack required documentation or eligibility. Providers must ensure medical necessity and complete documentation to reduce denial risk.

Denial triggers include: not individualized, not consistent with diagnosis, excessive, unsafe, primarily for convenience
Claims may be denied for lack of eligibility, duplicate services, experimental treatments, or missing documentation

Documentation Required

Providers Must Submit CMN/PA with Repair

For non-warranty repairs, providers must submit a completed CMN/PA with a repair estimate through NCTracks. The estimate must break out parts and labor hours and include device description, HCPCS code, device age, prior repair count, and current replacement cost in block 30 of the CMN/PA.

No charge allowed for pick-up/delivery or assembly of Medicaid-reimbursed parts
Missing or incomplete repair documentation may result in denial

Denial Risk

Provider Qualification Denial Risk

Providers who are not MD/DO/DPM/PA/NP must meet board certification or accreditation requirements (ABCOP, BOC, NEBO, BCCA, etc.) and be enrolled with Medicaid on the date of service. Failure to meet these qualifications may disqualify the provider and cause claim denials.

Non-physician providers must be board certified or accredited as listed
Providers shall not accept prescriptions from practitioners with an ownership interest in their agency

Billing Rule

Third-Party Liability Billing

Providers must exhaust reasonable measures to identify third-party liability (Medicare, private insurance). When third-party liability is established, providers must bill the third party before billing Medicaid.

Refer to NCTracks Provider Claims and Billing Assistance Guide for billing procedures
Failure to bill third-party payers when liability exists may trigger denial

Documentation Required

Prior Approval and Documentation

Prior approval requests must include the PA request and all health records and other documentation that demonstrate the beneficiary meets the policy criteria. Submit CMN/PA and supporting documentation through NCTracks.

Include all clinical records that support the criteria in Subsection 3.2
For beneficiaries under 21, request an EPSDT review via NCTracks

Documentation Required

Provider Certification Compliance

Providers must comply with Attachment B 'Required Provider Certification' listings when furnishing or billing for items. Failure to use the required provider certification on claims or in the provider file may result in denial.

Ensure the ordering/furnishing provider type meets the Required Provider Certification for each HCPCS L-code
Maintain provider credential documentation in the service record

Billing Rule

Billing and Claims Compliance

Providers must follow NCTracks billing guidance, fee schedules, and claim submission rules. Claims that do not follow billing/claims compliance (incorrect codes, missing documentation, wrong provider identifiers) may be denied or delayed.

Use the most specific CPT/HCPCS/ICD-10 codes that support medical necessity
Follow NCTracks filing instructions and fee schedule guidance

Billing Rule

Medicare/Medicaid Crossover Requirements

For dually eligible beneficiaries, claims filed to Medicare should cross over to Medicaid if a Medicare Crossover Request form is on file and data maps correctly. Providers must verify crossover on the Medicaid Remittance and Status Report and ensure Medicare provider number is cross-referenced to Medicaid provider number; resubmit claims with the correct NPI/taxonomy if necessary.

Verify crossover and provider cross-reference by contacting GDIT or using the Medicare Crossover Request form
If NPI differs between Medicare and Medicaid, resubmit with correct identifiers

Prior Authorization

Quantity Limit Exceedance

Requests that exceed established lifetime expectancies or quantity limits must be authorized via PA. Documentation must justify medical necessity for the exception and be included in the PA submission; otherwise, requests may be denied.

Explain why replacement is needed before usual life expectancy on the CMN/PA
Provide supporting documents for loss, theft, destruction, or disaster when applicable

Denial Risk

Missing Provider Certification

If a claim is missing the required provider certification associated with a specific HCPCS code, it may be denied. Providers must supply the credential information in the claim and retain certification documentation in the medical record.

Claims must document the ordering provider type meeting the 'Required Provider Certification'
Keep certification credentials on file for audits

Denial Risk

Exceeding Quantity Limits

Exceeding stated lifetime or quantity limitations without prior authorization may result in denial. Providers must request PA for overrides and include rationale and prescriber support.

PA override requests must include the usual PA documentation plus specific override information
Outcomes of override requests follow standard PA communication processes

Documentation Required

Provider Credentialing Requirement

Certain HCPCS L-codes require services to be provided by specified credentialed provider types. Requests may be denied if not furnished by an allowed provider type or if the provider's enrollment status does not meet Medicaid requirements on the date of service.

