Upper Extremities Custom Orthoses (Shoulder, elbow, wrist, hand, finger)
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This policy defines medical necessity, coverage criteria, required documentation, and billing codes for custom orthotic devices applied to the shoulder, elbow, wrist, hand, and fingers for Moda Health Plan members.
No material clinical or coverage changes in this revision.
Coverage Criteria for Custom Upper-Extremity Orthoses
Custom Orthosis — Initial medical necessity
Covered when ALL of the following are met:
Entry conditions
- Clinical indications (one required): i. Recent surgery to the upper extremity or cast removal (within 21 days of request) with need to: reduce pain by restricting mobility; facilitate healing of the affected body part or related soft tissue; support weak muscles and/or deformity; increase range of motion; or apply traction for correction or prevention of contractures; ii. Non-surgical fracture of the upper extremity requiring stabilization; iii. Rheumatoid arthritis, osteoarthritis, or overuse syndromes (e.g., carpal tunnel syndrome, tendonitis of the wrist or hand); iv. Sprain or strain; v. Acromioclavicular dislocation or fracture of the clavicle; vi. Complex regional pain disorder; vii. Joint contractures due to burns
Replacement and repair
Replacement/repair considered when ONE of the following is met:
Repair due to normal wear-and-tear is considered medically necessary when the item is a lateral purchase and the orthotic is still needed; coverage is based on contract guidelines for replacement DME.
Coverage excludes orthotics provided solely for sports or work-related activities unless the member is in a group exempted under Senate Bill SB 699. Requests for orthoses must be prescribed by a qualified provider; devices not ordered by an appropriate prescriber are not medically necessary. Over‑the‑counter support devices and upgraded or convenience/luxury features (for example, braces with microprocessor components) are not covered when an appropriate standard alternative exists. Additions such as socks or fracture-equal accessories that are not required for the orthosis to function are considered not medically necessary.
Myoelectric upper extremity orthotic devices are considered investigational and not medically necessary for all indications. This includes use for individuals with stroke, trauma, or other neurological disorders. Requests for myoelectric devices will be denied on the basis of investigational status.
Requests for spring‑loaded orthotics and static progressive stretch devices require prior trial of conventional treatments for joint stiffness or contracture before coverage will be considered. These devices are not covered when conventional methods have not been attempted and are limited to a maximum duration of 3 months when used for the indicated purpose; requests exceeding this duration are at risk for denial.
Billing Codes and Code Guidance
| L3702 | Shoulder orthotic, custom fabricated, includes fitting and adjustment |
| L3720 | Elbow orthotic (EO), without joints, custom fabricated, includes fitting and adjustment |
| L3730 | Elbow orthotic, double upright with forearm/arm cuffs, free motion, custom fabricated |
| L3740 | Elbow orthotic, extension/flexion assist, custom fabricated |
| L3763 | Elbow-wrist-hand-orthotic (EWHO), rigid without joints, custom fabricated, includes fitting and adjustment |
| L3764 | EWHO, includes one or more non-torsion joints, custom fabricated, includes fitting and adjustment |
| L3765 | Elbow-wrist-hand-finger-orthotic (EWHFO), rigid without joints, custom fabricated |
| L3766 | EWHFO, includes one or more non-torsion joints, custom fabricated |
| L3806 | Wrist-hand-finger orthotic (WHFO), custom, includes one or more non-torsion joints, turnbuckles, elastic bands/springs, includes fitting and adjustment |
| L3913 | Hand/finger orthotic, custom fabricated, includes fitting and adjustment |
| No codes listed |
| No codes listed |
Provider Requirements, Prior Authorization, and Documentation
Obtain prior authorization with clinical documentation for custom L‑codes
Prior authorization is required for listed custom HCPCS/L-codes; include clinical documentation demonstrating the criteria and the need for custom fabrication.
- Applies to listed HCPCS/L-codes (e.g., L3702, L3720, L3730, L3740, L3763–L3766, L3806, L3913, L3919, L3961, L3967, L3971, L3973, L3975–L3978).
- Clinical documentation must demonstrate the member meets all coverage criteria (ordered by treating provider; cannot be fitted with a prefabricated device; meets one of the clinical indications).
Stepwise trial: attempt prefabricated devices before custom
Document that the member cannot be fitted with a prefabricated orthosis and that other devices were tried and found inadequate or contraindicated before requesting a custom orthosis.
- If orthosis is requested immediately post‑operative, most orthotics are prefabricated — if requesting custom, provide clinical documentation for Medical Director review.
- Prefabricated devices should be attempted and documented inadequate unless contraindicated.
Submit complete clinical documentation with prior authorization
Include the following with any prior authorization request: a prescription/order stating the orthosis purpose; documentation of functional impairment and need for long‑term use; documentation of prior devices tried and found inadequate or contraindicated; and documentation addressing why a custom orthotic is required.
- Order/prescription from treating provider stating purpose of orthosis.
- Documentation of physical functional impairment affecting activities of daily living and need for long‑term use.
- Documentation of other devices tried and found inadequate or contraindicated.
- Specific documentation explaining the need for custom fabrication.
Denial risk if conventional treatments not tried or duration >3 months
Requests for spring‑loaded orthotics and static progressive stretch devices may be denied if conventional treatments have not been attempted or when requested for use longer than 3 months.
- Ensure documentation shows conventional methods were attempted and failed before requesting these devices.
- Limit requests to a duration of 3 months or provide justification showing criteria for exception (requests beyond 3 months are subject to denial).
Myoelectric orthoses are investigational — expect denial
Requests for myoelectric upper extremity orthotic devices will be denied because these devices are considered investigational and not medically necessary for all indications.
- Do not submit prior authorization requests for myoelectric orthoses — they are classified investigational/not medically necessary, including for stroke, trauma, or neurological disorders.
Background — Upper Extremity Orthoses
Upper extremity orthoses are rigid or semi‑rigid devices applied to the shoulder, elbow, wrist, hand, or fingers to support, immobilize, correct deformity, or assist function during rehabilitation. They are used to reduce pain, facilitate healing (including post-operative support and cast removal situations within 21 days), stabilize non‑surgical fractures, support weak muscles or deformity, improve range of motion, and prevent or treat contractures as part of a comprehensive treatment plan.
Definitions
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