Mountain State Medical Policy Bulletin

Section: Durable Medical Equipment
Number: B-54
Topic: Orthotics
Effective Date: October 12, 2009
Issued Date: October 12, 2009
Date Last Reviewed: 09/2009

General Policy Guidelines

Indications and Limitations of Coverage

An orthotic is a rigid or semi-rigid device used to support, restore, or protect body function. Orthotics may also redirect or restrict motion of an impaired body part.

Orthotic devices are considered medically necessary when prescribed by a qualified provider to be used for the therapeutic support, protection, restoration, or function for an impaired body part. Orthotic devices used for other diagnoses or conditions are considered not medically necessary. A participating, preferred, or network provider cannot bill the member for the denied service.

Orthotic devices include:

  • braces for leg, arm, neck, back, and shoulder;
  • corsets for back or for use after special surgical procedures;
  • splints for extremities;
  • trusses

See Medical Policy Bulletin O-12 for additional information on Foot orthotics for conditions other than diabetes.

Procedure Codes

97504L0112L0113L0120L0130L0140
L0150L0160L0170L0172L0174L0180
L0190L0200L0210L0220L0430L0450
L0452L0454L0456L0458L0460L0462
L0464L0466L0468L0470L0472L0480
L0482L0484L0486L0488L0490L0491
L0492L0621L0622L0623L0624L0625
L0626L0627L0628L0629L0630L0631
L0632L0633L0634L0635L0636L0637
L0638L0639L0640L0700L0710L0810
L0820L0830L0859L0861L0970L0972
L0974L0976L0978L0980L0982L0984
L0999L1000L1001L1005L1010L1020
L1025L1030L1040L1050L1060L1070
L1080L1085L1090L1100L1110L1120
L1200L1210L1220L1230L1240L1250
L1260L1270L1280L1290L1300L1310
L1499L1500L1510L1520L1600L1610
L1620L1630L1640L1650L1652L1660
L1680L1685L1686L1690L1700L1710
L1720L1730L1755L1900L1901L1902
L1904L1906L1907L1910L1920L1930
L1932L1940L1945L1950L1951L1960
L1970L1971L1980L1990L2000L2005
L2010L2020L2030L2034L2035L2036
L2037L2038L2040L2050L2060L2070
L2080L2090L2106L2108L2112L2114
L2116L2126L2128L2132L2134L2136
L2180L2182L2184L2186L2188L2190
L2192L2200L2210L2220L2230L2232
L2240L2250L2260L2265L2270L2280
L2300L2310L2335L2340L2350L2360
L2370L2375L2380L2387L2460L2500
L2510L2520L2525L2526L2530L2540
L2550L2570L2580L2600L2610L2620
L2622L2624L2627L2628L2630L2640
L2650L2660L2670L2680L2760L2768
L2770L2840L2850L3000L3001L3002
L3003L3010L3020L3030L3031L3040
L3050L3060L3070L3080L3090L3100
L3140L3150L3160L3170L3201L3202
L3203L3204L3206L3207L3208L3209
L3211L3212L3213L3214L3215L3216
L3217L3219L3221L3222L3224L3225
L3230L3250L3251L3252L3253L3254
L3255L3257L3260L3265L3300L3310
L3320L3330L3332L3334L3340L3350
L3360L3370L3380L3390L3400L3410
L3420L3430L3440L3450L3455L3460
L3465L3470L3480L3485L3500L3510
L3520L3530L3540L3550L3560L3570
L3580L3590L3595L3600L3610L3620
L3630L3640L3649L3650L3651L3652
L3660L3670L3671L3672L3673L3675
L3677L3700L3701L3702L3710L3720
L3730L3740L3760L3762L3763L3764
L3765L3766L3806L3807L3808L3900
L3901L3904L3905L3906L3908L3909
L3911L3912L3912L3915L3917L3919
L3921L3923L3925L3927L3929L3931
L3933L3935L3956L3960L3961L3962
L3964L3965L3966L3967L3968L3969
L3970L3971L3972L3973L3974L3975
L3976L3977L3978L3980L3982L3984
L3995L3999L4000L4002L4010L4020
L4030L4040L4045L4050L4055L4060
L4070L4080L4090L4100L4110L4130
L4350L4360L4370L4380L4386L4392
L4394L4396L4398   

Traditional Guidelines

Refer to General Policy Guidelines

FEP Guidelines

This medical policy may not apply to FEP. Medical policy is not an authorization, certification, explanation of benefits or a contract. Benefits are determined by the Federal Employee Program. The following codes are not covered for FEP: L3040, L3050, L3060, L3215, L3216, L3217, L3219, L3221, L2120, L3222, L3332, L3480 and L3485.

PPO Guidelines

Refer to General Policy Guidelines

Managed Care POS Guidelines

Refer to General Policy Guidelines

Publications

References

Blue Cross Blue Shield Association Medical Policy 1.03.01; Issue 1:2003

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Table Attachment

Text Attachment

Procedure Code Attachments

Diagnosis Codes

Glossary





This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

Medical policies are designed to supplement the terms of a member's contract. The member's contract defines the benefits available; therefore, medical policies should not be construed as overriding specific contract language. In the event of conflict, the contract shall govern.

Medical policies do not constitute medical advice, nor the practice of medicine. Rather, such policies are intended only to establish general guidelines for coverage and reimbursement under Mountain State Blue Cross Blue Shield plans. Application of a medical policy to determine coverage in an individual instance is not intended and shall not be construed to supercede the professional judgment of a treating provider. In all situations, the treating provider must use his/her professional judgment to provide care he/she believes to be in the best interest of the patient, and the provider and patient remain responsible for all treatment decisions.

Mountain State Blue Cross Blue Shield (MSBCBS) retains the right to review and update its medical policy guidelines at its sole discretion. These guidelines are the proprietary information of MSBCBS. Any sale, copying or dissemination of the medical policies is prohibited; however, limited copying of medical policies is permitted for individual use.