Verify provider enrollment and credentialing prior to furnishing items
Examples: some spinal, scoliosis, and lower limb L-codes list MD/DO/PA/NP or certified orthotics/prosthetics credentials

Billing Rule

Failure to Bill with the Specified L-code

Failure to bill using the specified L-code and to include the required provider certification on the claim may trigger denials. Claims must match the code-level descriptions and required credentials in Attachment B.

Use the L-code that most specifically describes the furnished device and supports medical necessity
Ensure laterality, quantity, and beneficiary age are consistent with documentation

Denial Risk

Claims for Orthopedic Shoes/Inserts Lack Required Certification

Claims for orthopedic shoes and inserts must document the required provider certification listed for those codes. Lack of the required certification on the claim or in the provider file may result in denial.

Examples: L3000–L3010, L3350–L3370, etc., list required certifications such as CO, BOCO, CPO, C.Ped., BOCPD, DPM
Quantity limits for shoes/inserts vary by age — follow Attachment B

Documentation Required

Medical Necessity Documentation

Providers must supply medical necessity documentation for every item provided. This includes a prescriber-signed letter of medical necessity or completion of the CMN/PA form and all supporting clinical records demonstrating how the device maintains or improves the beneficiary's medical, physical, or functional status.

Medical necessity must be documented by the prescriber (MD/DO/PA/NP)
For EPSDT (under 21), document how service corrects or ameliorates a condition

Documentation Required

Required Documentation

Required documentation for PA includes the CMN/PA form plus all health records and supporting documentation identified in the policy (diagnostic findings, therapy notes, surgeon documentation when applicable, anthropometric measures for cranial remolding, rehabilitation plan for upper limb prostheses, repair estimates for non-warranty repairs).

Include surgeon documentation and date/type of surgery for post-op cranial remolding orthoses
For deformational plagiocephaly include records of at least two months of conservative care unless exception applies

Documentation Required

Required Clinical Documentation

Clinical documentation must support specific criteria: e.g., surgeon documentation for post-op cranial remolding, conservative care trial records for deformational plagiocephaly, functional level and gait/ambulation documentation for lower limb prostheses, and prescriber-signed rehabilitation plans for upper limb prostheses.

Anthropometric measures (CVAI, CI) must be documented for cranial remolding orthoses
Lower limb prosthesis PA requires functional capability documentation and CMN/PA completion

Documentation Required

Providers Must Include Prescriber-Signed Rehabilitation Plan

Providers must include a prescriber-signed rehabilitation plan for upper limb prostheses that outlines expected goals and the beneficiary's motivation to use the device. This signed plan is required at PA submission and retained in records.

Rehabilitation plan must be signed by the treating physician, PA, or NP
Plan should include functional goals and training expectations

Documentation Required

Medical Justification Documentation

Medical justification for special components or systems (for example, flex-foot systems, vacuum pumps) must be documented on the CMN/PA or in attached medical records. When specific form(s) exist (e.g., Prior Approval Form for Lower Extremity Prosthetic Component), they may be used but are not required if documentation on CMN/PA suffices.

Document clinical rationale and functional benefit for higher-level prosthetic components
Attach functional assessments, therapy notes, and prior prosthesis history as applicable

Billing Rule

Claim Coding Instructions

Claims must use ICD-10-CM coding in the appropriate claim block and the most specific CPT/HCPCS codes that support medical necessity. Follow the current CPT/HCPCS codebook instructions for unlisted procedure codes and special reports when necessary.

ICD-10-CM replaced ICD-9-CM in block 21 per Attachment C instructions
If no specific code exists, use appropriate unlisted code and include a special report

Billing Rule

Coding Specificity and Special Reports

Report the most specific CPT/HCPCS/ICD-10 codes to substantiate medical necessity. When required, include special reports as described in the codebook instructions. Do not rely on generic or less-specific codes that fail to justify the requested device.

Follow the Instructions for Use in CPT and HCPCS for unlisted services and special reports
Provide supporting documentation that aligns with the code's clinical indications

Billing Rule

Provider Billing and NPI Verification

Providers should verify Medicaid remittance and status for Medicare crossover claims and ensure their Medicare provider number is cross-referenced to their Medicaid provider number. If the NPI on Medicare claims differs from Medicaid, resubmit with the correct NPI and taxonomy.

Contact GDIT to verify or cross-reference Medicare provider number: 800-688-6696
Resubmit claims with correct identifiers when mapping errors occur

Documentation Required

Provider Certification and Medical Necessity

Provider certification must be documented alongside medical necessity for codes that list both requirements. Documentation should demonstrate that the provider holds the listed certification and that the device is medically necessary for the beneficiary's condition and functional goals.

Include provider credential and evidence of medical necessity in the CMN/PA and service record
Documentation must justify device type, frequency, and alignment with lifetime/quantity limits

Documentation Required

Support Device Type, Frequency, and Provider Credential

Documentation supporting device type, frequency, and the credential of the furnishing provider must be consistent with the lifetime/quantity limitations listed in Attachment B. Claims should clearly state laterality, beneficiary age, and the specific L-code requested.

Medical records must support the need for frequency beyond standard limits when requesting overrides
Ensure CMN/PA and claim fields reflect laterality, age, and code-level specificity

Documentation Required

Medical Documentation Should Support the Request

Medical documentation should directly support the specific HCPCS L-code requested, including device description, laterality, functional impact, and beneficiary age. Records should be retained per record-keeping requirements and furnished upon request for audits.

Retain prescription signed by prescriber including quantity, frequency, and duration
Keep original CMN/PA and full device description in the beneficiary file for six years

Prior Authorization

Conservative Therapy Consideration

Before furnishing a device, providers must consider conservative therapy options and document that no equally effective and more conservative or less costly treatment is available statewide unless an exception applies (for example, age or contraindication).

For deformational plagiocephaly, document at least a two-month conservative therapy trial unless beneficiary is six months or older
Conservative options include repositioning regimen and physical/occupational therapy

Step Therapy

No Step Therapy Specified; Cast Boots/Post-Op Shoes Covered Without PA

No step therapy rules are specified for cast boots, post-operative sandals/shoes, or healing shoes. These items are covered without prior approval when the listed clinical indications are met.

Prior approval is not required when medically necessary for listed indications (protection of cast, support after surgery, wound care, lymphedema fitting issues)
Follow Attachment B for applicable HCPCS codes and limits

Billing Rule

Third-Party Payment Coordination

Providers must coordinate third-party payment and bill other liable payers prior to billing Medicaid. Document efforts to identify other payers and include third-party billing information where applicable.

Take reasonable measures to determine legal liabilities of third parties including Medicare and private insurance
Document and retain evidence of third-party billing and denial prior to Medicaid submission

Note

No Step Therapy Rules Specified in the Policy

No additional step therapy rules are specified in this policy beyond the conservative therapy expectations outlined for select conditions (for example, cranial remolding). Providers should follow the clinical criteria and PA requirements in this policy and Attachment B.

Adhere to conservative care trials where explicitly required
Use NCTracks and Attachment B to determine PA and documentation expectations

Prostheses must be reasonable and medically necessary, consistent with diagnosis and functional limitations, and of high quality with replacement parts available.

Included servicesEvaluation, fitting, base component costs, repairs due to normal wear within 90 days, and adjustments within 90 days are included in the prosthesis reimbursement and not separately billable.

Cranial remolding definition

Cranial remoldingUse of a custom helmet or band to mold cranial shape toward normal limits; used post-operatively for craniosynostosis or to treat deformational (non-synostotic) plagiocephaly.

PurposeMay be used either post-operatively for craniosynostosis or to treat deformational plagiocephaly.

Device typeCustom helmet or band (cranial remolding orthosis).

Plagiocephaly types — synostotic vs deformational

Synostotic plagiocephalyDeformity resulting from premature closure of cranial sutures (craniosynostosis); may require post-operative cranial remolding with surgeon documentation of date/type of surgery.

Deformational (non-synostotic) plagiocephalyDeformity from external/positional factors (e.g., intrauterine constraint, prematurity, torticollis) with open sutures; conservative trial required unless beneficiary ≥6 months.

Key distinctionIn deformational plagiocephaly cranial sutures remain open; in synostotic they are prematurely fused.

Head shape terms — brachycephaly/dolichocephaly/scaphocephaly

BrachycephalyShort–wide head shape.

Dolichocephaly (Scaphocephaly)Long–narrow head shape (dolichocephaly/scaphocephaly terminology used for long-narrow shapes).

Relation to plagiocephalyBoth asymmetry (plagiocephaly) and disproportionality (brachycephaly/dolichocephaly) are possible consequences of cranial deformity.

Upper limb prosthesis definition

Upper limb prosthesisDevice that replaces all or part of the function of a permanently inoperative, absent, or malfunctioning part of the upper limb and is required for activities of daily living or rehabilitation.

DocumentationTreating clinician must document beneficiary motivation and sign a written rehabilitation plan with expected goals.

AccessoriesAccessories essential to effective use (e.g., stump stockings, harness) are covered.

Elastic supports definition

Elastic supportsSupport garments covered when ordered for severe/incapacitating vascular problems, venous insufficiency, varicose veins, edema (including pregnancy-related), or lymphedema.

Covered indications (examples)Acute thrombophlebitis; massive venous stasis; pulmonary embolism; venous insufficiency; varicose veins; lower-extremity edema; pregnancy-related edema; lymphedema.

Coding/limitsRefer to Attachment B for HCPCS codes, lifetime expectancies, quantity limitations, and required provider certification.

Prosthesis definition (added when HCPCS codes included)

Prosthesis (general)Definition added in lower limb prostheses section when numerous HCPCS codes were included; denotes device replacing part or all of a limb's function.

Documentation/prior approvalTo be reimbursed, provider must be enrolled with appropriate board-certified credential for the specific device per Attachment B; prior approval required when item not listed or limits exceeded.

Included servicesEvaluation, fitting, base component costs, repairs within 90 days, and adjustments within 90 days included in reimbursement.

DPM abbreviation

DPMDPM indicates Doctor of Podiatric Medicine.

Use in policyDPM credential was added to Attachment B provider lists and applies to specified HCPCS codes.

Effective date noteDPM additions noted effective 12/15/2022 in Attachment B updates.

C.Ped., BOCPD abbreviations

C.Ped.Certified Pedorthist (American Board for Certification in Orthotics, Prosthetics, and Pedorthics).

BOCPDBoard of Certification/Accreditation – Certified Pedorthist.

ContextThese abbreviations appear in Attachment B as required provider certifications for specified HCPCS codes.

Provider certification abbreviations list

Common certification listBCO, CCA, CFts, CMF, CO, BOCO, COF, CP, BOCP, C.Ped., BOCPD, CPO, DO, MD, DPM, NP, PA, CFm, CFo.

MeaningEach abbreviation denotes a specific board certification or professional degree recognized for dispensing orthotic and prosthetic devices.

Attachment B useRequired provider certifications for each HCPCS code are listed in Attachment B.

Required provider certification abbreviations — common list

Frequently required certificationsCO, BOCO, CPO, C.Ped., BOCPD, CFts, DPM, MD, DO, PA, NP, CFo, COF.

Reimbursement requirementProvider must hold the required certification listed for the HCPCS code to be reimbursed.

ReferenceSee Attachment B for per-code 'Required Provider Certification.'

TLSO/LSO/CTLSO definitions

TLSO definitionThoracic-lumbo-sacral orthoses (TLSO): rigid or semi-rigid devices designed to restrict trunk motion in sagittal, coronal, and transverse planes; may be prefabricated or custom fabricated.

CTLSO definitionCTLSO: cervical-thoracic-lumbo-sacral orthotic (Milwaukee type), provides cervical through lumbar immobilization; described with furnishing/model details in Attachment B.

Quantity limitsMany TLSO/CTLSO codes have age-based quantity limits (commonly 1 per 6 months for ages 0-20; 1 per 3 years for ages 21+); required provider certifications listed per code.

Sacroiliac orthotic definition (L0621-L0624)

Sacroiliac orthotic (L0621-L0624)Flexible or semi-rigid pelvic–sacral support devices that reduce motion about the sacroiliac joint and may include pendulous abdomen designs; coded L0621–L0624.

Quantity limitsTypically 1 per 6 months for ages 0–20; 1 per year for ages 21 and older (per code L0621–L0624 specifics in Attachment B).

Required providersRequired provider certifications (e.g., CO, BOCO, CPO, CFo, COF) are listed per code in Attachment B.

Halo systems (L0810-L0861) description

Halo systems (L0810-L0861)Cervical halo procedures incorporated into jackets/body jackets or Milwaukee-type orthotics; additions and replacement liners are separately coded (e.g., L0859 additions, L0861 replacement liners).

Replacement linersL0861 replacement liner/interface material: quantity limit 2 per 6 months (all ages).

Provider certificationRequired provider certifications for halo-related codes include CO, BOCO, CPO as listed in Attachment B.

CTLSO/TLSO abbreviations

CTLSOCTLSO = cervical-thoracic-lumbo-sacral orthotic (Milwaukee type).

TLSOTLSO = thoracic-lumbar-sacral orthotic; both are detailed in Attachment B with code-specific descriptions and limits.

UseUsed to restrict trunk motion and provide spinal support as described per HCPCS code row.

Prefabricated vs custom fabricated — definition

Prefabricated itemsPrefabricated items may be trimmed or modified by a qualified individual to fit the patient.

Custom fabricated itemsCustom fabricated items are molded or created to a patient model (e.g., carved plaster or CAD-CAM model) and coded as custom fabricated.

Coding distinctionAttachment B differentiates prefabricated vs custom fabricated per HCPCS code descriptions.

Orthopedic shoe additions / modifications — definition

Orthopedic shoe additionsShoe components such as heel wedges, sole wedges, metatarsal bars, heel counters, insoles, toe taps, and conversions (e.g., to Velcro) are defined as orthopedic shoe additions and assigned distinct L-codes.

Quantity limitsMany shoe additions have limits of 2 left and 2 right per year for all ages unless specified otherwise in Attachment B.

Required providersRequired provider certifications for shoe additions include CO, BOCO, CPO, C.Ped., BOCPD, DPM as listed per code.

Upper limb orthoses series definition

Upper limb orthoses seriesIncludes prefabricated and custom-fabricated shoulder, elbow, wrist–hand–finger orthoses, dynamic and powered devices (L3650–L3930 series) with defined fitting/adjustment services and age-based quantity limits.

Quantity limitsMany upper limb orthoses: 1 left & 1 right per 6 months for ages 0–20; for ages 21+ limits vary (per year or per 3 years) depending on code.

Required providersRequired provider certifications often include CO, BOCO, CPO, CFo, COF and may also allow MD/DO/PA/NP depending on the code.

Coverage added for helmets used for plagiocephaly and cast-boot/post-op shoe coverage reorganized into a new section.

07/15/2024amendmentLatest

Attachment B updated to add numerous upper limb orthoses codes (including L3671–L3673, L3702, L3763–L3766, L3905, L3913, L3919, L3921, L3933, L3935, L3967, L3971, L3973, L3975–L3978) and to reflect other historical code changes.

01/01/2006HCPCS code end-dates & replacements

HCPCS codes K0628/K0629 were end-dated and replaced with A5512/A5513; K0630–K0649 were end-dated and replaced with L0621–L0640; L2039 was replaced with L2034 and L2387; L3963 replaced with L3961.

07/01/2006prior approval indicator update

Asterisks added to select codes (e.g., L3671, L3763, L7405) to indicate prior approval need; later deletions/adjustments to asterisks occurred for some codes.

01/01/2008HCPCS updates

Large set of HCPCS codes were end-dated, added, or revised (examples include deletion of many L39xx codes and addition of L3925, L3927, L3929 and others).

02/01/2009CPT/HCPCS updates

CPT/HCPCS code updates applied across multiple sections and attachments, including addition and end-dating of numerous L-codes effective 01/01/2009.

02/01/2022Attachment B updates

HCPCS Level II description updates incorporated into Attachment B for a large group of codes and new prefabricated off-the-shelf orthotic codes added in policy (effective Jan 1, 2014 revisions noted).

07/15/2024Attachment B HCPCS additionsLatest

Additional HCPCS descriptions and multiple upper limb orthoses codes added to Attachment B; effective amended date July 15, 2024.

02/01/2022clarificationLatest

Documentation criteria for medical justification of the flex-foot system were clarified and a brand reference (Seattle Carbon Copy II) was removed.

02/01/2022HCPCS description updates

HCPCS Level II 2020 description updates were applied to numerous HCPCS codes in Attachment B, including many L- and A-series codes.

01/15/2014 (policy noted) / reflected 02/01/2022prefabricated code split

CMS splits of prefabricated orthotic codes into separate off-the-shelf and customization-required codes were incorporated; new OTS codes (e.g., L0641, L0642, L0643, L0648, L0651) were added to Attachment B with revision effective Jan 1, 2014 and documented in policy updates.

07/15/2024HCPCS additions (upper limb) and other code updatesLatest

Attachment B was updated with numerous added HCPCS codes for upper limb orthoses (see added codes list) and other coding changes effective with the amended Jul 15, 2024 policy.